Clinical relevance of valgus deformity of proximal femur in cerebral palsy.

PubMed

Lee, Kyoung Min; Kang, Jong Yeol; Chung, Chin Youb; Kwon, Dae Gyu; Lee, Sang Hyeong; Choi, In Ho; Cho, Tae-Joon; Yoo, Won Joon; Park, Moon Seok

2010-01-01

Proximal femoral deformity related to physis has not been studied in patients with cerebral palsy (CP). This study was performed to investigate the clinical relevance of neck shaft angle (NSA), head shaft angle (HSA), and proximal femoral epiphyseal shape in patients with CP, which represent the deformities of metaphysis, physis, and epiphysis, respectively. Three hundred eighty-four patients with CP (mean age 9.1 y, 249 males and 135 females) were included. Extent of involvement and functional states [Gross Motor Function Classification System (GMFCS) level] were obtained. Radiographic measurements including NSA, HSA, and qualitative shape of the proximal femoral epiphysis were evaluated and analyzed according to extent of involvement and GMFCS level. Reliability and correlation with each measurement were assessed. Multiple regression test was performed to examine the significant contributing factors to migration percentage (MP) that represents hip instability. NSA showed excellent interobserver reliability with intraclass correlation coefficients of 0.976. Correlation with the MP was higher in the NSA (r=0.419, P<0.001) than in the HSA (r=0.256, P<0.001). NSA, HSA, and MP tended to increase with increasing GMFCS level, and proportion of valgus deformed proximal femoral epiphysis also increased with increasing GMFCS level, which means valgus deformity and unstable hips in the less favorable functional states. Multiple regression analysis revealed NSA, GMFCS level, and shape of the proximal femoral epiphysis to be significant factors affecting MP. NSA appeared to be more clinically relevant than HSA in evaluating proximal femoral deformity in patients with CP. Shape of proximal femoral epiphysis is believed to have clinical implications in terms of hip instability. Diagnostic level II.

Ability of independently ambulant children with cerebral palsy to ride a two-wheel bicycle: a case-control study.

PubMed

Toovey, Rachel; Reid, Susan M; Rawicki, Barry; Harvey, Adrienne R; Watt, Kerrianne

2017-04-01

Limited information exists on the ability of children with cerebral palsy (CP) to ride a two-wheel bicycle, an activity that may improve health and participation. We aimed to describe bicycle-riding ability and variables associated with ability to ride in children with CP (Gross Motor Functional Classification System [GMFCS] levels I-II) compared with children with typical development. This case-control study surveyed parents of 114 children with CP and 87 children with typical development aged 6 to 15 years (115 males, mean age 9y 11mo, standard deviation [SD] 2y 10mo). Kaplan-Meier methods were used to compare proportions able to ride at any given age between the two groups. Logistic regression was used to assess variables associated with ability to ride for children with CP and typical development separately. The proportion of children with CP able to ride at each level of bicycle-riding ability was substantially lower at each age than peers with typical development (p<0.001). While most children with typical development were able to ride independently by 10 years of age, 51% of children with CP classified as GMFCS level I and 3% of those classified as GMFCS level II had obtained independent riding in the community by 15 years of age. Variables associated with ability to ride for children classified as GMFCS level I were age and parent-rated importance of their child being able to ride. Some independently ambulant children with CP can learn to ride a bicycle, in particular if they are classified as GMFCS level I. Variables associated with ability to ride deserve consideration in shaping future efforts for the majority of this population who are not yet able to ride. © 2016 Mac Keith Press.

Focal treatment of spasticity using botulinum toxin A in cerebral palsy cases of GMFCS level V: evaluation of adverse effects☆☆☆

PubMed Central

Tedesco, Ana Paula; Martins, Juliana Saccol; Nicolini-Panisson, Renata D’Agostini

2014-01-01

Objective To report on the experience of injections of botulinum toxin A (BTA) in a series of patients with cerebral palsy of Gross Motor Function Classification System (GMFCS) level V. Methods This was a retrospective case series study on 33 patients with cerebral palsy of GMFCS level V who received 89 sessions of BTA application (of which 84 were Botox® and five were other presentations), in which the basic aim was to look for adverse effects. Results The mean number of application sessions per patient was three, and the mean age at the time of each injection was 4 + 6 years (range: 1.6–13 years). The muscles that most frequently received injections were the gastrocnemius, hamstrings, hip adductors, biceps brachii and finger flexors. The mean total dose was 193 U and the mean dose per weight was 12.5 U/kg. Only one patient received anesthesia for the injections and no sedation was used in any case. No local or systemic adverse effects were observed within the minimum follow-up of one month. Conclusion The absence of adverse effects in our series was probably related to the use of low doses and absence of sedation or anesthesia. According to our data, BTA can be safely used for patients with cerebral palsy of GMFCS level V, using low doses and preferably without sedation or anesthesia. PMID:26229827

Management of cerebral palsy varies by healthcare region.

PubMed

Rackauskaite, Gija; Uldall, Peter W; Bech, Bodil H; Østergaard, John R

2015-11-01

Cerebral palsy (CP) is the most common type of motor disability in childhood. The aim of the present paper was to describe regional differences in the management of CP in school-aged children in Denmark. This was a cross-sectional study based on the Danish Cerebral Palsy Registry. The parents of 462 children answered a questionnaire about their child's treatment and the family's characteristics. Descriptive and logistic regression analyses were performed for every treatment modality, stratified by the Gross Motor Function Classification System (GMFCS) level and adjusted for family and child characteristics. Significant regional differences were found regarding the provision of occupational therapy at all GMFCS levels, speech therapy at GMFCS levels II-V and orthopaedic surgery at GMFCS levels I and III-V. No regional differences were observed in the frequency of physiotherapy. We found no regional differences in the severity of disability. Regional differences in the management of CP cannot be explained by social differences or differences in the severity of the disability. This study was funded by the Research Foundation from the Central Denmark Region and the Department of Clinical Medicine at Aarhus University Hospital, the Augustinus Foundation, the Bevica Foundation, the Dagmar Marshalls Foundation, the Ludvig and Sara Elsass Foundation, and the Civil Engineer Frode V. Nyegaard's and his Wife's Foundation. not relevant.

Outcome assessments in children with cerebral palsy, part II: discriminatory ability of outcome tools.

PubMed

Bagley, Anita M; Gorton, George; Oeffinger, Donna; Barnes, Douglas; Calmes, Janine; Nicholson, Diane; Damiano, Diane; Abel, Mark; Kryscio, Richard; Rogers, Sarah; Tylkowski, Chester

2007-03-01

Discriminatory ability of several pediatric outcome tools was assessed relative to Gross Motor Function Classification System (GMFCS) level in patients with cerebral palsy. Five hundred and sixty-two patients (400 with diplegia, 162 with hemiplegia; 339 males, 223 females; age range 4-18y, mean 11y 1mo [SD 3y 7mo]), classified as GMFCS Levels I to III, participated in this prospective multicenter, cross-sectional study. All tools were completed by parents and participants when appropriate. Effect size indices (ESIs) for parametric variables and odds ratios for non-parametric data quantified the magnitude of differences across GMFCS levels. Binary logistic regression models determined discrimination, and receiver operating characteristic curves addressed sensitivity and specificity. Between Levels I and II, the most discriminatory tools were Gross Motor Function Measure (GMFM-66), velocity, and WeeFIM Mobility. Between Levels II and III, the most discriminatory tools were GMFM Dimension E, Pediatric Functional Independence Measure (WeeFIM) Self-Care and Mobility, cadence, and Gillette Functional Assessment Questionnaire Question 1. Large ESIs were noted for Parent and Child reports of Pediatric Outcomes Data Collection Instrument (PODCI) Sports & Physical Function, Parent report of PODCI Global Function, GMFM Dimension E, and GMFM-66 across all GMFCS level comparisons. The least discriminatory tools were the Quality of Life and cognition measures; however, these are important in comprehensive assessments of treatment effects.

Using the manual ability classification system in young adults with cerebral palsy and normal intelligence.

PubMed

van Meeteren, Jetty; Nieuwenhuijsen, Channah; de Grund, Arthur; Stam, Henk J; Roebroeck, Marij E

2010-01-01

The study aimed to establish whether the manual ability classification system (MACS), a valid classification system for manual ability in children with cerebral palsy (CP), is applicable in young adults with CP and normal intelligence. The participants (n = 83) were young adults with CP and normal intelligence and had a mean age of 19.9 years. In this study, inter observer reliability of the MACS was determined. We investigated relationships between the MACS level and patient characteristics (such as the gross motor function classification system (GMFCS) level, limb distribution of the spastic paresis and educational level) and with functional activities of the upper extremity (assessed with the Melbourne assessment, the Abilhand questionnaire and the domain self-care of the functional independence measure (FIM)). Furthermore, with a linear regression analysis it was determined whether the MACS is a significant determinant of activity limitations and participation restrictions. The reliability was good (intraclass correlation coefficient 0.83). The Spearman correlation coefficients with GMFCS level, limb distribution of the spastic paresis and educational level were 0.53, 0.46, and 0.26, respectively. MACS level correlated moderately with outcome measures of functional activities (correlations ranging from -0.38 to -0.55). MACS level is, in addition to the GMFCS level, an important determinant for limitations in activities and restrictions in participation. We conclude that the MACS is a feasible method to classify manual ability in young adults with CP and normal intelligence with a good manual ability.

Oropharyngeal dysphagia and gross motor skills in children with cerebral palsy.

PubMed

Benfer, Katherine A; Weir, Kelly A; Bell, Kristie L; Ware, Robert S; Davies, Peter S W; Boyd, Roslyn N

2013-05-01

To determine the prevalence of oropharyngeal dysphagia (OPD) and its subtypes (oral phase, pharyngeal phase, saliva control), and their relationship to gross motor functional skills in preschool children with cerebral palsy (CP). It was hypothesized that OPD would be present across all gross motor severity levels, and children with more severe gross motor function would have increased prevalence and severity of OPD. Children with a confirmed diagnosis of CP, 18 to 36 months corrected age, born in Queensland between 2006 and 2009, participated. Children with neurodegenerative conditions were excluded. This was a cross-sectional population-based study. Children were assessed by using 2 direct OPD measures (Schedule for Oral Motor Assessment; Dysphagia Disorders Survey), and observations of signs suggestive of pharyngeal phase impairment and impaired saliva control. Gross motor skills were described by using the Gross Motor Function Measure, Gross Motor Function Classification System (GMFCS), Manual Ability Classification System, and motor type/ distribution. OPD was prevalent in 85% of children with CP, and there was a stepwise relationship between OPD and GMFCS level. There was a significant increase in odds of having OPD, or a subtype, for children who were nonambulant (GMFCS V) compared with those who were ambulant (GMFCS I) (odds ratio = 17.9, P = .036). OPD was present across all levels of gross motor severity using direct assessments. This highlights the need for proactive screening of all young children with CP, even those with mild impairments, to improve growth and nutritional outcomes and respiratory health.

Pediatric outcomes data collection instrument scores in ambulatory children with cerebral palsy: an analysis by age groups and severity level.

PubMed

Barnes, Douglas; Linton, Judith L; Sullivan, Elroy; Bagley, Anita; Oeffinger, Donna; Abel, Mark; Damiano, Diane; Gorton, George; Nicholson, Diane; Romness, Mark; Rogers, Sarah; Tylkowski, Chester

2008-01-01

The Pediatric Outcomes Data Collection Instrument (PODCI) was developed in 1994 as a patient-based tool for use across a broad age range and wide array of musculoskeletal disorders, including children with cerebral palsy (CP). The purpose of this study was to establish means and SDs of the Parent PODCI measures by age groups and Gross Motor Function Classification System (GMFCS) levels for ambulatory children with CP. This instrument was one of several studied in a prospective, multicenter project of ambulatory patients with CP between the aged 4 and 18 years and GMFCS levels I through III. Participants included 338 boys and 221 girls at a mean age of 11.1 years, with 370 diplegic, 162 hemiplegic, and 27 quadriplegic. Both baseline and follow-up data sets of the completed Parent PODCI responses were statistically analyzed. Age was identified as a significant predictor of the PODCI measures of Upper Extremity Function, Transfers and Basic Mobility, Global Function, and Happiness With Physical Condition. Gross Motor Function Classification System levels was a significant predictor of Transfers and Basic Mobility, Sports and Physical Function, and Global Function. Pattern of involvement, sex, and prior orthopaedic surgery were not statistically significant predictors for any of the Parent PODCI measures. Mean and SD scores were calculated for age groups stratified by GMFCS levels. Analysis of the follow-up data set validated the findings derived from the baseline data. Linear regression equations were derived, with age as a continuous variable and GMFCS levels as a categorical variable, to be used for Parent PODCI predicted scores. The results of this study provide clinicians and researchers with a set of Parent PODCI values for comparison to age- and severity-matched populations of ambulatory patients with CP.

A Cross-sectional Survey of Growth and Nutritional Status in Children With Cerebral Palsy in West China.

PubMed

Wang, Fangfang; Cai, Qianyun; Shi, Wei; Jiang, Huayin; Li, Na; Ma, Dan; Wang, Qiu; Luo, Rong; Mu, Dezhi

2016-05-01

We describe the growth and nutritional status of children with cerebral palsy (2 to 18 years old) in West China and to explore the correlation between the nutritional status and age, gender, and gross and fine motor function. We performed a cross-sectional survey of children registered as having cerebral palsy in the China Disabled Persons' Federation branch in Chengdu. Growth (height and weight) and nutritional (body mass index) status were recorded. Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) were used to determine gross and fine motor function, respectively. The association between nutritional status and age, GMFCS and MACS levels was evaluated. We enrolled 377 children (53.6% male), among whom 160 (42.4%) were stunting, 48 (12.7%) underweight, 81 (21.5%) thin, and 70 (18.5%) overweight and obese. Thinness was the main nutritional problem in older patients (12 to 18 years), whereas overweight and obesity were the major issues in younger patients (2 to 12 years). Growth deviation and malnutrition were significantly more prevalent in patients with severe motor impairments. A significant negative correlation was found between nutritional status and age, GMFCS and MACS levels, and between growth and GMFCS and MACS levels. Growth abnormality is common in children with cerebral palsy. Malnutrition and overnutrition both exist in children with cerebral palsy. Characteristics at different age stages and motor functional levels should be taken into consideration in the management of growth and nutrition in this population. Copyright © 2016 Elsevier Inc. All rights reserved.

Cerebral palsy in Victoria: motor types, topography and gross motor function.

PubMed

Howard, Jason; Soo, Brendan; Graham, H Kerr; Boyd, Roslyn N; Reid, Sue; Lanigan, Anna; Wolfe, Rory; Reddihough, Dinah S

2005-01-01

To study the relationships between motor type, topographical distribution and gross motor function in a large, population-based cohort of children with cerebral palsy (CP), from the State of Victoria, and compare this cohort to similar cohorts from other countries. An inception cohort was generated from the Victorian Cerebral Palsy Register (VCPR) for the birth years 1990-1992. Demographic information, motor types and topographical distribution were obtained from the register and supplemented by grading gross motor function according to the Gross Motor Function Classification System (GMFCS). Complete data were obtained on 323 (86%) of 374 children in the cohort. Gross motor function varied from GMFCS level I (35%) to GMFCS level V (18%) and was similar in distribution to a contemporaneous Swedish cohort. There was a fairly even distribution across the topographical distributions of hemiplegia (35%), diplegia (28%) and quadriplegia (37%) with a large majority of young people having the spastic motor type (86%). The VCPR is ideal for population-based studies of gross motor function in children with CP. Gross motor function is similar in populations of children with CP in developed countries but the comparison of motor types and topographical distribution is difficult because of lack of consensus with classification systems. Use of the GMFCS provides a valid and reproducible method for clinicians to describe gross motor function in children with CP using a universal language.

Spectrum of gross motor function in extremely low birth weight children with cerebral palsy at 18 months of age.

PubMed

Vohr, Betty R; Msall, Michael E; Wilson, Dee; Wright, Linda L; McDonald, Scott; Poole, W Kenneth

2005-07-01

The purpose of this study was to evaluate the relationship between cerebral palsy (CP) diagnoses as measured by the topographic distribution of the tone abnormality with level of function on the Gross Motor Function Classification System (GMFCS) and developmental performance on the Bayley Scales of Infant Development II (BSID-II). It was hypothesized that (1) the greater the number of limbs involved, the higher the GMFCS and the lower the BSID-II Motor Scores and (2) there would be a spectrum of function and skill achievement on the GMFCS and BSID-II Motor Scores for children in each of the CP categories. A multicenter, longitudinal cohort study was conducted of 1860 extremely low birth weight (ELBW) infants who were born between August 1, 1995 and February 1, 1998, and evaluated at 18 to 22 months' corrected age. Children were categorized into impairment groups on the basis of the typography of neurologic findings: spastic quadriplegia, triplegia, diplegia, hemiplegia, monoplegia, hypotonic and/or athetotic CP, other abnormal neurologic findings, and normal. The neurologic category then was compared with GMFCS level and BSID-II Motor Scores. A total of 282 (15.2%) of the 1860 children evaluated had CP. Children with more limbs involved had more abnormal GMFCS levels and lower BSID-II scores, reflecting more severe functional limitations. However, for each CP diagnostic category, there was a spectrum of gross motor functional levels and BSID-II scores. Although more than 1 (26.6%) in 4 of the children with CP had moderate to severe gross motor functional impairment, 1 (27.6%) in 4 had motor functional skills that allowed for ambulation. Given the range of gross motor skill outcomes for specific types of CP, the GMFCS is a better indicator of gross motor functional impairment than the traditional categorization of CP that specifies the number of limbs with neurologic impairment. The neurodevelopmental assessment of young children is optimized by combining a standard neurologic examination with measures of gross and fine motor function (GMFCS and Bayley Psychomotor Developmental Index). Additional studies to examine longer term functional motor and adaptive-functional developmental skills are required to devise strategies that delineate therapies to optimize functional performance.

Participation in home, extracurricular, and community activities among children and young people with cerebral palsy.

PubMed

Orlin, Margo N; Palisano, Robert J; Chiarello, Lisa A; Kang, Lin-Ju; Polansky, Marcia; Almasri, Nihad; Maggs, Jill

2010-02-01

Participation in home, extracurricular, and community activities is a desired outcome of rehabilitation services for children and young people with cerebral palsy (CP). The purpose of this study was to investigate the effect of age and gross motor function on participation among children and young people with CP. Five hundred participants (277 males, 223 females) were grouped by age and Gross Motor Function Classification System (GMFCS) level. There were 291 children aged 6 to 12 years and 209 young people aged 13 to 21 years. There were 128 participants in GMFCS level I, 220 in levels II/III, and 152 in levels IV/V. Participants completed the Children's Assessment of Participation and Enjoyment to measure number of activities (diversity) and how often they were performed (intensity) in the past 4 months. Children had higher overall participation diversity and intensity than young people (p<0.001). Children and young people in GMFCS level I had the highest overall participation, followed by children and young people in levels II/III and IV/V. Children had higher participation in recreational (p<0.001) but not formal (such as team sports or clubs) or physical activities. Children (p<0.01) and young people (p<0.001) in level I had the highest participation in physical activities; diversity and intensity were generally low. The findings provide evidence of the effect of age and gross motor function on participation of children and young people with CP. Low participation in physical activities may have implications for fitness and health, especially for children and young people in GMFCS levels IV and V.

Multimorbidity in Middle-Aged Adults with Cerebral Palsy

PubMed Central

Cremer, Nicole; Hurvitz, Edward A.; Peterson, Mark D.

2017-01-01

Background Individuals with cerebral palsy have less lean body mass, greater relative adiposity, and lower fitness and physical activity participation; and yet, the prevalence of age-related multimorbidity in this population has yet to be established. Purpose To examine the prevalence of lifestyle-related chronic conditions and multimorbidity in a sample of middle-aged adults with cerebral palsy. Methods A clinic-based sample of middle-aged adults with cerebral palsy was examined using Electronic Medical Records Search Engine (EMERSE) software. Our cohort included n= 435 individuals aged 40–60 years old, with an ICD-9/10-CM Diagnosis Code for cerebral palsy. Prevalence of 12 chronic conditions were evaluated, including existing diagnoses or historical record of: osteopenia/osteoporosis, myocardial infarction, stroke, coronary artery disease, impaired glucose tolerance/type 2 diabetes, other cardiovascular conditions, rheumatoid arthritis, osteoarthritis, asthma, emphysema, pre-hypertension/hypertension, and hyperlipidemia. Multivariate logistic models were used to estimate adjusted mulitmorbidity (i.e., ≥2 chronic conditions), adjusting for age, sex, smoking status, obesity, and Gross Motor Function Classification System (GMFCS). Results There were 137 unique multimorbidity combinations. Multimorbidity was significantly more prevalent among obese versus non-obese individuals for both GMFCS I–III (75.8% vs. 53.6%) and GMFCS IV–V (79.0% vs 64.2%), but was also significantly higher in non-obese individuals with GMFCS IV–V (64.2%) compared to individuals with non-obese individuals with GMFCS I–III (53.6%). Both obesity status (OR: 2.20; 95% CI 1.32–2.79) and the GMFCS IV–V category (OR: 1.81; 95% CI 1.32–3.68) were independently associated with multimorbidity. Conclusion Middle-aged adults with cerebral palsy have high estimates of multimorbidity, and both obesity and higher GMFCS levels are independently associated with greater risk. PMID:28065772

The Gross Motor Function Classification System Family Report Questionnaire: reliability between special-education teachers and caregivers.

PubMed

Ramrit, Sirinun; Yonglitthipagon, Ponlapat; Janyacharoen, Taweesak; Emasithi, Alongkot; Siritaratiwat, Wantana

2017-05-01

The aim of this study was to investigate the reliability of the Thai Gross Motor Function Classification System Family Report Questionnaire (GMFCS-FR) and the possibility of special-education teachers and caregivers in the community using this system in children with cerebral palsy (CP). The reliability was examined by two teachers and two caregivers who classified 21 children with CP aged 2 to 12 years. A GMFCS-FR workshop was organized for raters. The teachers and caregivers classified the mobility of 362 children. The rater reliability was analysed using the weighted kappa coefficient. The possibility of using the GMFCS-FR is reported. The reliability of using the GMFCS-FR in the community was analysed by the intraclass correlation coefficient. The intrarater reliability ranged from 0.91 to 1.00. The interrater reliability between teachers was 0.85 (95% confidence interval [CI] 0.69-0.97) and between caregivers was 0.84 (95% CI 0.70-0.97). Ninety-seven percent of raters used the Thai GMFCS-FR correctly. The overall intraclass correlation coefficient between raters was 0.90 (95% CI 0.88-0.92). The Thai GMFCS-FR is a reliable system for classifying the motor function of young children with CP by teachers and caregivers in the community. © 2016 Mac Keith Press.

Correlation of technical surgical goals to the GDI and investigation of post-operative GDI change in children with cerebral palsy.

PubMed

Bickley, Christina; Linton, Judi; Scarborough, Nancy; Sullivan, Elroy; Mitchell, Katy; Barnes, Douglas

2017-06-01

The purpose of this study was to introduce a standardized set of surgical technical achievement goals (TAGs) as part of a comprehensive outcome assessment model for children with spastic cerebral palsy (CP) undergoing orthopaedic surgical intervention to improve gait. Examination of relationships of these surgical goals to the Gait Deviation Index (GDI) and use of two assessments in tandem provided a thorough picture of technical surgical outcomes. This study also investigated changes in GDI in children with spastic CP after surgery. Data from 269 participants with spastic CP, aged 4 to 19 years with Gross Motor Function Classification System (GMFCS) levels I, II, and III who underwent lower extremity orthopaedic surgical intervention to improve gait were retrospectively analyzed. Data were examined as one heterogeneous group and sub-grouped based on pattern of involvement and GMFCS level to determine change in GDI and relationships between GDI and TAGs. Differences in TAG achievement and GDI change by GMFCS level suggest a pairing of GDI with another technical measure to be beneficial. Analysis of the outcome tools individually revealed a significant difference between the pre-operative GDI and post-operative GDI mean for the entire group, as well as each of the subgroups. A significant difference in TAG achievement by GMFCS level was also noted. This paper provides evidence that lower extremity orthopedic intervention for the ambulatory child with spastic diplegic or hemiplegic CP improves gait and that a pairing of the GDI and TAGs system is beneficial to capture an accurate technical outcome assessment in both higher and lower functioning patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Leisure participation-preference congruence of children with cerebral palsy: a Children's Assessment of Participation and Enjoyment International Network descriptive study.

PubMed

Imms, Christine; King, Gillian; Majnemer, Annette; Avery, Lisa; Chiarello, Lisa; Palisano, Robert; Orlin, Margo; Law, Mary

2017-04-01

To examine participation-preference congruence, regional differences in participation-preference congruence, and predictors of whether children with cerebral palsy participate in preferred activities. The sample (n=236) included 148 males and 88 females aged 10 to 13 years, living in Victoria, Australia (n=110), Ontario (n=80), or Quebec (n=46), Canada. Ninety-nine (41.9%) were classed at Gross Motor Function Classification System (GMFCS) level I; 89 (37.7%) at GMFCS level II/III; and 48 (20.3%) at GMFCS level IV/V. Participants completed the Children's Assessment of Participation and Enjoyment and Preferences for Activity of Children questionnaires. Regional comparisons were performed using one-way analyses of variance and factors influencing participation-preference congruence were explored using multiple linear regression. The proportion of children doing non-preferred activities in each activity type was generally low (2-17%), with only one regional difference. Higher proportions were not doing preferred active physical (range 23.2-29.1% across regions), skill-based (range 21.7-27.9% across regions), and social activities (range 12.8-14.5% across regions). GMFCS level was the most important predictor associated with not doing preferred activities. Children with cerebral palsy did not always participate in preferred active physical and skill-based activities. Understanding discrepancies between preferences and actual involvement may allow families and rehabilitation professionals to address participation barriers. © 2016 Mac Keith Press.

Relationship between gross motor and intellectual function in children with cerebral palsy: a cross-sectional study.

PubMed

Dalvand, Hamid; Dehghan, Leila; Hadian, Mohammad Reza; Feizy, Awat; Hosseini, Seyed Ali

2012-03-01

To explore the relationship between gross motor and intellectual function in children with cerebral palsy (CP). A cross-sectional study. Occupational therapy clinic. Children with CP (N=662; 281 girls, 381 boys; age range, 3-14y). Not applicable. Intelligence testing was carried out by means of the Wechsler Preschool and Primary Scale of Intelligence and the Wechsler Intelligence Scale for Children-Revised. Gross motor function level was determined by the Gross Motor Function Classification System Expanded and Revised (GMFCS E&R). Of the children, 10.4% were at level I of the GMFCS E&R, 38% at levels II and III, and 51.5% at levels IV and V. The lowest level of intelligence or profound intellectual disability was found in children with spastic quadriplegia (n=28, 62.2%). Children at the lowest levels (I-IV, GMFCS E&R) obtained higher ratings in terms of intelligence in comparison with children at level V. Based on the present results, the diagnosis was statistically related to the intellectual level as dependent variable (P<.01); accordingly, hypotonic, quadriplegic, and hemiplegic patients had the highest odds to assign higher ratings in abnormal intelligence, respectively. Sex and age were not statistically related to the dependent variable. The study results demonstrated a significant association between GMFCS E&R and intellectual function. Therefore, we suggest that particular attention should be paid to the intellectual level in terms of evaluations of gross motor function. These results, in respect, might be interested for occupational and physical therapists who are involved in rehabilitation programs for these children. Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Noncommunicable disease and multimorbidity in young adults with cerebral palsy.

PubMed

Whitney, Daniel G; Hurvitz, Edward A; Ryan, Jennifer M; Devlin, Maureen J; Caird, Michelle S; French, Zachary P; Ellenberg, Elie C; Peterson, Mark D

2018-01-01

Individuals with cerebral palsy (CP) are at increased risk for frailty and chronic disease due to factors experienced throughout the lifespan, such as excessive sedentary behaviors and malnutrition. However, little is known about noncommunicable diseases (NCDs) and multimorbidity profiles in young adults with CP. The study objective was to compare NCD and multimorbidity profiles between young adults with and without CP. A clinic-based sample of adults (18-30 years) with (n=452) and without (n=448) CP was examined at the University of Michigan Medical Center. The prevalence and predictors of 13 NCDs were evaluated, including existing diagnoses or historical record of musculoskeletal, cardiometabolic, and pulmonary morbidities. The level of motor impairment was determined by the Gross Motor Function Classification System (GMFCS) and stratified by less vs more severe motor impairment (GMFCS I-III vs IV-V). Logistic regression was used to determine the odds of NCD morbidity and multimorbidity in adults with CP compared to adults without CP, and for GMFCS IV-V compared to GMFCS I-III in those with CP, after adjusting for age, sex, body mass index, and smoking. Adults with CP had a higher prevalence of osteopenia, osteoporosis, hypertension, myocardial infarction, hyperlipidemia, asthma, and multimorbidity compared to adults without CP, and higher odds of musculoskeletal (odds ratio [OR]: 6.97) and cardiometabolic morbidity (OR: 1.98), and multimorbidity (OR: 2.67). Adults with CP with GMFCS levels IV-V had a higher prevalence of osteopenia/osteoporosis, osteoarthritis, hypertension, other cardiovascular conditions, pulmonary embolism, and multimorbidity, and higher odds of musculoskeletal (OR: 3.41), cardiometabolic (OR: 2.05), pulmonary morbidity (OR: 1.42), and multimorbidity (OR: 3.45) compared to GMFCS I-III. Young adults with CP have a higher prevalence of chronic NCDs and multimorbidity compared to young adults without CP, which is pronounced in those with more severe motor impairment. These findings reiterate the importance of early screening for prevention of NCDs in CP.

Noncommunicable disease and multimorbidity in young adults with cerebral palsy

PubMed Central

Whitney, Daniel G; Hurvitz, Edward A; Ryan, Jennifer M; Devlin, Maureen J; Caird, Michelle S; French, Zachary P; Ellenberg, Elie C; Peterson, Mark D

2018-01-01

Purpose Individuals with cerebral palsy (CP) are at increased risk for frailty and chronic disease due to factors experienced throughout the lifespan, such as excessive sedentary behaviors and malnutrition. However, little is known about noncommunicable diseases (NCDs) and multimorbidity profiles in young adults with CP. The study objective was to compare NCD and multimorbidity profiles between young adults with and without CP. Methods A clinic-based sample of adults (18–30 years) with (n=452) and without (n=448) CP was examined at the University of Michigan Medical Center. The prevalence and predictors of 13 NCDs were evaluated, including existing diagnoses or historical record of musculoskeletal, cardiometabolic, and pulmonary morbidities. The level of motor impairment was determined by the Gross Motor Function Classification System (GMFCS) and stratified by less vs more severe motor impairment (GMFCS I–III vs IV–V). Logistic regression was used to determine the odds of NCD morbidity and multimorbidity in adults with CP compared to adults without CP, and for GMFCS IV–V compared to GMFCS I–III in those with CP, after adjusting for age, sex, body mass index, and smoking. Results Adults with CP had a higher prevalence of osteopenia, osteoporosis, hypertension, myocardial infarction, hyperlipidemia, asthma, and multimorbidity compared to adults without CP, and higher odds of musculoskeletal (odds ratio [OR]: 6.97) and cardiometabolic morbidity (OR: 1.98), and multimorbidity (OR: 2.67). Adults with CP with GMFCS levels IV–V had a higher prevalence of osteopenia/osteoporosis, osteoarthritis, hypertension, other cardiovascular conditions, pulmonary embolism, and multimorbidity, and higher odds of musculoskeletal (OR: 3.41), cardiometabolic (OR: 2.05), pulmonary morbidity (OR: 1.42), and multimorbidity (OR: 3.45) compared to GMFCS I–III. Conclusion Young adults with CP have a higher prevalence of chronic NCDs and multimorbidity compared to young adults without CP, which is pronounced in those with more severe motor impairment. These findings reiterate the importance of early screening for prevention of NCDs in CP. PMID:29750055

Development and face validity of a cerebral visual impairment motor questionnaire for children with cerebral palsy.

PubMed

Salavati, M; Waninge, A; Rameckers, E A A; van der Steen, J; Krijnen, W P; van der Schans, C P; Steenbergen, B

2017-01-01

The objectives of this study were (i) to develop two cerebral visual impairment motor questionnaires (CVI-MQ's) for children with cerebral palsy (CP): one for children with Gross Motor Function Classification System (GMFCS) levels I, II and III and one for children with GMFCS levels IV and V; (ii) to describe their face validity and usability; and (iii) to determine their sensitivity and specificity. The initial versions of the two CVI-MQ's were developed based on literature. Subsequently, the Delphi method was used in two groups of experts, one familiar with CVI and one not familiar with CVI, in order to gain consensus about face validity and usability. The sensitivity and specificity of the CVI-MQ's were subsequently assessed in 82 children with CP with (n = 39) and without CVI (n = 43). With the receiver operating curve the cut-off scores were determined to detect possible presence or absence of CVI in children with CP. Both questionnaires showed very good face validity (percentage agreement above 96%) and good usability (percentage agreement 95%) for practical use. The CVI-MQ version for GMFCS levels I, II and III had a sensitivity of 1.00 and specificity of 0.96, with a cut-off score of 12 points or higher, and the version for GMFCS levels IV and V had a sensitivity of 0.97 and a specificity of 0.98, with a cut-off score of eight points or higher. The CVI-MQ is able to identify at-risk children with CP for the probability of having CVI. © 2016 John Wiley & Sons Ltd.

Early results of one-stage correction for hip instability in cerebral palsy.

PubMed

Kim, Hui Taek; Jang, Jae Hoon; Ahn, Jae Min; Lee, Jong Seo; Kang, Dong Joon

2012-06-01

We evaluated the clinical and radiological results of one-stage correction for cerebral palsy patients. We reviewed clinical outcomes and radiologic indices of 32 dysplastic hips in 23 children with cerebral palsy (13 males, 10 females; mean age, 8.6 years). Ten hips had dislocation, while 22 had subluxation. Preoperative Gross Motor Function Classification System (GMFCS) scores of the patients were as follows; level V (13 patients), level IV (9), and level III (1). Acetabular deficiency was anterior in 5 hips, superolateral in 7, posterior in 11 and mixed in 9, according to 3 dimensional computed tomography. The combined surgery included open reduction of the femoral head, release of contracted muscles, femoral shortening varus derotation osteotomy and the modified Dega osteotomy. Hip range of motion, GMFCS level, acetabular index, center-edge angle and migration percentage were measured before and after surgery. The mean follow-up period was 28.1 months. Hip abduction (median, 40°), sitting comfort and GMFCS level were improved after surgery, and pain was decreased. There were two cases of femoral head avascular necrosis, but no infection, nonunion, resubluxation or redislocation. All radiologic indices showed improvement after surgery. A single event multilevel surgery including soft tissue, pelvic and femoral side correction is effective in treating spastic dislocation of the hip in cerebral palsy.

Introduction of the gross motor function classification system in Venezuela--a model for knowledge dissemination.

PubMed

Löwing, Kristina; Arredondo, Ynes C; Tedroff, Marika; Tedroff, Kristina

2015-09-04

A current worldwide common goal is to optimize the health and well-being of children with cerebral palsy (CP). In order to reach that goal, for this heterogeneous group, a common language and classification systems are required to predict development and offer evidence based interventions. In most countries in Africa, South America, Asia and Eastern Europe the classification systems for CP are unfamiliar and rarely used. Education and implementation are required. The specific aims of this study were to examine a model in order to introduce the Gross Motor Function Classification System (GMFCS-E&R) in Venezuela, and to examine the validity and the reliability. Children with CP, registered at a National child rehabilitation centre in Venezuela, were invited to participate. The Spanish version of GMFCS-E&R was used. The Wilson mobility scale was translated and used to examine the concurrent validity. A structured questionnaire, comprising aspects of mobility and gross motor function, was constructed. In addition, each child was filmed. A paediatrician in Venezuela received supervised self-education in GMFCS-E&R and the Wilson mobility scale. A Swedish student was educated in GMFCS-E&R and the Wilson mobility scale prior to visiting Venezuela. In Venezuela, all children were classified and scored by the paediatrician and student independently. An experienced paediatric physiotherapist (PT) in Sweden made independent GMFCS-E&R classifications and Wilson mobility scale scorings, accomplished through merging data from the structured questionnaire with observations of the films. Descriptive statistics were used and reliability was presented with weighted Kappa (Kw). Spearman's correlation coefficient was calculated to explore the concurrent validity between GMFCS-E&R and Wilson mobility scale. Eighty-eight children (56 boys), mean age 10 years (3-18), with CP participated. The inter-rater reliability of GMFCS-E&R between; the paediatrician and the PT was Kw = 0.85 (95% CI: 0.75-0.88), the PT and student was Kw = 0.91 (95% CI: 0.86-0.95) and the paediatrician and student was Kw = 0.85 (95 % CI: 0.79-0.90). The correlations between GMFCS-E&R and Wilson mobility scale were high rs =0.94-0.95 (p < 0.001). In a setting with no previous knowledge of GMFCS-E&R, the model with education, supervised self-education and practice was efficient and resulted in very good reliability and validity.

The impact of visual impairment on the ability to perform activities of daily living for persons with severe/profound intellectual disability.

PubMed

Dijkhuizen, Annemarie; Hilgenkamp, Thessa I M; Krijnen, Wim P; van der Schans, Cees P; Waninge, Aly

2016-01-01

The ability to perform activities of daily living (ADL) as a component of participation is one of the factors that contribute to quality of life. The ability to perform ADL for persons experiencing severe/profound intellectual disability (ID) may be reduced due to their cognitive and physical capacities. However, until recently, the impact of the significantly prevalent visual impairments on the performance of activities of daily living has not yet been revealed within this group. The purpose of this prospective cross-sectional study was to investigate the impact of visual impairment on the performance of activities of daily living for persons with a severe/profound intellectual disability. The Barthel Index (BI) and Comfortable Walking Speed (CWS) were used to measure the ability of performing activities of daily living (ADL) in 240 persons with severe/profound ID and having Gross Motor Functioning Classification System (GMFCS) levels I, II or III; this included 120 persons with visual impairment. The impact of visual impairment on ADL was analyzed with linear regression. The results of the study demonstrated that visual impairment slightly affects the ability of performing activities of daily living (BI) for persons experiencing a severe/profound intellectual disability. GMFCS Levels II or III, profound ID level, and visual impairment each have the effect of lowering BI scores. GMFCS Levels II or III, and profound ID level each have the effect of increasing CWS scores, which indicates a lower walking speed. A main effect of visual impairment is present on CWS, but our results do show a substantive interaction effect between GMFCS level III and visual impairment on Comfortable Walking Speed in persons with a severe/profound intellectual disability. Visual impairment has a slight effect on ability to perform ADL in persons experiencing severe/profound ID. Copyright © 2015 Elsevier Ltd. All rights reserved.

Three-dimensional lumbar segment movement characteristics during paediatric cerebral palsy gait.

PubMed

Kiernan, D; Malone, A; O'Brien, T; Simms, C K

2017-03-01

Kinematic analysis of the trunk during cerebral palsy (CP) gait has been well described. In contrast, movement of the lumbar spine is generally ignored. This is most likely due to the complex nature of the spine. As an alternative to using complex sensor protocols, this study modelled the lumbar region as a single segment and investigated characteristic patterns of movement during CP gait. In addition, the impact of functional level of impairment and the relationship with lower lumbar spinal loading were examined. Fifty-two children with CP (26 GMFCS I and 26 GMFCS II) and 26 controls were recruited. A full barefoot 3-dimensional kinematic and kinetic analysis were conducted. Lumbar segment movement demonstrated increased forward flexion for CP children. This movement became more pronounced according to GMFCS level with GMFCS II children demonstrating increases of up to 8°. In addition, a moderate correlation was present between lumbar flexion/extension and L5/S1 sagittal moments (r=0.427 in the global frame and r=0.448 with respect to the pelvis, p<0.01). Children with CP demonstrated increased movement of the lumbar region compared to TD, with movement becoming more excessive as GMFCS level increased. Excessive forward flexion and loading at the lumbar spine were linked. However, the moderate correlation suggests other contributors to increased loading were present. In conclusion, this study is a first step at identifying how lumbar segment movement is altered during CP gait. Copyright © 2017 Elsevier B.V. All rights reserved.

Computerized Adaptive Tests Detect Change Following Orthopaedic Surgery in Youth with Cerebral Palsy.

PubMed

Mulcahey, M J; Slavin, Mary D; Ni, Pengsheng; Vogel, Lawrence C; Kozin, Scott H; Haley, Stephen M; Jette, Alan M

2015-09-16

The Cerebral Palsy Computerized Adaptive Test (CP-CAT) is a parent-reported outcomes instrument for measuring lower and upper-extremity function, activity, and global health across impairment levels and a broad age range of children with cerebral palsy (CP). This study was performed to examine whether the Lower Extremity/Mobility (LE) CP-CAT detects change in mobility following orthopaedic surgery in children with CP. This multicenter, longitudinal study involved administration of the LE CP-CAT, the Pediatric Outcomes Data Collection Instrument (PODCI) Transfer/Mobility and Sports/Physical Functioning domains, and the Timed "Up & Go" test (TUG) before and after elective orthopaedic surgery in a convenience sample of 255 children, four to twenty years of age, who had CP and a Gross Motor Function Classification System (GMFCS) level of I, II, or III. Standardized response means (SRMs) and 95% confidence intervals (CIs) were calculated for all measures at six, twelve, and twenty-four months following surgery. SRM estimates for the LE CP-CAT were significantly greater than the SRM estimates for the PODCI Transfer/Mobility domain at twelve months, the PODCI Sports/Physical Functioning domain at twelve months, and the TUG at twelve and twenty-four months. When the results for the children at GMFCS levels I, II, and III were grouped together, the improvements in function detected by the LE CP-CAT at twelve and twenty-four months were found to be greater than the changes detected by the PODCI Transfer/Mobility and Sports/Physical Functioning scales. The LE CP-CAT outperformed the PODCI scales for GMFCS levels I and III at both of these follow-up intervals; none of the scales performed well for patients with GMFCS level II. The results of this study showed that the LE CP-CAT displayed superior sensitivity to change than the PODCI and TUG scales after musculoskeletal surgery in children with CP. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.

Investigating the impact of pain, age, Gross Motor Function Classification System, and sex on health-related quality of life in children with cerebral palsy.

PubMed

Findlay, Briar; Switzer, Lauren; Narayanan, Unni; Chen, Shiyi; Fehlings, Darcy

2016-03-01

To explore whether health-related quality of life (HRQOL) can be predicted by pain, age, Gross Motor Function Classification System (GMFCS) level, and sex in children with cerebral palsy (CP) and whether different pain etiologies have varying effects on HRQOL. Children with CP aged 3 to 19 years and their caregivers were consecutively recruited. Caregivers reported their child's pain (Health Utilities Index 3 [HUI3] pain subset) and HRQOL (DISABKIDS questionnaires). Physicians identified pain etiologies. A multiple linear regression model determined whether pain, GMFCS level, sex, and age predicted HRQOL. An ANOVA evaluated the effects of pain etiologies on HRQOL. Three hundred and forty-four participants were approached and 87% (n=300) participated. Sufficient data were available on 248 (72% of total sample). Sixty-six participants (27%) formed the pain group with HUI3 pain scores of at least 3. The presence of pain and increasing age significantly negatively predicted HRQOL (p<0.001, R(2) =0.141), while GMFCS and sex did not. Musculoskeletal deformity (24%) and hypertonia (18%) were the most frequent pain causes. HRQOL statistically differed depending on the pain etiology (p=0.028) with musculoskeletal deformity showing the lowest mean HRQOL. The presence of pain and increasing age negatively predict HRQOL in CP. musculoskeletal deformity has the greatest negative impact on HRQOL. © 2015 Mac Keith Press.

Relationship between communication skills and gross motor function in preschool-aged children with cerebral palsy.

PubMed

Coleman, Andrea; Weir, Kelly A; Ware, Robert S; Boyd, Roslyn N

2013-11-01

To explore the communication skills of children with cerebral palsy (CP) at 24 months' corrected age with reference to typically developing children, and to determine the relationship between communication ability, gross motor function, and other comorbidities associated with CP. Prospective, cross-sectional, population-based cohort study. General community. Children with CP (N=124; mean age, 24mo; functional severity on Gross Motor Function Classification System [GMFCS]: I=47, II=14, III=22, IV=19, V=22). Not applicable. Parents reported communication skills on the Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP) Infant-Toddler Checklist. Two independent physiotherapists classified motor type, distribution, and GMFCS. Data on comorbidities were obtained from parent interviews and medical records. Children with mild CP (GMFCS I/II) had mean CSBS-DP scores that were 0.5 to 0.6 SD below the mean for typically developing peers, while those with moderate-severe impairment (GMFCS III-V) were 1.4 to 2.6 SD below the mean. GMFCS was significantly associated with performance on the CSBS-DP (F=18.55, P<.001), with gross motor ability accounting for 38% of the variation in communication. Poorer communication was strongly associated with gross motor function and full-term birth. Preschool-aged children with CP, with more severe gross motor impairment, showed delayed communication, while children with mild motor impairment were less vulnerable. Term-born children had significantly poorer communication than those born prematurely. Because a portion of each gross motor functional severity level is at risk, this study reinforces the need for early monitoring of communication development for all children with CP. Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Should the Gross Motor Function Classification System be used for children who do not have cerebral palsy?

PubMed

Towns, Megan; Rosenbaum, Peter; Palisano, Robert; Wright, F Virginia

2018-02-01

This literature review addressed four questions. (1) In which populations other than cerebral palsy (CP) has the Gross Motor Function Classification System (GMFCS) been applied? (2) In what types of study, and why was it used? (3) How was it modified to facilitate these applications? (4) What justifications and evidence of psychometric adequacy were used to support its application? A search of PubMed, MEDLINE, and Embase databases (January 1997 to April 2017) using the terms: 'GMFCS' OR 'Gross Motor Function Classification System' yielded 2499 articles. 118 met inclusion criteria and reported children/adults with 133 health conditions/clinical descriptions other than CP. Three broad GMFCS applications were observed: as a categorization tool, independent variable, or outcome measure. While the GMFCS is widely used for children with health conditions/clinical description other than CP, researchers rarely provided adequate justification for these uses. We offer recommendations for development/validation of other condition-specific classification systems and discuss the potential need for a generic gross motor function classification system. The Gross Motor Function Classification System should not be used outside cerebral palsy or as an outcome measure. The authors provide recommendations for development and validation of condition-specific or generic classification systems. © 2017 Mac Keith Press.

Musculoskeletal system problems and quality of life of mothers of children with cerebral palsy with different levels of disability.

PubMed

Kavlak, Erdoğan; Altuğ, Filiz; Büker, Nihal; Şenol, Hande

2015-01-01

The objective of this study is to investigate musculoskeletal system problems and quality of life of mothers of children with cerebral palsy with different levels of disability. 100 children (37 girls and 63 boys) with cerebral palsy (CP) and their mothers were included in this study. Functional levels of children with CP were assessed by using the Gross Motor Function Classification System (GMFCS) and the Pediatric Functional Independence Measure (WeeFIM). Quality of life of mothers regarding health was assessed by using the Nottingham Health Profile (NHP). Musculoskeletal system problems of mothers were assessed by using the Neck Disability Index (NDI) and the Roland-Morris Disability Questionnaire (RMDQ). No statistical significance was found when GMFCS levels of children with CP and the NHP, DASH-T, RMDQ, NDI and the BAE values of mothers were compared in an inter-group way (p> 0.05). When the NHP parameters and the existence of lower and arm pains of mothers were compared with their BAI, NDI, RMDQ and DASH-T scores, a statistically significant relationship was found among them (p< 0.05). As functional levels of children with CP get worse, upper extremity, lower back and neck problems and anxiety levels of mothers increase and this situation negatively affects mothers' quality of life.

Comprehension of spoken language in non-speaking children with severe cerebral palsy: an explorative study on associations with motor type and disabilities.

PubMed

Geytenbeek, Joke J M; Vermeulen, R Jeroen; Becher, Jules G; Oostrom, Kim J

2015-03-01

To assess spoken language comprehension in non-speaking children with severe cerebral palsy (CP) and to explore possible associations with motor type and disability. Eighty-seven non-speaking children (44 males, 43 females, mean age 6y 8mo, SD 2y 1mo) with spastic (54%) or dyskinetic (46%) CP (Gross Motor Function Classification System [GMFCS] levels IV [39%] and V [61%]) underwent spoken language comprehension assessment with the computer-based instrument for low motor language testing (C-BiLLT), a new and validated diagnostic instrument. A multiple linear regression model was used to investigate which variables explained the variation in C-BiLLT scores. Associations between spoken language comprehension abilities (expressed in z-score or age-equivalent score) and motor type of CP, GMFCS and Manual Ability Classification System (MACS) levels, gestational age, and epilepsy were analysed with Fisher's exact test. A p-value <0.05 was considered statistically significant. Chronological age, motor type, and GMFCS classification explained 33% (R=0.577, R(2) =0.33) of the variance in spoken language comprehension. Of the children aged younger than 6 years 6 months, 52.4% of the children with dyskinetic CP attained comprehension scores within the average range (z-score ≥-1.6) as opposed to none of the children with spastic CP. Of the children aged older than 6 years 6 months, 32% of the children with dyskinetic CP reached the highest achievable age-equivalent score compared to 4% of the children with spastic CP. No significant difference in disability was found between CP-related variables (MACS levels, gestational age, epilepsy), with the exception of GMFCS which showed a significant difference in children aged younger than 6 years 6 months (p=0.043). Despite communication disabilities in children with severe CP, particularly in dyskinetic CP, spoken language comprehension may show no or only moderate delay. These findings emphasize the importance of introducing alternative and/or augmentative communication devices from early childhood. © 2014 Mac Keith Press.

Reliability and Construct Validity of the 6-Minute Racerunner Test in Children and Youth with Cerebral Palsy, GMFCS Levels III and IV.

PubMed

Bolster, Eline A M; Dallmeijer, Annet J; de Wolf, G Sander; Versteegt, Marieke; Schie, Petra E M van

2017-05-01

To determine the test-retest reliability and construct validity of a novel 6-Minute Racerunner Test (6MRT) in children and youth with cerebral palsy (CP) classified as Gross Motor Function Classification System (GMFCS) levels III and IV. The racerunner is a step-propelled tricycle. The participants were 38 children and youth with CP (mean age 11 y 2 m, SD 3 y 7 m; GMFCS III, n = 19; IV, n = 19). Racerunner capability was determined as the distance covered during the 6MRT on three occasions. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), and smallest detectable differences (SDD) were calculated to assess test-retest reliability. The ICC for tests 2 and 3 were 0.89 (SDD 37%; 147 m) for children in level III and 0.91 for children in level IV (SDD 52%; 118 m). When the average of two separate test occasions was used, the SDDs were reduced to 26% (104 m; level III) and 37% (118 m; level IV). For tests 1 to 3, the mean distance covered increased from 345 m (SD 148 m) to 413 m (SD 137 m) for children in level III, and from 193 m (SD 100 m) to 239 m (SD 148 m) for children in level IV. Results suggest high test-retest reliability. However, large SDDs indicate that a single 6MRT measurement is only useful for individual evaluation when large improvements are expected, or when taking the average of two tests. The 6MRT discriminated the distance covered between children and youth in levels III and IV, supporting construct validity.

Body mass index in ambulatory cerebral palsy patients.

PubMed

Feeley, Brian T; Gollapudi, Kiran; Otsuka, Norman Y

2007-05-01

Malnutrition is a common problem in children with cerebral palsy. Although malnutrition is often recognized in patients with severe cerebral palsy, it can be unrecognized in less severely affected patients. The consequences of malnutrition are serious, and include decreased muscle strength, poor immune status, and depressed cerebral functioning. Low body mass index has been used as a marker for malnutrition. The purpose of this study was to determine which patients in an ambulatory cerebral palsy patient population were at risk for low body mass index. A retrospective chart review was performed on 75 patients. Age, sex, height, weight, type of cerebral palsy, and functional status [gross motor functional classification system (GMFCS) level] was recorded from the chart. Descriptive statistics with bivariate and multivariate regression analyses were performed. Thirty-eight boys and 37 girls with an average age of 8.11 years were included in the study. Unique to our patient population, all cerebral palsy patients were independent ambulators. Patients with quadriplegic cerebral palsy had a significantly lower body mass index than those with diplegic and hemiplegic cerebral palsy. Patients with a GMFCS III had significantly lower body mass index than those with GMFCS I and II. When multivariate regression analysis to control for age and sex was performed, low body mass index remained associated with quadriplegic cerebral palsy and GMFCS III. Malnutrition is a common health problem in patients with cerebral palsy, leading to significant morbidity in multiple organ systems. We found that in an ambulatory cerebral palsy population, patients with lower functional status or quadriplegia had significantly lower body mass index, suggesting that even highly functioning ambulatory cerebral palsy patients are at risk for malnutrition.

Quality of Life and Health-Related Quality of Life of Adolescents with Cerebral Palsy

ERIC Educational Resources Information Center

Rosenbaum, Peter L.; Livingston, Michael H.; Palisano, Robert J.; Galuppi, Barbara E.; Russell, Dianne J.

2007-01-01

This study assessed quality of life (QOL) and health-related quality of life (HRQOL) of 203 adolescents with cerebral palsy (111 males, 92 females; mean age 16y [SD 1y 9mo]). Participants were classified using the Gross Motor Function Classification System (GMFCS), as Level I (n=60), Level II (n=33), Level III (n=28), Level IV (n=50), or Level V…

The Importance of Motor Functional Levels from the Activity Limitation Perspective of ICF in Children with Cerebral Palsy

ERIC Educational Resources Information Center

Mutlu, Akmer

2010-01-01

Our purpose in this study was to evaluate performance and capacity as defined by Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) from the "activity limitation" perspective of International Classification of Functioning, Disability, and Health (ICF) and to investigate the relationship between the…

Humeral external rotation handling by using the Bobath concept approach affects trunk extensor muscles electromyography in children with cerebral palsy.

PubMed

Grazziotin Dos Santos, C; Pagnussat, Aline S; Simon, A S; Py, Rodrigo; Pinho, Alexandre Severo do; Wagner, Mário B

2014-10-20

This study aimed to investigate the electromyographic activity of cervical and trunk extensors muscles in children with cerebral palsy during two handlings according to the Bobath concept. A crossover trial involving 40 spastic diplegic children was conducted. Electromyography (EMG) was used to measure muscular activity at sitting position (SP), during shoulder internal rotation (IR) and shoulder external rotation (ER) handlings, which were performed using the elbow joint as key point of control. Muscle recordings were performed at the fourth cervical (C4) and at the tenth thoracic (T10) vertebral levels. The Gross Motor Function Classification System (GMFCS) was used to assess whether muscle activity would vary according to different levels of severity. Humeral ER handling induced an increase on EMG signal of trunk extensor muscles at the C4 (P=0.007) and T10 (P<0.001) vertebral levels. No significant effects were observed between SP and humeral IR handling at C4 level; However at T10 region, humeral IR handling induced an increase of EMG signal (P=0.019). Humeral ER resulted in an increase of EMG signal at both levels, suggesting increase of extensor muscle activation. Furthermore, the humeral ER handling caused different responses on EMG signal at T10 vertebra level, according to the GMFCS classification (P=0.017). In summary, an increase of EMG signal was observed during ER handling in both evaluated levels, suggesting an increase of muscle activation. These results indicate that humeral ER handling can be used for diplegic CP children rehabilitation to facilitate cervical and trunk extensor muscles activity in a GMFCS level-dependent manner. Copyright © 2014 Elsevier Ltd. All rights reserved.

Congenital cytomegalovirus is associated with severe forms of cerebral palsy and female sex in a retrospective population-based study.

PubMed

Smithers-Sheedy, Hayley; Raynes-Greenow, Camille; Badawi, Nadia; McIntyre, Sarah; Jones, Cheryl A

2014-09-01

Congenital cytomegalovirus (cCMV) infection can result in poor outcomes including cerebral palsy (CP). The aim of this study was to describe the incidence and comorbidities of CP reported to the Australian Cerebral Palsy Register (ACPR) as attributed to cCMV infection. This was a retrospective population-based study. Cases were drawn from Australian state CP registers with population level ascertainment, 1993 to 2003 (n=2265; 56.4% males, Gross Motor Function Classification System [GMFCS] ratings available for Victorian cases only: 70% GMFCS levels I to III and 30% GMFCS levels IV to V). Clinical data were extracted and cases with cCMV reported as a known cause were compared with cases where cCMV was not reported. Children with cCMV (n=34; 12 males, 22 females; mean [SD] gestational age, 36.4 wk [4.4], range 24-41 wk) accounted for 1.5% of CP cases; 2.9 per 100,000 live births, (95% confidence intervals 1.9-3.9). When compared with CP cases where cCMV was not reported, proportionally, more CP cases with cCMV were born to younger mothers (p<0.001), were female (64% vs 43%, p=0.014), had spastic quadriplegia (73% vs 21%, p<0.001), required wheeled mobility i.e. GMFCS IV or V (78% vs 28%, p<0.001), had epilepsy (70% vs 30%, p<0.001), deafness (40% vs 2%, p<0.001), functional blindness (20% vs 5%, p<0.001), and severe communication impairment (71% vs 25%, p<0.001). cCMV is an important potentially preventable cause of CP and is associated with severe disability and female sex in cases reported to the ACPR. Future studies utilising prospective sample collection for cCMV testing are needed to confirm these findings. © 2014 Mac Keith Press.

Do the self-concept and quality of life decrease in CP patients? Focussing on the predictors of self-concept and quality of life.

PubMed

Soyupek, Feray; Aktepe, Evrim; Savas, Serpil; Askin, Ayhan

2010-01-01

To find out if the quality of life (QOL) and self-concept of the children with cerebral palsy (CP) was different from that of children without disability, to investigate predictive variables that could affect self-concept and QOL. A total of 40 children with CP and 46 age-matched peers were included. The baseline characteristics including sex, type of CP, the level of disability according to Gross Motor Function Classification System (GMFCS) were recorded. Education levels of both children and parents, demographic features of parents, features of living area, usage of devices and associated impairments were filled out. Self-concept was measured using Piers-Harris Self-concept (PH) Scale. Quality of life was measured by Pediatric Quality of Life Inventory 4.0 (PedsQL). The physical and psychosocial health subscale scores of PedsQL (P-PedsQL and PS-PedsQL) were recorded. Significant differences in mean scores favouring the control group were found for PH scale, PedsQL scale (p < 0.001). P-PedsQL and PS-PedsQL of the CP group were lower than the control group (p < 0.001). PS-PedsQL report was significant predictor of self-concept. The presence of incontinence and GMFCS level were significant predictors of PedsQL and PPedsQL, respectively. Self-concept and QOL of the CP children were lower than the children without CP. Presence of incontinence, self-concept rating and GMFCS level were important to predict domains of QOL.

Depression and anxiety levels in mothers of children with cerebral palsy: a controlled study.

PubMed

Yilmaz, H; Erkin, G; Nalbant, L

2013-12-01

Studies investigating depression and anxiety levels in mothers of children with CP and related factors are limited, and controversial findings are reported in these studies. The study was aimed to determine depression and anxiety levels in mothers of children with cerebral palsy (CP) and to define factors related to depression and anxiety levels. A descriptive study. Outpatient physical medicine and rehabilitation clinic of an education and research hospital. The study was composed of two groups: group 1, 116 mothers of children with CP and group 2, 114 mothers of healthy children. Mothers of children with spastic-type CP were included into group 1. Functional levels in children with CP were investigated with The Gross Motor Function Classification System (GMFCS). Depression levels of mothers in both groups were assessed with Beck Depression Inventory (BDI), and anxiety levels with Beck Anxiety Inventory (BAI). BDI and BAI scores were statistically and significantly higher in group 1, compared to group 2. Among mothers in group 1, a positive correlation was determined between GMFCS score, and depression and anxiety levels. However, no correlation was detected between depression and anxiety levels, and body involvement of CP, education status, age and economic level among patients. In logistic regression analysis, the most significant risk factors of depressive symptoms were detected to be GMFCS score and speech defects. Our findings indicate that depression and anxiety levels of mothers with CP children are higher than those with healthy children and associated with speech defects and functional disability levels in children with CP. Healthcare professionals should take into account that depression and anxiety levels may be higher in mothers of children with CP. For an effective rehabilitation program related to children with CP, depression and anxiety levels in mothers of such children should be taken into account, and mothers should closely be followed and if necessary, psychologically supported.

Comparisons of severity classification systems for oropharyngeal dysfunction in children with cerebral palsy: Relations with other functional profiles.

PubMed

Goh, Yu-Ra; Choi, Ja Young; Kim, Seon Ah; Park, Jieun; Park, Eun Sook

2018-01-01

This study aimed to investigate the relationships between various classification systems assessing the severity of oropharyngeal dysphagia and communication function and other functional profiles in children with cerebral palsy (CP). This is a prospective, cross-sectional, study in a university-affiliated, tertiary-care hospital. We recruited 151 children with CP (mean age 6.11 years, SD 3.42, range 3-18yr). The Eating and Drinking Ability Classification System (EDACS) and the dysphagia scales of Functional Oral Intake Scale (FOIS), Swallow Function Scales (SFS), and Food Intake Level Scale (FILS) were used. The Communication Function Classification System (CFCS) and Viking Speech Scale (VSS) were employed to classify communication function and speech intelligibility, respectively. The Pediatric Evaluation of Disability Inventory (PEDI) with the Gross Motor Function Classification System (GFMCS) and the Manual Ability Classification System (MACS) level were also assessed. Spearman correlation analysis to investigate the associations between measures and univariate and multivariate logistic regression models to identify significant factors were used. Median GMFCS level of participants was III (interquartile range II-IV). Significant dysphagia based on EDACS level III-V was noted in 23 children (15.2%). There were strong to very strong relationships between the EDACS level with the dysphagia scales. The EDACS presented strong associations with MACS, CFCS, and VSS, a moderate association with GMFCS level, and a moderate to strong association with each domain of the PEDI. In multivariate analysis, poor functioning in EDACS were associated with poor functioning in gross motor and communication functions. Copyright © 2017. Published by Elsevier Ltd.

Postural asymmetries in young adults with cerebral palsy.

PubMed

Rodby-Bousquet, Elisabet; Czuba, Tomasz; Hägglund, Gunnar; Westbom, Lena

2013-11-01

The purpose was to describe posture, ability to change position, and association between posture and contractures, hip dislocation, scoliosis, and pain in young adults with cerebral palsy (CP). Cross-sectional data of 102 people (63 males, 39 females; age range 19-23 y, median 21 y) out of a total population with CP was analysed in relation to Gross Motor Function Classification System (GMFCS) levels I (n=38), II (n=21), III (n=13), IV (n=10), and V (n=20). The CP subtypes were unilateral spastic (n=26), bilateral spastic (n=45), ataxic (n=12), and dyskinetic CP (n=19). The Postural Ability Scale was used to assess posture. The relationship between posture and joint range of motion, hip dislocation, scoliosis, and pain was analysed using logistic regression and Spearman's correlation. At GMFCS levels I to II, head and trunk asymmetries were most common; at GMFCS levels III to V postural asymmetries varied with position. The odds ratios (OR) for severe postural asymmetries were significantly higher for those with scoliosis (OR=33 sitting), limited hip extension (OR=39 supine), or limited knee extension (OR=37 standing). Postural asymmetries correlated to hip dislocations: supine (r(s) =0.48), sitting (r(s) =0.40), standing (r(s) =0.41), and inability to change position: supine (r(s) =0.60), sitting (r(s) =0.73), and standing (r(s) =0.64). Postural asymmetries were associated with scoliosis, hip dislocations, hip and knee contractures, and inability to change position. © 2013 The Authors. Developmental Medicine & Child Neurology published by John Wiley & Sons Ltd on behalf of Mac Keith Press.

Postural asymmetries in young adults with cerebral palsy

PubMed Central

Rodby-Bousquet, Elisabet; Czuba, Tomasz; Hägglund, Gunnar; Westbom, Lena

2013-01-01

Aim The purpose was to describe posture, ability to change position, and association between posture and contractures, hip dislocation, scoliosis, and pain in young adults with cerebral palsy (CP). Methods Cross-sectional data of 102 people (63 males, 39 females; age range 19–23y, median 21y) out of a total population with CP was analysed in relation to Gross Motor Function Classification System (GMFCS) levels I (n=38), II (n=21), III (n=13), IV (n=10), and V (n=20). The CP subtypes were unilateral spastic (n=26), bilateral spastic (n=45), ataxic (n=12), and dyskinetic CP (n=19). The Postural Ability Scale was used to assess posture. The relationship between posture and joint range of motion, hip dislocation, scoliosis, and pain was analysed using logistic regression and Spearman’s correlation. Results At GMFCS levels I to II, head and trunk asymmetries were most common; at GMFCS levels III to V postural asymmetries varied with position. The odds ratios (OR) for severe postural asymmetries were significantly higher for those with scoliosis (OR=33 sitting), limited hip extension (OR=39 supine), or limited knee extension (OR=37 standing). Postural asymmetries correlated to hip dislocations: supine (rs=0.48), sitting (rs=0.40), standing (rs=0.41), and inability to change position: supine (rs=0.60), sitting (rs=0.73), and standing (rs=0.64). Conclusions Postural asymmetries were associated with scoliosis, hip dislocations, hip and knee contractures, and inability to change position. This article is commented on by Novak on page 974 of this issue. PMID:23834239

Ambulatory Physical Activity Performance in Youth With Cerebral Palsy and Youth Who Are Developing Typically

PubMed Central

Bjornson, Kristie F; Belza, Basia; Kartin, Deborah; Logsdon, Rebecca; McLaughlin, John F

2007-01-01

Background and Purpose Assessment of walking activity in youth with cerebral palsy (CP) has traditionally been “capacity-based.” The purpose of this study was to describe the day-to-day ambulatory activity “performance” of youth with CP compared with youth who were developing typically. Subjects Eighty-one youth with CP, aged 10 to 13 years, who were categorized as being in Gross Motor Function Classification System (GMFCS) levels I to III and 30 age-matched youth who were developing typically were recruited. Methods Using a cross-sectional design, participants wore the StepWatch monitor for 7 days while documenting average daily total step counts, percentage of all time active, ratio of medium to low activity levels, and percentage of time at high activity levels. Results The youth with CP demonstrated significantly lower levels of all outcomes than the comparison group. Discussion and Conclusion Daily walking activity and variability decreased as functional walking level (GMFCS level) decreased. Ambulatory activity performance within the context of the daily life for youth with CP appears valid and feasible as an outcome for mobility interventions in CP. PMID:17244693

Validation of Accelerometer Cut-Points in Children With Cerebral Palsy Aged 4 to 5 Years.

PubMed

Keawutan, Piyapa; Bell, Kristie L; Oftedal, Stina; Davies, Peter S W; Boyd, Roslyn N

2016-01-01

To derive and validate triaxial accelerometer cut-points in children with cerebral palsy (CP) and compare these with previously established cut-points in children with typical development. Eighty-four children with CP aged 4 to 5 years wore the ActiGraph during a play-based gross motor function measure assessment that was video-taped for direct observation. Receiver operating characteristic and Bland-Altman plots were used for analyses. The ActiGraph had good classification accuracy in Gross Motor Function Classification System (GMFCS) levels III and V and fair classification accuracy in GMFCS levels I, II, and IV. These results support the use of the previously established cut-points for sedentary time of 820 counts per minute in children with CP aged 4 to 5 years across all functional abilities. The cut-point provides an objective measure of sedentary and active time in children with CP. The cut-point is applicable to group data but not for individual children.

An intensive virtual reality program improves functional balance and mobility of adolescents with cerebral palsy.

PubMed

Brien, Marie; Sveistrup, Heidi

2011-01-01

To examine functional balance and mobility in adolescents with cerebral palsy classified at Gross Motor Function Classification System (GMFCS) level I following an intensive short-duration virtual reality (VR) intervention. Single-subject, multiple-baseline design with 4 adolescents. Outcomes included the Community Balance and Mobility Scale (CB&M), the 6-Minute Walk Test (6MWT), the Timed Up and Down Stairs, and the Gross Motor Function Measure Dimension E. Assessments were recorded 3 to 6 times at baseline, 5 times during intervention, and 4 times at follow-up. Daily 90-minute VR intervention was completed for 5 consecutive days. Visual, statistical, and clinical significance analyses were used. Statistically significant improvements were shown in all adolescents on CB&M and 6MWT. True change was recorded in all for the CB&M and in 3 for the 6MWT. Functional balance and mobility in adolescents with cerebral palsy classified at GMFCS level I improve with intense, short duration VR intervention, and changes are maintained at 1-month posttraining.

Bone mineral density and insulin-like growth factor-1 in children with spastic cerebral palsy.

PubMed

Nazif, H; Shatla, R; Elsayed, R; Tawfik, E; Osman, N; Korra, S; Ibrahim, A

2017-04-01

Children with cerebral palsy (CP) have significant decrease linear growth rate and low bone mineral density (BMD). This study is to evaluate BMD in children with CP and its relation to the levels of insulin-like growth factor-1 (IGF-1). This cross-sectional study was carried out on 58 children suffering from spastic CP with the age range 4-12 years compared to 19 controls. All assessed by dual energy x-ray absorptiometry (DXA) to measure BMD, serum level of IGF-1, and serum vitamin D. The patients were classified according to their GMFCS. Fractures were reported in seven (12.1%) of cases. Our study demonstrated that, IGF-1 level and BMD decrease in correlation with the severity of CP. IGF-1correlates positively with serum vitamin D, BMI, and BMD. CP children with severe GMFCS level or who use anticonvulsive drugs are at a high risk for low BMD and low levels of IGF-1. Both BMD and IGF-1 were significantly in low children with spastic CP; IGF-1 negatively correlates with the severity of osteopenia in children with spastic. Children with CP who are not independently ambulant or with severe GMFCS level or who use anticonvulsive drugs are at a high risk for developing low BMD.

Assessment of oral and dental health status in children with cerebral palsy: An exploratory study

PubMed Central

Sedky, Nabila A

2018-01-01

Objectives: Evaluating oral and dental health status in Egyptian children with cerebral palsy (CP) in relation to gross motor skills and types of CP. Methods: A Cross-sectional study was conducted at el-Shatby Hospital for Children, Alexandria-Egypt. Oral examination for 62 children with CP between the age ranges 3–12 years was performed and decay missing filling-tooth/decay filling-tooth (DMFT/dft), simplified oral hygiene index (OHI-S), and modified gingival index (MGI) indices were charted. Maxillofacial defects, dental problems and drooling of saliva were assessed. Children’s CP type, motor milestone, and gross motor skills were determined. All statistical analyses were performed at P < 0.05 and 0.01. Results: About 84.0% of children had spastic quadriplegia, 41.9% were sit supported, 32.3% had Level IV gross motor function classification system (GMFCS), and 29.0% had Level V. No maxillofacial defects, 14.5% had dentine exposure >1/3 of the surface, and 22.6% had frequent/severe drooling saliva. Caries prevalence comprised 54.8%, 53.2% had poor oral hygiene (OHI-S index), and 43.6% had severe gingival inflammation (MGI index). The first best predictor variable for dft was “Motor Milestone.” GMFCS (Level IV and V) was the first best predictor variable for DMFT, OHI-S, and MGI indices. Conclusion: The majority of children had dental caries, poor oral hygiene, and severe gingival inflammation. Children who were sit supported had no neck support and stand supported were suffering from dental caries (dft) more than children who were sitting and walking alone. Children with Levels IV/V GMFCS were prone to have dental caries (DMFT), susceptible to suffer from bad oral hygiene, and older children experiencing severe gingivitis more than younger ones. PMID:29623011

Morphometric analysis of acetabular dysplasia in cerebral palsy: three-dimensional CT study.

PubMed

Gose, Shinichi; Sakai, Takashi; Shibata, Toru; Murase, Tsuyoshi; Yoshikawa, Hideki; Sugamoto, Kazuomi

2009-12-01

Three-dimensional computed tomography (3D-CT) eliminates the positioning errors and allows the clinician to more accurately assess the radiographic parameters present. To elucidate the 3D geometry of the acetabulum and the extent of hip subluxation/dislocation in patients with cerebral palsy (CP), quantitative morphometric analysis was performed using 3D-CT data. We evaluated 150 hips in 75 patients with bilateral spastic CP. The mean age of the patients was 5.4 years (range: 2.7 to 6.9 y). The fitting plane of the ilium was projected onto the coronal plane and then onto the sagittal plane, and then the angle formed with a horizontal line was defined as CTalpha (the lateral opening angle) and CTbeta (the sagittal inclination angle), respectively. The center of the acetabulum and the femoral head were defined, and the distance between these centers was divided by the femoral head diameter, defined as CT migration percentage (CTMP, %). In 123 (82%) of the 150 hips, the femoral head center was located posteriorly, superiorly, and laterally relative to the acetabular center. Large CTalpha cases tended to show large CTMP. CTalpha and CTMP were significantly larger in the cases with Gross Motor Functional Classification System (GMFCS) level IV/V and spastic quadriplegia, than in the cases with GMFCS level II/III and spastic diplegia. CTbeta showed significant correlation with the acetabular defect on the lateral 3D reconstructed images. Three-dimensional acetabular geometry and migration percentage in CP patients can be analyzed quantitatively using 3D-CT regardless of the abnormal spastic posture. The extent of acetabular dysplasia and subluxation is more severe in patients with GMFCS level IV/V and spastic quadriplesia. Level 4.

Sex differences in cerebral palsy incidence and functional ability: a total population study.

PubMed

Chounti, A; Hägglund, G; Wagner, P; Westbom, L

2013-07-01

To describe gender difference in a total population of children with cerebral palsy (CP), related to subtype, gross and fine motor function, and to compare CP incidence trends in girls and boys. All 590 children with CP born in southern Sweden 1990-2005 were included. CP subtype was classified according to the Surveillance of Cerebral Palsy in Europe, gross motor function according to Gross Motor Function Classification System (GMFCS) and manual ability according to Manual Ability Classification System (MACS). Trends in CP incidence by birth year were analysed using Poisson regression modelling. There was a male predominance in all levels of GMFCS except level II, in all levels of MACS and in all CP subtypes except ataxic CP. There was no statistically significant difference between males and females regarding gross motor function or manual ability. The CP incidence trends in boys compared with girls did not change during the period 1990-2005. No equalization was detected in the incidence of CP between girls and boys during recent years in this total population. We could not confirm any consistent sex difference in motor function levels. Male sex is a risk factor for CP. ©2013 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

Measurement of Habitual Physical Activity Performance in Adolescents with Cerebral Palsy: A Systematic Review

ERIC Educational Resources Information Center

Clanchy, Kelly M.; Tweedy, Sean M.; Boyd, Roslyn

2011-01-01

Aim: This systematic review compares the validity, reliability, and clinical use of habitual physical activity (HPA) performance measures in adolescents with cerebral palsy (CP). Method: Measures of HPA across Gross Motor Function Classification System (GMFCS) levels I-V for adolescents (10-18y) with CP were included if at least 60% of items…

Are sporadic fidgety movements as clinically relevant as is their absence?

PubMed

Einspieler, Christa; Yang, Hong; Bartl-Pokorny, Katrin D; Chi, Xia; Zang, Fei-Fei; Marschik, Peter B; Guzzetta, Andrea; Ferrari, Fabrizio; Bos, Arend F; Cioni, Giovanni

2015-04-01

Infants with normal fidgety movements at 3 to 5 months after term are very likely to show neurologically normal development, while the absence of fidgety movements is an early marker for an adverse neurological outcome, mainly cerebral palsy (CP). The clinical significance of so-called sporadic fidgety movements (i.e., fidgety movements occur isolated in a few body parts and are of 1- to 3-second-duration) is not yet known. Our objective was to determine whether infants who had developed CP and had sporadic fidgety movements have a better outcome than infants who did not have fidgety movements. Longitudinal study. Retrospective analysis of prospectively collected data. 61 infants who developed CP (46 male, 15 female; 29 infants born preterm; videoed for the assessment of movements and postures at 9 to 16 weeks post-term age). The Gross Motor Function Classification System (GMFCS) was applied at 3 to 5 years of age. There was no difference between children diagnosed with CP who had sporadic fidgety movements at 9 to 16 weeks post-term age (n = 9) and those who never developed fidgety movements (n = 50) with regard to their functional mobility and activity limitation at 3 to 5 years of age. One infant had normal FMs and developed unilateral CP, GMFCS Level I; the remaining infant had abnormal FMs and developed bilateral CP, GMFCS Level II. There is no evidence that the occurrence of occasional isolated fidgety bursts indicates a milder type of CP. Copyright © 2015. Published by Elsevier Ireland Ltd.

Fundamental movement skills testing in children with cerebral palsy.

PubMed

Capio, Catherine M; Sit, Cindy H P; Abernethy, Bruce

2011-01-01

To examine the inter-rater reliability and comparative validity of product-oriented and process-oriented measures of fundamental movement skills among children with cerebral palsy (CP). In total, 30 children with CP aged 6 to 14 years (Mean = 9.83, SD = 2.5) and classified in Gross Motor Function Classification System (GMFCS) levels I-III performed tasks of catching, throwing, kicking, horizontal jumping and running. Process-oriented assessment was undertaken using a number of components of the Test of Gross Motor Development (TGMD-2), while product-oriented assessment included measures of time taken, distance covered and number of successful task completions. Cohen's kappa, Spearman's rank correlation coefficient and tests to compare correlated correlation coefficients were performed. Very good inter-rater reliability was found. Process-oriented measures for running and jumping had significant associations with GMFCS, as did seven product-oriented measures for catching, throwing, kicking, running and jumping. Product-oriented measures of catching, kicking and running had stronger associations with GMFCS than the corresponding process-oriented measures. Findings support the validity of process-oriented measures for running and jumping and of product-oriented measures of catching, throwing, kicking, running and jumping. However, product-oriented measures for catching, kicking and running appear to have stronger associations with functional abilities of children with CP, and are thus recommended for use in rehabilitation processes.

Treatment of Cerebral Palsy with Stem Cells: A Report of 17 Cases.

PubMed

Abi Chahine, Nassim H; Wehbe, Tarek W; Hilal, Ramzi A; Zoghbi, Victoria V; Melki, Alia E; Habib, Emil B Bou

2016-05-30

Cerebral Palsy (CP) is a disabling condition that affects a child's life and his/her family irreversibly. It is usually a non-progressive condition but improvement over time is rarely seen. The condition can be due to prenatal hypoxia, metabolic, genetic, infectious, traumatic or other causes. It is therefore a heterogeneous group that results in functional motor disability associated with different degrees of cognitive abnormalities. There are no treatments that can cure or even improve CP and the best available approach aims at functional, social and nutritional supportive care and counseling. In this paper, we report 17 sequential patients with CP treated with intrathecal administration of Bone Marrow Mononuclear Cells (BMMC). All patients had an uneventful post-injection course with 73% of the evaluable patients treated having a good response using the Gross Motor Function Classification System (GMFCS). The average improvement was 1.3 levels on the GMFCS with cognitive improvements as well.

Training effects of wheelchair dance on aerobic fitness in bedridden individuals with severe athetospastic cerebral palsy rated to GMFCS level V.

PubMed

Terada, Kyoko; Satonaka, Ayako; Terada, Yasuto; Suzuki, Nobuharu

2017-10-01

There were few studies about training effects of wheelchair dance on aerobic fitness in the bedridden individuals with severe cerebral palsy for whom the traditional maximal or submaximal exercise tests were not applicable. As the oxygen pulse (O2P), the oxygen uptake divided by the heart rate, is regarded to be a relative measure of stroke volume and the O2P correlates to peak oxygen uptake, we would be able to assess the training effects of wheelchair dance on aerobic fitness in those individuals measuring O2P. To study training effects of wheelchair dance on aerobic fitness in bedridden individuals with severe athetospastic cerebral palsy. Pre-post study design. A laboratory and a community care center. Bedridden individuals with athetospastic cerebral palsy rated to Gross Motor Function Classification System (GMFCS) level V (N.=6). The O2P was compared between during the rest, the waltz, and the jive at the baseline, the 3rd, the 6th, and the 12th month of the intervention of wheelchair dance 6 to 15 minutes at a time, 2 days a week or more. Paired Student's t-test showed that O2P during the waltz and the jive was significantly increased compared with that during the rest at the 6th and the 12th month, and O2P during the jive was also significantly increased compared with that during the rest at the 3rd, the 6th, and the 12th month of the intervention period. This is the first study that shows wheelchair dance may possibly increase aerobic fitness in bedridden individuals with severe athetospastic cerebral palsy rated GMFCS level V. Future studies with a larger sample will be warranted to prove the claim.

Ambulatory Activity of Children with Cerebral Palsy: Which Characteristics Are Important?

ERIC Educational Resources Information Center

van Wely, Leontien; Becher, Jules G.; Balemans, Astrid C. J.; Dallmeijer, Annet J.

2012-01-01

Aim: To assess ambulatory activity of children with cerebral palsy (CP), aged 7 to 13 years, and identify associated characteristics. Method: Sixty-two children with spastic CP (39 males, 23 females; mean age 10y 1mo, SD 1y 8mo; age range 7-13y), classified as Gross Motor Function Classification System (GMFCS) levels I to III, participated.…

Motor function domains in alternating hemiplegia of childhood.

PubMed

Masoud, Melanie; Gordon, Kelly; Hall, Amanda; Jasien, Joan; Lardinois, Kara; Uchitel, Julie; Mclean, Melissa; Prange, Lyndsey; Wuchich, Jeffrey; Mikati, Mohamad A

2017-08-01

To characterize motor function profiles in alternating hemiplegia of childhood, and to investigate interrelationships between these domains and with age. We studied a cohort of 23 patients (9 males, 14 females; mean age 9y 4mo, range 4mo-43y) who underwent standardized tests to assess gross motor, upper extremity motor control, motor speech, and dysphagia functions. Gross Motor Function Classification System (GMFCS), Gross Motor Function Measure-88 (GMFM-88), Manual Ability Classification System (MACS), and Revised Melbourne Assessment (MA2) scales manifested predominantly mild impairments; motor speech, moderate to severe; Modified Dysphagia Outcome and Severity Scale (M-DOSS), mild-to moderate deficits. GMFCS correlated with GMFM-88 scores (Pearson's correlation, p=0.002), MACS (p=0.038), and MA2 fluency (p=0.005) and accuracy (p=0.038) scores. GMFCS did not correlate with motor speech (p=0.399), MA2 dexterity (p=0.247), range of motion (p=0.063), or M-DOSS (p=0.856). Motor speech was more severely impaired than the GMFCS (p<0.013). There was no correlation between any of the assessment tools and age (p=0.210-0.798). Our data establish a detailed profile of motor function in alternating hemiplegia of childhood, argue against the presence of worse motor function in older patients, identify tools helpful in evaluating this population, and identify oropharyngeal function as the more severely affected domain, suggesting that brain areas controlling this function are more affected than others. © 2017 Mac Keith Press.

Gait pathology subtypes are not associated with self-reported fall frequency in children with cerebral palsy.

PubMed

Boyer, Elizabeth R; Patterson, Aleksys

2018-05-05

Trips and falls are common concerns reported by parents of children with cerebral palsy. Specific gait pathologies (excessive internal hip rotation, intoeing, and stiff knee gait) are anecdotally associated with higher rates of falls. Is fall frequency higher for the aforementioned gait pathologies? Parent-reported fall frequency from 1063 children with cerebral palsy who also had a three-dimensional gait analysis was retrospectively reviewed. Frequency of 10 common gait pathologies was determined and fall frequency for the gait pathologies of interest were compared to matched control groups. Possible effects of Gross Motor Functional Classification System (GMFCS) level and age on fall frequency were also assessed and matched in the control group, as appropriate. In general, parent-reported fall frequency increased from GMFCS level I to II and then decreased until level IV. Moreover, younger children tended to report greater fall frequency, though children who reported never falling were of similar age as those who reported weekly falls, resulting in an inverted-U shaped relationship. Children with cerebral palsy who walked with excessive internal hip rotation, excessive intoeing, or stiff knee gait did not report increased fall frequencies compared to other children with cerebral palsy matched on GMFCS level and age that did not walk with those gait patterns. Approximately 35% of children reported never falling, 35% reported falling daily, and 30% reported falling monthly or weekly for each gait pattern. Therefore, elevated fall frequency appears to be a generic problem for most children with CP rather than a function of a specific gait pattern. Clinicians should be aware of these relationships, or lack thereof, when trying to decipher the cause of a child's falling and when determining appropriate interventions. Future studies may seek to more objectively quantify fall frequency, as self-report is the main limitation of this study. Copyright © 2018 Elsevier B.V. All rights reserved.

The Quality Function Measure: reliability and discriminant validity of a new measure of quality of gross motor movement in ambulatory children with cerebral palsy.

PubMed

Wright, F Virginia; Rosenbaum, Peter; Fehlings, Darcy; Mesterman, Ronit; Breuer, Ute; Kim, Marie

2014-08-01

Optimizing movement quality is a common rehabilitation goal for children with cerebral palsy (CP). The new Quality Function Measure (QFM)--a revision of the Gross Motor Performance Measure (GMPM)--evaluates five attributes: Alignment, Co-ordination, Dissociated movement, Stability, and Weight-shift, for the Gross Motor Function Measure (GMFM) Stand and Walk/Run/Jump items. This study evaluated the reliability and discriminant validity of the QFM. Thirty-three children with CP (17 females, 16 males; mean age 8y 11mo, SD 3y 1mo; Gross Motor Function Classification System [GMFCS] levels I [n=17], II [n=7], III [n=9]) participated in reliability testing. Each did a GMFM Stand/Walk assessment, repeated 2 weeks later. Both GMFM assessments were videotaped. A physiotherapist assessor pair independently scored the QFM from an assigned child's GMFM video. GMFM data from 112 children. That is, (GMFCS I [n=38], II [n=27], III [n=47]) were used for discriminant validity evaluation. QFM mean scores varied from 45.0% (SD 27.2; Stability) to 56.2% (SD 27.5; Alignment). Reliability was excellent across all attributes: intraclass correlation coefficients (ICCs) ≥0.97 (95% confidence intervals [CI] 0.95-0.99), interrater ICCs ≥0.89 (95% CI 0.80-0.98), and test-retest ICCs ≥0.90 (95% CI 0.79-0.99). QFM discriminated qualitative attributes of motor function among GMFCS levels (maximum p<0.05). The QFM is reliable and valid, making it possible to assess how well young people with CP move and what areas of function to target to enhance quality of motor control. © 2014 Mac Keith Press.

Treatment of Cerebral Palsy with Stem Cells: A Report of 17 Cases

PubMed Central

Abi Chahine, Nassim H.; Wehbe, Tarek W.; Hilal, Ramzi A.; Zoghbi, Victoria V.; Melki, Alia E.; Bou Habib, Emil B.

2016-01-01

Cerebral Palsy (CP) is a disabling condition that affects a child’s life and his/her family irreversibly. It is usually a non-progressive condition but improvement over time is rarely seen. The condition can be due to prenatal hypoxia, metabolic, genetic, infectious, traumatic or other causes. It is therefore a heterogeneous group that results in functional motor disability associated with different degrees of cognitive abnormalities. There are no treatments that can cure or even improve CP and the best available approach aims at functional, social and nutritional supportive care and counseling. In this paper, we report 17 sequential patients with CP treated with intrathecal administration of Bone Marrow Mononuclear Cells (BMMC). All patients had an uneventful post-injection course with 73% of the evaluable patients treated having a good response using the Gross Motor Function Classification System (GMFCS). The average improvement was 1.3 levels on the GMFCS with cognitive improvements as well. PMID:27426090

An innovative cycling exergame to promote cardiovascular fitness in youth with cerebral palsy.

PubMed

Knights, Shannon; Graham, Nicholas; Switzer, Lauren; Hernandez, Hamilton; Ye, Zi; Findlay, Briar; Xie, Wen Yan; Wright, Virginia; Fehlings, Darcy

2016-01-01

To evaluate the effects of an internet-platform exergame cycling programme on cardiovascular fitness of youth with cerebral palsy (CP). In this pilot prospective case series, eight youth with bilateral spastic CP, Gross Motor Functional Classification System (GMFCS) level III, completed a six-week exergame programme. Outcomes were obtained at baseline and post-intervention. The primary outcome measure was the GMFCS III-specific shuttle run test (SRT-III). Secondary outcomes included health-related quality of life (HQL) as measured by the KIDSCREEN-52 questionnaire, six-minute walk test, Wingate arm cranking test and anthropomorphic measurements. There were significant improvements in the SRT-III (t = -2.5, p = 0.04, d = 0.88) post-intervention. There were no significant changes in secondary outcomes. An exergame cycling programme may lead to improvement in cardiovascular fitness in youth with CP. This study was limited by small sample size and lack of a comparison group. Future research is warranted.

Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children.

PubMed

D'Aquino, Daniel; Moussa, Ahmad A; Ammar, Amr; Ingale, Harshal; Vloeberghs, Michael

2018-04-01

Selective dorsal rhizotomy (SDR) has been established as an effective surgical treatment for spastic diplegia. The applicability of SDR to the full spectrum of spastic cerebral palsy and the durability of its therapeutic effects remain under investigation. There are currently limited data in the literature regarding efficacy and outcomes following SDR in Gross Motor Function Classification System (GMFCS) IV and V patients. Intrathecal baclofen has traditionally been the surgical treatment of choice for these patients. When utilised primarily as a treatment for the relief of spasticity, it is proposed that SDR represents a rational and effective treatment option for this patient group. We report our outcomes of SDR performed on children with severe cerebral palsy (GMFCS grade IV and V). The commensurate improvement in upper as well as lower limb spasticity is highlighted. Apparent benefit to urological function following SDR in this patient group is also discussed. A retrospective review of prospectively collected data for 54 paediatric patients with severe cerebral palsy (GMFCS IV-V) who received SDR plus specialised physiotherapy. Mean age was 10.2 years (range, 3.0-19.5). SDR guided by electrophysiological monitoring was performed by a single experienced neurosurgeon. All subjects received equivalent physiotherapy. The primary outcome measure was change to the degree of spasticity following SDR. Spasticity of upper and lower limb muscle groups were quantified and standardised using the Ashworth score. Measures were collected at baseline and at 2-, 8- and 14-month postoperative intervals. In addition, baseline and 6-month postoperative urological function was also evaluated as a secondary outcome measure. The mean lower limb Ashworth score at baseline was 3.2 (range, 0-4). Following SDR, significant reduction in lower limb spasticity scores was observed at 2 months and maintained at 8 and 14 months postoperatively (Wilcoxon rank, p < 0.001). The mean reduction at 2, 8 and 14 months was 3.0, 3.2 and 3.2 points respectively (range, 1-4), confirming a sustained improvement of spasticity over a 1-year period of follow-up. Significant reduction in upper limb spasticity scores following SDR was also observed (mean, 2.9; Wilcoxon rank, p < 0.001). Overall, the improvement to upper and lower limb tone following SDR-generally to post-treatment Ashworth scores of 0-was clinically and statistically significant in GMFCS IV and V patients. Urological assessment identified pre-existing bladder dysfunction in 70% and 90% of GMFCS IV and V patients respectively. Following SDR, improvement in urinary continence was observed in 71% of affected GMFCS IV and 42.8% of GMFCS V patients. No serious postoperative complications were identified. We conclude that SDR is safe and-in combination with physiotherapy-effectively reduces spasticity in GMFCS grade IV and V patients. Our series suggests that spastic quadriplegia is effectively managed with significant improvements in upper limb spasticity that are commensurate with those observed in lower limb muscle groups. These gains are furthermore sustained more than a year postoperatively. In light of these findings, we propose that SDR constitutes an effective treatment option for GMFCS IV and V patients and a rational alternative to intrathecal baclofen.

Hip health at skeletal maturity: a population-based study of young adults with cerebral palsy.

PubMed

Wawrzuta, Joanna; Willoughby, Kate L; Molesworth, Charlotte; Ang, Soon Ghee; Shore, Benjamin J; Thomason, Pam; Graham, H Kerr

2016-12-01

We studied 'hip health' in a population-based cohort of adolescents and young adults with cerebral palsy to investigate associations between hip morphology, pain, and gross motor function. Ninety-eight young adults (65 males, 33 females) from the birth cohort were identified as having developed hip displacement (migration percentage >30) and were reviewed at a mean age of 18 years 10 months (range 15-24y). Hip morphology was classified using the Melbourne Cerebral Palsy Hip Classification Scale (MCPHCS). Severity and frequency of pain were recorded using Likert scales. Gross motor function was classified by the Gross Motor Function Classification System (GMFCS). Hip pain was reported in 72% of participants. Associations were found between pain scores and both hip morphology and GMFCS. Median pain severity score for MCPHCS grades 1 to 4 was 2 (interquartile range [IQR] 1.0-3.0) compared to 7 (IQR 6.0-8.0) for grades 5 and 6 (severe subluxation or dislocation). Hip surveillance and access to surgery were associated with improved hip morphology and less pain. Poor hip morphology at skeletal maturity was associated with high levels of pain. Limited hip surveillance and access to surgery, rather than GMFCS, was associated with poor hip morphology. The majority of young adults who had access to hip surveillance, and preventive and reconstructive surgery, had satisfactory hip morphology at skeletal maturity and less pain. © 2016 Mac Keith Press.

Validation of Gujarati Version of ABILOCO-Kids Questionnaire.

PubMed

Diwan, Shraddha; Diwan, Jasmin; Patel, Pankaj; Bansal, Ankita B

2015-10-01

ABILOCO-Kids is a measure of locomotion ability for children with cerebral palsy (CP) aged 6 to 15 years & is available in English & French. To validate the Gujarati version of ABILOCO-Kids questionnaire to be used in clinical research on Gujarati population. ABILOCO-Kids questionnaire was translated into Gujarati from English using forward-backward-forward method. To ensure face & content validity of Gujarati version using group consensus method, each item was examined by group of experts having mean experience of 24.62 years in field of paediatric and paediatric physiotherapy. Each item was analysed for content, meaning, wording, format, ease of administration & scoring. Each item was scored by expert group as either accepted, rejected or accepted with modification. Procedure was continued until 80% of consensus for all items. Concurrent validity was examined on 55 children with Cerebral Palsy (6-15 years) of all Gross Motor Functional Classification System (GMFCS) level & all clinical types by correlating score of ABILOCO-Kids with Gross Motor Functional Measure & GMFCS. In phase 1 of validation, 16 items were accepted as it is; 22 items accepted with modification & 3 items went for phase 2 validation. For concurrent validity, highly significant positive correlation was found between score of ABILOCO-Kids & total GMFM (r=0.713, p<0.005) & highly significant negative correlation with GMFCS (r= -0.778, p<0.005). Gujarati translated version of ABILOCO-Kids questionnaire has good face & content validity as well as concurrent validity which can be used to measure caregiver reported locomotion ability in children with CP.

Therapy service use in children and adolescents with cerebral palsy: An Australian perspective.

PubMed

Meehan, Elaine; Harvey, Adrienne; Reid, Susan M; Reddihough, Dinah S; Williams, Katrina; Crompton, Kylie E; Omar, Suhaila; Scheinberg, Adam

2016-03-01

The aim of this study was to describe the patterns of therapy service use for a sample of children and adolescents with cerebral palsy over a 1 year period and to identify factors associated with frequency of therapy and parental satisfaction with therapy frequency. Parents of 83 children completed a survey on their child's use of occupational therapy, physiotherapy and speech and language pathology services over the previous year. Participants were randomly selected from a sample stratified by age and Gross Motor Function Classification System (GMFCS) level. During the year prior to survey completion, 83% of children had received occupational therapy, 88% had received physiotherapy and 60% had received speech and language pathology services. Frequency of therapy was higher for younger children (P < 0.01), those classified at GMFCS levels IV-V (P < 0.05) and those attending schools specifically for children with disabilities. Current structures for therapy service delivery for children with cerebral palsy are systems-based, and age-based funding systems and the organisation of services around the education system are preventing the delivery of needs-based therapy. Paediatricians that care for children and young people with cerebral palsy need to pay particular attention to those that may miss out on therapy due to age or school type, and support these families in accessing appropriate therapy. © 2015 The Authors. Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

What is the Best Configuration of Wearable Sensors to Measure Spatiotemporal Gait Parameters in Children with Cerebral Palsy?

PubMed Central

Carcreff, Lena; Paraschiv-Ionescu, Anisoara; De Coulon, Geraldo; Armand, Stéphane; Aminian, Kamiar

2018-01-01

Wearable inertial devices have recently been used to evaluate spatiotemporal parameters of gait in daily life situations. Given the heterogeneity of gait patterns in children with cerebral palsy (CP), the sensor placement and analysis algorithm may influence the validity of the results. This study aimed at comparing the spatiotemporal measurement performances of three wearable configurations defined by different sensor positioning on the lower limbs: (1) shanks and thighs, (2) shanks, and (3) feet. The three configurations were selected based on their potential to be used in daily life for children with CP and typically developing (TD) controls. For each configuration, dedicated gait analysis algorithms were used to detect gait events and compute spatiotemporal parameters. Fifteen children with CP and 11 TD controls were included. Accuracy, precision, and agreement of the three configurations were determined in comparison with an optoelectronic system as a reference. The three configurations were comparable for the evaluation of TD children and children with a low level of disability (CP-GMFCS I) whereas the shank-and-thigh-based configuration was more robust regarding children with a higher level of disability (CP-GMFCS II–III). PMID:29385700

Reliability and responsiveness of the gross motor function measure-88 in children with cerebral palsy.

PubMed

Ko, Jooyeon; Kim, MinYoung

2013-03-01

The Gross Motor Function Measure (GMFM-88) is commonly used in the evaluation of gross motor function in children with cerebral palsy (CP). The relative reliability of GMFM-88 has been assessed in children with CP. However, little information is available regarding the absolute reliability or responsiveness of GMFM-88. The purpose of this study was to determine the absolute and relative reliability and the responsiveness of the GMFM-88 in evaluating gross motor function in children with CP. A clinical measurement design was used. Ten raters scored the GMFM-88 in 84 children (mean age=3.7 years, SD=1.9, range=10 months to 9 years 9 months) from video records across all Gross Motor Function Classification System (GMFCS) levels to establish interrater reliability. Two raters participated to assess intrarater reliability. Responsiveness was determined from 3 additional assessments after the baseline assessment. The interrater and intrarater intraclass correlation coefficients (ICCs) with 95% confidence intervals, standard error of measurement (SEM), smallest real difference (SRD), effect size (ES), and standardized response mean (SRM) were calculated. The relative reliability of the GMFM was excellent (ICCs=.952-1.000). The SEM and SRD for total score of the GMFM were acceptable (1.60 and 3.14, respectively). Additionally, the ES and SRM of the dimension goal scores increased gradually in the 3 follow-up assessments (GMFCS levels I and II: ES=0.5, 0.6, and 0.8 and SRM=1.3, 1.8, and 2.0; GMFCS levels III-V: ES=0.4, 0.7, and 0.9 and SRM=1.5, 1.7, and 2.0). Children over 10 years of age with CP were not included in this study, so the results should not be generalized to all children with CP. Both the reliability and the responsiveness of the GMFM-88 are reasonable for measuring gross motor function in children with CP.

Cerebral Palsy in Children as a Risk Factor for Malnutrition.

PubMed

Perenc, Lidia; Przysada, Grzegorz; Trzeciak, Jadwiga

2015-01-01

The main aim of this study was to determine some malnutrition risk factors among children with cerebral palsy (CP). Children with CP often require the assistance of physical therapy centers. Experience suggests that, apart from physical disabilities, this group often suffers from malnutrition. Data were gathered in the hospital among 128 children aged 3-18 years who were suffering from CP. The children were admitted from 2011 to 2013 to the Center for Neurological Physical Therapy for children in the Regional Hospital No. 2. St. Queen Jadwiga in Rzeszow (RORE). Statistical analyses were conducted for data on gender, age, type of CP, motor function level according to Gross Motor Function Classification Scale (GMFCS), body mass index (BMI) and hemoglobin levels in blood. The risk of anemia differs based on gender--the risk is 6 times greater among boys than among girls (p = 0.0398). Risk of malnutrition is 3.5 times higher in children with tetraplegia than in children with diplegia or hemiplegia (p = 0.0043). Higher GMFCS scores are connected to greater proportions of malnourished children (for BMI z-score <-1.64, p = 0.0010). Among children with CP, malnourishment risk factors are male gender for anemia and tetraplegia and high GMFCS values. 2015 S. Karger AG, Basel.

Association between gross motor function and nutritional status in children with cerebral palsy: a cross-sectional study from Colombia.

PubMed

Herrera-Anaya, Elizabeth; Angarita-Fonseca, Adriana; Herrera-Galindo, Víctor M; Martínez-Marín, Rocío D P; Rodríguez-Bayona, Cindy N

2016-09-01

To determine the association between gross motor function and nutritional status in children with cerebral palsy (CP) residing in an urban area in a developing country. We conducted a cross-sectional study in 177 children (ages 2-12y, 59.3% male) with a diagnosis of CP who were attending rehabilitation centres in Bucaramanga, Colombia (2012-2013). A physiotherapist evaluated patients using the Gross Motor Function Classification System (GMFCS, levels I to V). Nutritional status was evaluated by nutritionists and classified according to the World Health Organization growth charts. We used linear and multinomial logistic regression methods to determine the associations. There were 39.5%, 6.8%, 5.6%, 16.4%, and 31.6% patients classified in levels I to V respectively. The mean adjusted differences for weight-for-age, height-for-age, BMI-for-age, and height-for-weight z-scores were significantly larger for children classified in levels II to V compared with those in level I. The children classified in levels IV and V were more likely to have malnutrition (adjusted odds ratio [OR] 5.64; 95% confidence interval [CI] 2.27-14.0) and stunting (OR 8.42; 95% CI 2.90-24.4) than those classified in GMFCS levels I to III. Stunting and malnutrition are prevalent conditions among paediatric patients with CP, and both are directly associated with higher levels of gross motor dysfunction. © 2016 Mac Keith Press.

Test-Retest Reliability of the 10-Metre Fast Walk Test and 6-Minute Walk Test in Ambulatory School-Aged Children with Cerebral Palsy

ERIC Educational Resources Information Center

Thompson, Patricia; Beath, Tricia; Bell, Jacqueline; Jacobson, Gabrielle; Phair, Tegan; Salbach, Nancy M.; Wright, F. Virginia

2008-01-01

Short-term test-retest reliability of the 10-metre fast walk test (10mFWT) and 6-minute walk test (6MWT) was evaluated in 31 ambulatory children with cerebral palsy (CP), with subgroup analyses in Gross Motor Function Classification System (GMFCS) Levels I (n=9), II (n=8), and III (n=14). Sixteen females and 15 males participated, mean age 9 years…

Caracterization of adults with cerebral palsy.

PubMed

Margre, Anna L M; Reis, Maria G L; Morais, Rosane L S

2010-01-01

cerebral Palsy (CP) is a group of permanent disorders of the development of movement and posture that cause functional limitation and are attributed to non-progressive disorders which occur in the fetal or infant brain. In recent years, with the increase in life expectancy of individuals with CP, several studies have described the impact of musculoskeletal disabilities and functional limitations over the life cycle. to characterize adults with CP through sociodemographic information, classifications, general health, associated conditions, physical complications and locomotion. twenty-two adults with CP recruited from local rehabilitation centers in an inner town of Brazil participated in this study. A questionnaire was used to collect data on sociodemographic characteristics, comorbities, and physical complications. A brief physical therapy evaluation was carried out, and the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS) were applied. Data were analyzed through descriptive statistics. the mean age was 28.7 (SD 10.6) years, 86.4% of participants lived with parents, and 4.5% were employed. Most of the sample consisted of spastic quadriplegic subjects, corresponding to levels IV and V of the GMFCS and MACS. Different comorbidities and important physical complications such as scoliosis and muscle contractures were present. More than half of the participants were unable to walk. Most participants demonstrated important restrictions in social participation and lower educational level. Adults with CP can be affected by several physical complications and progressive limitations in gait.

Change in basic motor abilities, quality of movement and everyday activities following intensive, goal-directed, activity-focused physiotherapy in a group setting for children with cerebral palsy.

PubMed

Sorsdahl, Anne Brit; Moe-Nilssen, Rolf; Kaale, Helga K; Rieber, Jannike; Strand, Liv Inger

2010-04-27

The effects of intensive training for children with cerebral palsy (CP) remain uncertain. The aim of the study was to investigate the impact on motor function, quality of movements and everyday activities of three hours of goal-directed activity-focused physiotherapy in a group setting, five days a week for a period of three weeks. A repeated measures design was applied with three baseline and two follow up assessments; immediately and three weeks after intervention. Twenty-two children with hemiplegia (n = 7), diplegia (n = 11), quadriplegia (n = 2) and ataxia (n = 2) participated, age ranging 3-9 y. All levels of Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) were represented. Parents and professionals participated in goal setting and training. ANOVA was used to analyse change over repeated measures. A main effect of time was shown in the primary outcome measure; Gross Motor Function Measure-66 (GMFM-66), mean change being 4.5 (p < 0.01) from last baseline to last follow up assessment. An interaction between time and GMFCS-levels was found, implying that children classified to GMFCS-levels I-II improved more than children classified to levels III-V. There were no main or interaction effects of age or anti-spastic medication. Change scores in the Pediatric Evaluation of Disability Inventory (PEDI) ranged 2.0-6.7, p < 0.01 in the Self-care domain of the Functional Skills dimension, and the Self-care and Mobility domains of the Caregiver Assistance dimension. The children's individual goals were on average attained, Mean Goal Attainment Scaling (GAS) T-score being 51.3. Non-significant improved scores on the Gross Motor Performance Measure (GMPM) and the Quality of Upper Extremities Skills Test (QUEST) were demonstrated. Significant improvement in GMPM scores were found in improved items of the GMFM, not in items that maintained the same score. Basic motor abilities and self-care improved in young children with CP after goal-directed activity-focused physiotherapy with involvement of their local environment, and their need for caregiver assistance in self-care and mobility decreased. The individualized training within a group context during a limited period of time was feasible and well-tolerated. The coherence between acquisition of basic motor abilities and quality of movement should be further examined.

Functional outcomes in children and young people with dyskinetic cerebral palsy.

PubMed

Monbaliu, Elegast; De La Peña, Mary-Grace; Ortibus, Els; Molenaers, Guy; Deklerck, Jan; Feys, Hilde

2017-06-01

This cross-sectional study aimed to map the functional profile of individuals with dyskinetic cerebral palsy (CP), to determine interrelationships between the functional classification systems, and to investigate the relationship of functional abilities with dystonia and choreoathetosis severity. Fifty-five children (<15y) and young people (15-22y) (30 males, 25 females; mean age 14y 6mo, standard deviation 4y 1mo) with dyskinetic CP were assessed using the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), Eating and Drinking Ability Classification System (EDACS), and Viking Speech Scale (VSS), as well as the Dyskinesia Impairment Scale. Over 50 per cent of the participants exhibited the highest limitation levels in GMFCS, MACS, and VSS. Better functional abilities were seen in EDACS and CFCS. Moderate to excellent interrelationship was found among the classification scales. All scales had significant correlation (r s =0.65 - 0.81) with dystonia severity except for CFCS in the young people group. Finally, only MACS (r s =0.40) and EDACS (r s =0.55) in the young people group demonstrated significant correlation with choreoathetosis severity. The need for inclusion of speech, eating, and drinking in the functional assessment of dyskinetic CP is highlighted. The study further supports the strategy of managing dystonia in particular at a younger age followed by choreoathetosis in a later stage. © 2017 Mac Keith Press.

Validation of Gujarati Version of ABILOCO-Kids Questionnaire

PubMed Central

Diwan, Jasmin; Patel, Pankaj; Bansal, Ankita B.

2015-01-01

Background ABILOCO-Kids is a measure of locomotion ability for children with cerebral palsy (CP) aged 6 to 15 years & is available in English & French. Aim To validate the Gujarati version of ABILOCO-Kids questionnaire to be used in clinical research on Gujarati population. Materials and Methods ABILOCO-Kids questionnaire was translated into Gujarati from English using forward-backward-forward method. To ensure face & content validity of Gujarati version using group consensus method, each item was examined by group of experts having mean experience of 24.62 years in field of paediatric and paediatric physiotherapy. Each item was analysed for content, meaning, wording, format, ease of administration & scoring. Each item was scored by expert group as either accepted, rejected or accepted with modification. Procedure was continued until 80% of consensus for all items. Concurrent validity was examined on 55 children with Cerebral Palsy (6-15 years) of all Gross Motor Functional Classification System (GMFCS) level & all clinical types by correlating score of ABILOCO-Kids with Gross Motor Functional Measure & GMFCS. Result In phase 1 of validation, 16 items were accepted as it is; 22 items accepted with modification & 3 items went for phase 2 validation. For concurrent validity, highly significant positive correlation was found between score of ABILOCO-Kids & total GMFM (r=0.713, p<0.005) & highly significant negative correlation with GMFCS (r= -0.778, p<0.005). Conclusion Gujarati translated version of ABILOCO-Kids questionnaire has good face & content validity as well as concurrent validity which can be used to measure caregiver reported locomotion ability in children with CP. PMID:26557603

Effects of Aquatic Intervention on Gross Motor Skills in Children with Cerebral Palsy: A Systematic Review.

PubMed

Roostaei, Meysam; Baharlouei, Hamzeh; Azadi, Hamidreza; Fragala-Pinkham, Maria A

2017-10-20

To review the literature on the effects of aquatic intervention on gross motor skills for children with cerebral palsy (CP). Six databases were searched from inception to January 2016. Aquatic studies for children aged 1-21 years with any type or CP classification and at least one outcome measuring gross motor skills were included. Information was extracted on study design, outcomes, and aquatic program type, frequency, duration, and intensity. Quality was rated using the Centre of Evidence-Based Medicine: Levels of Evidence and the PEDro scale. Of the 11 studies which met inclusion criteria, only two used randomized control trial design, and the results were mixed. Quality of evidence was rated as moderate to high for only one study. Most studies used quasi-experimental designs and reported improvements in gross motor skills for within group analyses after aquatic programs were held for two to three times per week and lasting for 6-16 weeks. Participants were classified according to the Gross Motor Function Classification System (GMFCS) levels I-V, and were aged 3-21 years. Mild to no adverse reactions were reported. Evidence on aquatic interventions for ambulatory children with CP is limited. Aquatic exercise is feasible and adverse effects are minimal; however, dosing parameters are unclear. Further research is needed to determine aquatic intervention effectiveness and exercise dosing across age categories and GMFCS levels.

The relationship between spasticity and gross motor capability in nonambulatory children with spastic cerebral palsy.

PubMed

Katusic, Ana; Alimovic, Sonja

2013-09-01

Spasticity has been considered as a major impairment in cerebral palsy (CP), but the relationship between this impairment and motor functions is still unclear, especially in the same group of patients with CP. The aim of this investigation is to determine the relationship between spasticity and gross motor capability in nonambulatory children with spastic CP. Seventy-one children (30 boys, 41 girls) with bilateral spastic cerebral palsy and with Gross Motor Function Classification System (GMFCS) levels IV (n=34) and V (n=37) were included in the study. The spasticity level in lower limbs was evaluated using the Modified Modified Ashworth Scale and the gross motor function with the Gross Motor Function Measure (GMFM-88). Spearman's correlation analysis was used to determine the nature and the strength of the relationship. The results showed a moderate correlation between spasticity and gross motor skills (ρ=0.52 for the GMFCS level; ρ=0.57 for the GMFM-88), accounting for less than 30% of the explained variance. It seems that spasticity is just one factor among many others that could interfere with gross motor skills, even in children with severe forms of spastic CP. Knowledge of the impact of spasticity on motor skills may be useful in the setting of adequate rehabilitation strategies for nonambulatory children with spastic CP.

[Neuromotor assessment of patients with spastic cerebral palsy treated with orthopedic surgery at the National Rehabilitation Institute].

PubMed

Piana, A R; Viñals, C L; Del Valle, M C; Arellano, M S; Redón, A T; Peralta, S C; León, S L

2010-01-01

Cerebral palsy (CP) is a static neurologic condition resulting from a brain lesion occurring before the completion of brain development. The goal of management is not cure, but increasing patients' functionality and improving their capabilities and maintaining their locomotion, cognitive development, social interaction and independence. The best results are obtained with an early and intensive management that includes physical and occupational therapy, medical and surgical treatments, mechanical aids and the management of concomitant conditions. To assess the neuromotor improvement in patients with spastic CP after surgical treatment at the National Rehabilitation Institute. Patients with a diagnosis of spastic CP who presented at the Pediatric Rehabilitation outpatient service were referred to the Joint CP Clinic from January 2007 to January 2008, and underwent surgical treatment of the pelvic limbs. They were assessed 3 times and underwent neuromotor tests with gross motor function measure (GMFM), which was rated with the gross motor function classification system (GMFCS). Most of the patients had improvement in the muscle tone and contracture assessments as well as in the GMFM, and their self-mobility increased one level. Significant improvements were seen in the muscle tone and contractures after surgery; the GMFM and the self-mobility levels in the GMFCS also improved. Multiple level surgery together with a postoperative physical therapy program results in considerable improvements in the gross motor function measure of patients with spastic CP.

Assessment and correction of skinfold thickness equations in estimating body fat in children with cerebral palsy.

PubMed

Gurka, Matthew J; Kuperminc, Michelle N; Busby, Marjorie G; Bennis, Jacey A; Grossberg, Richard I; Houlihan, Christine M; Stevenson, Richard D; Henderson, Richard C

2010-02-01

To assess the accuracy of skinfold equations in estimating percentage body fat in children with cerebral palsy (CP), compared with assessment of body fat from dual energy X-ray absorptiometry (DXA). Data were collected from 71 participants (30 females, 41 males) with CP (Gross Motor Function Classification System [GMFCS] levels I-V) between the ages of 8 and 18 years. Estimated percentage body fat was computed using established (Slaughter) equations based on the triceps and subscapular skinfolds. A linear model was fitted to assess the use of a simple correction to these equations for children with CP. Slaughter's equations consistently underestimated percentage body fat (mean difference compared with DXA percentage body fat -9.6/100 [SD 6.2]; 95% confidence interval [CI] -11.0 to -8.1). New equations were developed in which a correction factor was added to the existing equations based on sex, race, GMFCS level, size, and pubertal status. These corrected equations for children with CP agree better with DXA (mean difference 0.2/100 [SD=4.8]; 95% CI -1.0 to 1.3) than existing equations. A simple correction factor to commonly used equations substantially improves the ability to estimate percentage body fat from two skinfold measures in children with CP.

Quantifying weight bearing while in passive standers and a comparison of standers.

PubMed

Kecskemethy, Heidi H; Herman, Daniel; May, Ryan; Paul, Kathleen; Bachrach, Steven J; Henderson, Richard C

2008-07-01

Mechanical loading plays an important role in skeletal health, and this is a major reason standing devices are widely used with non-ambulatory persons. However, little is known about the true axial loading that occurs while in a stander, or the factors which may impact loading. The purpose of this study was to quantify weight borne while in a stander, and to directly compare different standers. Load measuring footplate adaptors were designed and fabricated specifically for this study. Weight bearing loads in 20 non-ambulatory persons with quadriplegic cerebral palsy aged 6 to 21 years (median 14 y) were continuously monitored during routine 30-minute standing sessions. Fourteen participants were female, six were male; one was Gross Motor Function Classification System (GMFCS) Level IV, and 19 were GMFCS Level V. Each participant was monitored on four to six occasions over an 8-week period, two to three times in each of two different standers (total 108 standing sessions). Weight bearing loads ranged widely from 37 to 101% of body weight. The difference between standers was as much as 29% body weight. There is wide variance in the actual weight borne while in passive standers. The type of stander utilized is one factor which can significantly affect the amount of weight borne.

Intensity, perception, and descriptive characteristics of chronic pain in children with cerebral palsy.

PubMed

Houlihan, Christine M; Hanson, Amber; Quinlan, Nicole; Puryear, Carol; Stevenson, Richard D

2008-01-01

Children with cerebral palsy (CP) experience bodily pain, leading to functional impairment and decreased quality of life. The purpose of this study is to characterize subjective descriptors of chronic pain in children with CP. One hundred fifty-seven children were invited to participate in a quantitative pilot survey. Parents were mailed the Varni-Thompson Pediatric Pain Questionnaire, designed to assess three dimensions of pain: sensory (physical aspects), affective (emotional response), and evaluative (the combined intensity of the emotional and physical responses). Parents assessed their child's pain using non-verbal and verbal cues. Fifty-two families responded (33% return rate). Thirty-eight children ages 6-8 years with CP and Gross Motor Function Classification System (GMFCS) levels I-V were included. Ninety percent of families reported that their child was experiencing some pain at the time of the survey. At the time of assessment the children's pain was mild. Their pain, at its worst, was in the distressing range. The two largest GMFCS groups of children, levels I and IV, were compared in both severity and intensity of pain experienced. Increasing intensity of pain was reported in children in the level IV group compared to children classified as level I. Pain severity in all dimensions was reported as increasing in Level IV children compared to Level I. Children with CP experience frequent pain, which increases with worsening impairment. Descriptive qualifiers of pain help to elucidate the etiology of various types of pain which would lead to the development of more effective approaches to pain management and treatment.

Reliability and cross-cultural validation of the Turkish version of Manual Ability Classification System (MACS) for children with cerebral palsy.

PubMed

Akpinar, Pinar; Tezel, Canan G; Eliasson, Ann-Christin; Icagasioglu, Afitap

2010-01-01

To determine the reliability and cross-cultural validation of the Turkish translation of the Manual Ability Classification System (MACS) for children with cerebral palsy (CP) and to investigate the relation to gross motor function and other comorbidities. After the forward and backward translation procedures, inter-rater and test-retest reliability was assessed between parents, physiotherapists and physicians using the intra-class correlation coefficient (ICC). Children (N = 118, 4 to 18 years, mean age 9 years 4 months; 68 boys, 50 girls) with various types of CP were classified. Additional data on the Gross Motor Function Classification System (GMFCS), intellectual delay, visual acuity, and epilepsy were collected. The inter-rater reliability was high; the ICC ranged from 0.89 to 0.96 among different professionals and parents. Between two persons of the same profession it ranged from 0.97 to 0.98. For the test-retest reliability it ranged from 0.91 to 0.98. Total agreement between the GMFCS and the MACS occurred in only 45% of the children. The level of the MACS was found to correlate with the accompanying comorbidities, namely intellectual delay and epilepsy. The Turkish version of the MACS is found to be valid and reliable, and is suggested to be appropriate for the assessment of manual ability within the Turkish population.

Aerobic Capacity in Children and Adolescents with Cerebral Palsy

ERIC Educational Resources Information Center

Verschuren, Olaf; Takken, Tim

2010-01-01

This study described the aerobic capacity [VO[subscript 2peak] (ml/kg/min)] in contemporary children and adolescents with cerebral palsy (CP) using a maximal exercise test protocol. Twenty-four children and adolescents with CP classified at Gross Motor Functional Classification Scale (GMFCS) level I or level II and 336 typically developing…

Children's perceptions of their cerebral palsy and their impact on life satisfaction.

PubMed

Chong, Jimmy; Mackey, Anna H; Broadbent, Elizabeth; Stott, N Susan

2012-01-01

To assess an individual child's cognitive and emotional perceptions of their cerebral palsy (CP) and how these are associated with their reported life satisfaction and their functional walking ability. Convenience sample of 48 children with cerebral palsy, GMFCS (Gross Motor Function Classification System) I-IV, mean age of 12.2 ± 2.5 years was recruited from tertiary level out-patient clinics. All children completed the Brief Illness Perception Questionnaire-Cerebral Palsy version (BIPQ-CP), Students' Life Satisfaction Scale (SLSS) and 1- and 6-min walk tests. Children with CP reported levels of global life satisfaction (mean score 31.4/42) equivalent to previous studies of typically developing children. Higher total SLSS scores were associated with lower concern about CP (rho = -0.61, p < 0.001), lower emotional impact (rho = -0.58, p < 0.001), fewer perceived consequences (rho = -0.53, p < 0.001) and perceptions of higher levels of personal control (rho = 0.40, p = 0.01). Multiple regression models using BIPQ-CP constructs found that a combination of lower level of concern and fewer perceived consequences predicted 46% of the variance in SLSS score (p < 0.001). GMFCS levels, walk distance and age were not significant predictors of life satisfaction. Life satisfaction in this group of children was strongly associated with a child's perceptions of their CP but was not associated with functional walking ability. Although the cross-sectional nature of the study precludes assumptions of causality, understanding children's cognitive and emotional beliefs about their cerebral palsy would seem to be an important adjunct to clinical management.

Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy

PubMed Central

LAW, MARY C; DARRAH, JOHANNA; POLLOCK, NANCY; WILSON, BRENDA; RUSSELL, DIANNE J; WALTER, STEPHEN D; ROSENBAUM, PETER; GALUPPI, BARB

2011-01-01

AIM This study evaluated the efficacy of a child-focused versus context-focused intervention in improving performance of functional tasks and mobility in young children with cerebral palsy. METHOD A randomized controlled trial cluster research design enrolled 128 children (49 females, 79 males; age range 12mo to 5y 11mo; mean age 3y 6mo, SD −1y 5mo) who were diagnosed with cerebral palsy. Children across levels I to V on the Gross Motor Classification System (GMFCS) were included in the study. Children were excluded if there were planned surgical or medication changes during the intervention period. Therapists from 19 children's rehabilitation centers were block randomized (by occupational therapist or physical therapist) to a treatment arm. Children from consenting families followed their therapists into their assigned group. Children received child-focused (n=71) or context-focused intervention (n=57) over 6 months, returning to their regular therapy schedule and approach between 6 and 9 months. The primary outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI). Secondary outcome measures included the Gross Motor Function Measure (GMFM-66), range of motion of hip abduction, popliteal angle and ankle dorsiflexion, the Assessment of Preschool Children's Participation (APCP), and the Family Empowerment Scale (FES). Outcome evaluators were masked to group assignment and completed assessments at baseline, 6 months, and 9 months. RESULTS Ten children did not complete the full intervention, six in the child group and four in context group. GMFCS levels for children in the study were level I (n=37), level II (n=23), level III (n=21), level IV (n=21), and level V (n=26). There were no significant differences at baseline between the treatment groups for GMFCS level, parental education, or parental income. For the PEDI, there was no significant difference between the treatment groups, except for a small effect (p<0.03) on the Caregiver Assistance Mobility subscale between baseline and 9 months. The mean scores of both groups changed significantly on the Functional Skills Scales (p<0.001) and Caregiver Assistance Scales (p<0.02) of the PEDI after the 6-month intervention. There was no additional statistically significant change on the PEDI during the follow-up period from 6 to 9 months. A subgroup effect was found for age (p<0.001), with children younger than 3 years changing significantly more than older children. GMFCS level at baseline did not influence the amount of change on the PEDI scales. There were no significant differences between the treatment groups on the GMFM, range of motion measures, APCP or FES assessments. For the GMFM, there was a significant change over time from baseline to 6 months (p<0.001) and no significant change between 6 and 9 months. There was no adverse side effect as range of motion did not decrease in either group. Hip abduction increased significantly (p<0.01) at the 9-month assessment for both groups. For the APCP, significant changes for both treatment groups were found between baseline and 6 months for play intensity (p<0.04), physical activity intensity and diversity (p<0.001), and total score intensity (p<0.01). INTERPRETATION This study shows that child- or context-focused therapy approaches are equally effective and that frequency of intervention may be a critical component of successful intervention. Further evaluation is required to identify the various `dose-response' relations of amount of treatment and changes in functional abilities. PMID:21569012

Sleep disorders in children with cerebral palsy: neurodevelopmental and behavioral correlates.

PubMed

Romeo, Domenico M; Brogna, Claudia; Quintiliani, Michela; Baranello, Giovanni; Pagliano, Emanuela; Casalino, Tiziana; Sacco, Annalisa; Ricci, Daniela; Mallardi, Maria; Musto, Elisa; Sivo, Serena; Cota, Francesco; Battaglia, Domenica; Bruni, Oliviero; Mercuri, Eugenio

2014-02-01

We aimed to estimate the frequency of sleep disorders in children with cerebral palsy (CP) using the Sleep Disturbance Scale for Children (SDSC) and to evaluate the relations between sleep disorders and motor, cognitive, and behavioral problems. One hundred and sixty-five children with CP ages 6-16 years (mean age, 11years) were assessed using the SDSC, the Gross Motor Function Classification System (GMFCS), the Wechsler Intelligence Scale for Children and the Child Behavior Check List (CBCL) to assess sleep, motor, cognitive, and behavioral problems, respectively. An abnormal total sleep score was found in 19% of children with CP; more than 40% of children had an abnormal score on at least one SDSC factor. The SDSC total score was significantly associated (P<.01) with mental retardation, epilepsy, CBCL scores, and level 5 on the GMFCS. Our results confirm that sleep disorders are common in children with cerebral palsy. The relationship between motor and cognitive behavior and epilepsy should be further explored to better understand how these factors influence one another to identify effective treatments and to improve the well-being of the child. Copyright © 2014 Elsevier B.V. All rights reserved.

Oropharyngeal dysphagia in preschool children with cerebral palsy: oral phase impairments.

PubMed

Benfer, Katherine A; Weir, Kelly A; Bell, Kristie L; Ware, Robert S; Davies, Peter S W; Boyd, Roslyn N

2014-12-01

This study aimed to document the prevalence and patterns of oral phase oropharyngeal dysphagia (OPD) in preschool children with cerebral palsy (CP), and its association with mealtime duration, frequency and efficiency. Cross-sectional population-based cohort study of 130 children diagnosed with CP at 18-36 months ca (mean = 27.4 months, 81 males) and 40 children with typical development (mean = 26.2, 18 males). Functional abilities of children with CP were representative of a population sample (GMFCS I = 57, II = 15, III = 23, IV = 12, V = 23). Oral phase impairment was rated from video using the Dyspahgia Disorders Survey, Schedule for Oral Motor Impairment, and Pre-Speech Assessment Scale. Parent-report was collected on a feeding questionnaire. Mealtime frequency, duration and efficiency were calculated from a three day weighed food record completed by parents. Gross motor function was classified using the Gross Motor Function Classification System (GMFCS). Overall, 93.8% of children had directly assessed oral phase impairments during eating or drinking, or in controlling saliva (78.5% with modified cut-points). Directly assessed oral phase impairments were associated with declining gross motor function, with children from GMFCS I having a 2-fold increased likelihood of oral phase impairment compared to the children with TD (OR = 2.0, p = 0.18), and all children from GMFCS II-V having oral phase impairments. Difficulty biting (70%), cleaning behaviours (70%) and chewing (65%) were the most common impairments on solids, and difficulty sipping from a cup (60%) for fluids. OPD severity and GMFCS were not related to mealtime frequency, duration or efficiency, although children on partial tube feeds had significantly reduced mealtime efficiency. Oral phase impairments were common in preschool children with CP, with severity increasing stepwise with declining gross motor function. The prevalence and severity of oral phase impairments were significantly greater for most tasks when compared to children with typical development, even for those with mild CP. Children who were partially tube fed had significantly lower feeding efficiency, so this could be a useful early indicator of children needing supplementation to their nutrition (through increasing energy density of foods/fluids, or tube feeds). Copyright © 2014 Elsevier Ltd. All rights reserved.

Assessment and correction of skinfold thickness equations in estimating body fat in children with cerebral palsy

PubMed Central

GURKA, MATTHEW J; KUPERMINC, MICHELLE N; BUSBY, MARJORIE G; BENNIS, JACEY A; GROSSBERG, RICHARD I; HOULIHAN, CHRISTINE M; STEVENSON, RICHARD D; HENDERSON, RICHARD C

2010-01-01

AIM To assess the accuracy of skinfold equations in estimating percentage body fat in children with cerebral palsy (CP), compared with assessment of body fat from dual energy X-ray absorptiometry (DXA). METHOD Data were collected from 71 participants (30 females, 41 males) with CP (Gross Motor Function Classification System [GMFCS] levels I–V) between the ages of 8 and 18 years. Estimated percentage body fat was computed using established (Slaughter) equations based on the triceps and subscapular skinfolds. A linear model was fitted to assess the use of a simple correction to these equations for children with CP. RESULTS Slaughter’s equations consistently underestimated percentage body fat (mean difference compared with DXA percentage body fat −9.6/100 [SD 6.2]; 95% confidence interval [CI] −11.0 to −8.1). New equations were developed in which a correction factor was added to the existing equations based on sex, race, GMFCS level, size, and pubertal status. These corrected equations for children with CP agree better with DXA (mean difference 0.2/100 [SD=4.8]; 95% CI −1.0 to 1.3) than existing equations. INTERPRETATION A simple correction factor to commonly used equations substantially improves the ability to estimate percentage body fat from two skinfold measures in children with CP. PMID:19811518

Course of employment in adults with cerebral palsy over a 14-year period.

PubMed

Benner, Joyce L; Hilberink, Sander R; Veenis, Thessa; van der Slot, Wilma M A; Roebroeck, Marij E

2017-07-01

To explore the course of employment in adults with cerebral palsy (CP) over 14 years, and to identify subgroups at risk for unemployment. Sixty-five adults with CP (33 males, 32 females; baseline age 25y 8mo, standard deviation [SD] 3y 2mo; intellectual impairment 25%; bilateral CP 65%) participated in a prospective cohort study. Self-reports of employment and work hours per week in 1996, 2000, and 2010 were documented. The course of employment (including sheltered work) and work hours per week were analysed, using generalized estimating equations (GEE). Overall, employment rate was stable over time (38-45%, p=0.413), but lower than in the general population (75-86%, p<0.001). Employment rates were specifically low in adults with intellectual impairment, bilateral CP, and in adults with Gross Motor Function Classification System (GMFCS) levels IV and V. Work hours per week declined (35.0 [SD 7.9] to 31.2 [SD 10.3], p=0.033), especially among females (32.3 [SD 6.4] to 23.4 [SD 7.4], p<0.001). Similar to the general population, females often worked part-time. Employment was low compared with the general population, but remained stable in the long term; however, work hours per week decreased. Adults with intellectual impairment, bilateral CP, and GMFCS levels IV and V are subgroups at risk for unemployment. © 2017 Mac Keith Press.

Severe hip displacement reduces health-related quality of life in children with cerebral palsy.

PubMed

Ramstad, Kjersti; Jahnsen, Reidun B; Terjesen, Terje

2017-04-01

Background and purpose - Hip displacement is common in children with severe cerebral palsy (CP) and can cause problems such as pain, contractures, and nursing difficulties. Caregiver priorities and child health index of life with disabilities (CPCHILD) is a recently developed measure of health-related quality of life (HRQL) in children with severe CP. The associations between CPCHILD scores and hip displacement have not been investigated. We explored the effect of hip displacement on HRQL. Patients and methods - 67 children were recruited from the population-based Norwegian CP register. Mean age was 9 (7-12) years. There were 40 boys. Gross motor function classification system (GMFCS) distribution was 12 level III, 17 level IV, and 38 level V. Hip displacement was assessed by radiographic migration percentage (MP). The criterion for hip displacement was MP of the worst hip of ≥40%. Primary caregivers responded to 5 of the 6 domains of the CPCHILD questionnaire. Results - Hip displacement was found in 18 children and it was significantly associated with lower scores on the CPCHILD domains 3 (Comfort and Emotions) and 5 (Health), but not with domains 1 (Activities of Daily Living/Personal Care), 2 (Positioning, Transfer, and Mobility), and 6 (Overall Quality of Life). GMFCS level V was a significant predictor of low scores in all the domains. Interpretation - For the assessment of HRQL in children with severe CP and hip problems, we propose a modified and simplified version of the CPCHILD consisting of 14 of 37 questions. This would reduce the responders' burden and probably increase the response rate in clinical studies without losing important information.

Burke-Fahn-Marsden dystonia severity, Gross Motor, Manual Ability, and Communication Function Classification scales in childhood hyperkinetic movement disorders including cerebral palsy: a 'Rosetta Stone' study.

PubMed

Elze, Markus C; Gimeno, Hortensia; Tustin, Kylee; Baker, Lesley; Lumsden, Daniel E; Hutton, Jane L; Lin, Jean-Pierre S-M

2016-02-01

Hyperkinetic movement disorders (HMDs) can be assessed using impairment-based scales or functional classifications. The Burke-Fahn-Marsden Dystonia Rating Scale-movement (BFM-M) evaluates dystonia impairment, but may not reflect functional ability. The Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) are widely used in the literature on cerebral palsy to classify functional ability, but not in childhood movement disorders. We explore the concordance of these three functional scales in a large sample of paediatric HMDs and the impact of dystonia severity on these scales. Children with HMDs (n=161; median age 10y 3mo, range 2y 6mo-21y) were assessed using the BFM-M, GMFCS, MACS, and CFCS from 2007 to 2013. This cross-sectional study contrasts the information provided by these scales. All four scales were strongly associated (all Spearman's rank correlation coefficient rs >0.72, p<0.001), with worse dystonia severity implying worse function. Secondary dystonias had worse dystonia and less function than primary dystonias (p<0.001). A longer proportion of life lived with dystonia is associated with more severe dystonia (rs =0.42, p<0.001). The BFM-M is strongly linked with the GMFCS, MACS, and CFCS, irrespective of aetiology. Each scale offers interrelated but complementary information and is applicable to all aetiologies. Movement disorders including cerebral palsy can be effectively evaluated using these scales. © 2015 Mac Keith Press.

Functional Capacity in Adults With Cerebral Palsy: Lower Limb Muscle Strength Matters.

PubMed

Gillett, Jarred G; Lichtwark, Glen A; Boyd, Roslyn N; Barber, Lee A

2018-05-01

To investigate the relation between lower limb muscle strength, passive muscle properties, and functional capacity outcomes in adults with cerebral palsy (CP). Cross-sectional study. Tertiary institution biomechanics laboratory. Adults with spastic-type CP (N=33; mean age, 25y; range, 15-51y; mean body mass, 70.15±21.35kg) who were either Gross Motor Function Classification System (GMFCS) level I (n=20) or level II (n=13). Not applicable. Six-minute walk test (6MWT) distance (m), lateral step-up (LSU) test performance (total repetitions), timed up-stairs (TUS) performance (s), maximum voluntary isometric strength of plantar flexors (PF) and dorsiflexors (DF) (Nm.kg -1 ), and passive ankle joint and muscle stiffness. Maximum isometric PF strength independently explained 61% of variance in 6MWT performance, 57% of variance in LSU test performance, and 50% of variance in TUS test performance. GMFCS level was significantly and independently related to all 3 functional capacity outcomes, and age was retained as a significant independent predictor of LSU and TUS test performance. Passive medial gastrocnemius muscle fascicle stiffness and ankle joint stiffness were not significantly related to functional capacity measures in any of the multiple regression models. Low isometric PF strength was the most important independent variable related to distance walked on the 6MWT, fewer repetitions on the LSU test, and slower TUS test performance. These findings suggest lower isometric muscle strength contributes to the decline in functional capacity in adults with CP. Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Scoliosis in Patients with Severe Cerebral Palsy: Three Different Courses in Adolescents.

PubMed

Oda, Yoshiaki; Takigawa, Tomoyuki; Sugimoto, Yoshihisa; Tanaka, Masato; Akazawa, Hirofumi; Ozaki, Toshifumi

2017-04-01

Patients with cerebral palsy (CP) frequently present with scoliosis; however, the pattern of curve progression is difficult to predict. We aimed to clarify the natural course of the progression of scoliosis and to identify scoliosis predictors. This was a retrospective, single-center, observational study. Total of 92 CP patients from Asahikawasou Ryouiku Iryou Center in Okayama, Japan were retrospectively analyzed. Cobb angle, presence of hip dislocation and pelvic obliquity, and Gross Motor Function Classification System (GMFCS) were investigated. Severe CP was defined as GMFCS level IV or V. The mean observation period was 10.7 years. Thirtyfour severe CP patients presented with scoliosis and were divided into 3 groups based on their clinical courses: severe, moderate and mild. The mean Cobb angles at the final follow-up were 129°, 53°, and 13° in the severe, moderate, and mild groups, respectively. The average progressions from 18 to 25 years were 2.7°/year, 0.7°/year, and 0.1°/year in the severe, moderate, and mild curve groups, respectively. We observed the natural course of scoliosis and identified 3 courses based on the Cobb angle at 15 and 18 years of age. This method of classification may help clinicians predict the patients' disease progression.

Dynamical structure of center-of-pressure trajectories with and without functional taping in children with cerebral palsy level I and II of GMFCS.

PubMed

Pavão, Silvia Leticia; Ledebt, Annick; Savelsbergh, Geert J P; Rocha, Nelci Adriana C F

2017-08-01

Postural control during quiet standing was examined in typical children (TD) and children with cerebral palsy (CP) level I and II of GMFCS. The immediate effect on postural control of functional taping on the thighs was analyzed. We evaluated 43 TD, 17 CP children level I, and 10 CP children level II. Participants were evaluated in two conditions (with and without taping). The trajectories of the center of pressure (COP) were analyzed by means of conventional posturography (sway amplitude, sway-path-length) and dynamic posturography (degree of twisting-and-turning, sway regularity). Both CP groups showed larger sway amplitude than the TD while only the CP level II showed more regular COP trajectories with less twisting-and-turning. Functional taping didn't affect sway amplitude or sway-path-length. TD children exhibited more twisting-and-turning with functional taping, whereas no effects on postural sway dynamics were observed in CP children. Functional taping doesn't result in immediate changes in quiet stance in CP children, whereas in TD it resulted in faster sway corrections. Children level II invest more attention in postural control than level I, and TD. While quiet standing was more automatized in children level I than in level II, both CP groups showed a less stable balance than TD. Copyright © 2017 Elsevier B.V. All rights reserved.

Brain magnetic resonance imaging and motor and intellectual functioning in 86 patients born at term with spastic diplegia.

PubMed

Numata, Yurika; Onuma, Akira; Kobayashi, Yasuko; Sato-Shirai, Ikuko; Tanaka, Soichiro; Kobayashi, Satoru; Wakusawa, Keisuke; Inui, Takehiko; Kure, Shigeo; Haginoya, Kazuhiro

2013-02-01

To investigate the association between magnetic resonance imaging (MRI) patterns and motor function, epileptic episodes, and IQ or developmental quotient in patients born at term with spastic diplegia. Eighty-six patients born at term with cerebral palsy (CP) and spastic diplegia (54 males, 32 females; median age 20 y, range 7-42 y) among 829 patients with CP underwent brain MRI between 1990 and 2008. The MRI and clinical findings were analysed retrospectively. Intellectual disability was classified according to the Enjoji developmental test or the Wechsler Intelligence Scale for Children (3rd edition). The median ages at diagnosis of CP, assignment of Gross Motor Function Classification System (GMFCS) level, cognitive assessment, and MRI were 2 years (range 5 mo-8 y), 6 years (2 y 8 mo-19 y), 6 years (1 y 4 mo-19 y), and 7 years (10 mo-30 y) respectively. MRI included normal findings (41.9%), periventricular leukomalacia, hypomyelination, and porencephaly/periventricular venous infarction. The frequency of patients in GMFCS levels III to V and intellectual disability did not differ between those with normal and abnormal MRI findings. Patients with normal MRI findings had significantly fewer epileptic episodes than those with abnormal ones (p=0.001). Varied MRI findings, as well as the presence of severe motor dysfunction and intellectual disability (despite normal MRI), suggest that patients born at term with spastic diplegia had heterogeneous and unidentified pathophysiology. © The Authors. Developmental Medicine & Child Neurology © 2012 Mac Keith Press.

Severe hip displacement reduces health-related quality of life in children with cerebral palsy

PubMed Central

Ramstad, Kjersti; Jahnsen, Reidun B; Terjesen, Terje

2017-01-01

Background and purpose Hip displacement is common in children with severe cerebral palsy (CP) and can cause problems such as pain, contractures, and nursing difficulties. Caregiver priorities and child health index of life with disabilities (CPCHILD) is a recently developed measure of health-related quality of life (HRQL) in children with severe CP. The associations between CPCHILD scores and hip displacement have not been investigated. We explored the effect of hip displacement on HRQL. Patients and methods 67 children were recruited from the population-based Norwegian CP register. Mean age was 9 (7–12) years. There were 40 boys. Gross motor function classification system (GMFCS) distribution was 12 level III, 17 level IV, and 38 level V. Hip displacement was assessed by radiographic migration percentage (MP). The criterion for hip displacement was MP of the worst hip of ≥40%. Primary caregivers responded to 5 of the 6 domains of the CPCHILD questionnaire. Results Hip displacement was found in 18 children and it was significantly associated with lower scores on the CPCHILD domains 3 (Comfort and Emotions) and 5 (Health), but not with domains 1 (Activities of Daily Living/Personal Care), 2 (Positioning, Transfer, and Mobility), and 6 (Overall Quality of Life). GMFCS level V was a significant predictor of low scores in all the domains. Interpretation For the assessment of HRQL in children with severe CP and hip problems, we propose a modified and simplified version of the CPCHILD consisting of 14 of 37 questions. This would reduce the responders’ burden and probably increase the response rate in clinical studies without losing important information. PMID:27892753

The benefits of a comprehensive rehabilitation program in patients diagnosed with spastic quadriplegia

PubMed Central

Rogoveanu, OC; Tuțescu, NC; Kamal, D; Alexandru, DO; Kamal, C; Streba, CT; Trăistaru, MR

2016-01-01

Spastic quadriplegia has as an etiopathogenic substrate, a non-progressive brain lesion; however, the clinical manifestations of the disease evolve over time. Children diagnosed with spastic quadriplegia show a variety of symptoms in different areas: sensorimotor, emotional, cognitive, and social. The purpose of this study was to assess the functional status in patients diagnosed with spastic quadriplegia, who followed a complex medical rehabilitation program, during a year, and highlight the importance of using physical and kinetic techniques in improving their status. A total of 10 children diagnosed with spastic quadriplegia were included in the study and the Gross Motor Function Classification System (GMFCS) and manual ability classification system (MACS) were used to evaluate the functionality status of each patient. Every patient was evaluated initially (T1), after six months of program (T2), and after they completed the study. All the children were originally monitored daily, for 5 days per week for a period of one month, then two times a week for a year. A statistically significant difference regarding the modification of the GMFCS and MACS stage was found, which occurred between the first and the third evaluation. The inverse correlation of the statistical significance between the ages of patients and the decrease in GMFCS or MACS stage was highlighted; the younger the patient, the more the scale decreased. A direct link between the gross motor function and the manual ability was noticed. Applying a complex rehabilitation program has proven efficient by improving both the gross motor functionality and the manual ability. PMID:27974931

The benefits of a comprehensive rehabilitation program in patients diagnosed with spastic quadriplegia.

PubMed

Rogoveanu, O C; Tuțescu, N C; Kamal, D; Alexandru, D O; Kamal, C; Streba, C T; Trăistaru, M R

2016-01-01

Spastic quadriplegia has as an etiopathogenic substrate, a non-progressive brain lesion; however, the clinical manifestations of the disease evolve over time. Children diagnosed with spastic quadriplegia show a variety of symptoms in different areas: sensorimotor, emotional, cognitive, and social. The purpose of this study was to assess the functional status in patients diagnosed with spastic quadriplegia, who followed a complex medical rehabilitation program, during a year, and highlight the importance of using physical and kinetic techniques in improving their status. A total of 10 children diagnosed with spastic quadriplegia were included in the study and the Gross Motor Function Classification System (GMFCS) and manual ability classification system (MACS) were used to evaluate the functionality status of each patient. Every patient was evaluated initially (T1), after six months of program (T2), and after they completed the study. All the children were originally monitored daily, for 5 days per week for a period of one month, then two times a week for a year. A statistically significant difference regarding the modification of the GMFCS and MACS stage was found, which occurred between the first and the third evaluation. The inverse correlation of the statistical significance between the ages of patients and the decrease in GMFCS or MACS stage was highlighted; the younger the patient, the more the scale decreased. A direct link between the gross motor function and the manual ability was noticed. Applying a complex rehabilitation program has proven efficient by improving both the gross motor functionality and the manual ability.

Clinical characteristics and functional status of children with different subtypes of dyskinetic cerebral palsy.

PubMed

Sun, Dianrong; Wang, Qiang; Hou, Mei; Li, Yutang; Yu, Rong; Zhao, Jianhui; Wang, Ke

2018-05-01

Dyskinetic cerebral palsy (CP) is the second major subtype of CP. Dyskinetic CP can be classified into different subtypes, but the exact clinical characteristics of these subtypes have been poorly studied. To investigate the clinical characteristics and functional classification of dyskinetic CP from the perspective of neurologic subtypes in a hospital-based follow-up study.This was an observational study of consecutive children with dyskinetic CP treated at The Affiliated Women & Children Hospital of Qingdao University (China) from October 2005 to February 2015. The children were stratified according to their neurologic subtype and assessed with the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS). MRI scanning was conducted at 1 year of age for most children.Twenty-six participants (28.0%) had dystonic CP, 26 (28.0%) had choreoathetotic CP, and 41 (44.1%) had mixed CP. Auditory impairment and basal ganglion lesions occurred more frequently in the dystonia group (n = 8, 31%; and n = 16, 67%), while seizures, microcephaly, white matter lesions, and mixed lesions were more frequent in the mixed type (n = 14, 34%; n = 10, 24%; n = 15, 41%; n = 12, 32%). Functional classification levels were distributed unequally among the 3 subgroups (P < .01). No significant difference between GMFCS and MACS was found among the 3 subgroups (P > .05).Different subtypes of dyskinetic CP have specific comorbidities, radiological characteristics, and functional attributes according to their etiological factors and brain lesions. Children with dystonic CP have more limited functional status than children with choreoathetotic CP.

The Relationship between Manual Ability and Ambulation in Adolescents with Cerebral Palsy

ERIC Educational Resources Information Center

Majnemer, Annette; Shikako-Thomas, Keiko; Shevell, Michael; Poulin, Chantal; Lach, Lucyna; Law, Mary; Schmitz, Norbert

2013-01-01

This study examined the relationship between gross motor function and manual ability in 120 adolescents with cerebral palsy (CP) (15.2, SD 2.1 years, 59.8% male). Adolescents were evaluated using the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS). A neurologist classified CP subtype. Most…

Effects of Botulinum Toxin-A and Goal-Directed Physiotherapy in Children with Cerebral Palsy GMFCS Levels I & II.

PubMed

Löwing, Kristina; Thews, Karin; Haglund-Åkerlind, Yvonne; Gutierrez-Farewik, Elena M

2017-08-01

To evaluate short and long-term effects of botulinum toxin-A combined with goal-directed physiotherapy in children with cerebral palsy (CP). A consecutive selection of 40 children, ages 4-12 years, diagnosed with unilateral or bilateral CP, and classified in GMFCS levels I-II. During the 24 months, 9 children received one BoNT-A injection, 10 children two injections, 11 children three injections, and 10 children received four injections. 3D gait analysis, goal-attainment scaling, and body function assessments were performed before and at 3, 12, and 24 months after initial injections. A significant but clinically small long-term improvement in gait was observed. Plantarflexor spasticity was reduced after three months and remained stable, while passive ankle dorsiflexion increased after 3 months but decreased slightly after 12 months. Goal-attainment gradually increased, reached the highest levels at 12 months, and levels were maintained at 24 months. The treatments' positive effect on spasticity reduction was identified, but did not relate to improvement in gait or goal-attainment. No long-term positive change in passive ankle dorsiflexion was observed. Goal attainment was achieved in all except four children. The clinical significance of the improved gait is unclear. Further studies are recommended to identify predictors for positive treatment outcome.

Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy.

PubMed

Law, Mary C; Darrah, Johanna; Pollock, Nancy; Wilson, Brenda; Russell, Dianne J; Walter, Stephen D; Rosenbaum, Peter; Galuppi, Barb

2011-07-01

This study evaluated the efficacy of a child-focused versus context-focused intervention in improving performance of functional tasks and mobility in young children with cerebral palsy. A randomized controlled trial cluster research design enrolled 128 children (49 females, 79 males; age range 12 mo to 5 y 11 mo; mean age 3 y 6 mo, SD -1 y 5 mo) who were diagnosed with cerebral palsy. Children across levels I to V on the Gross Motor Classification System (GMFCS) were included in the study. Children were excluded if there were planned surgical or medication changes during the intervention period. Therapists from 19 children's rehabilitation centers were block randomized (by occupational therapist or physical therapist) to a treatment arm. Children from consenting families followed their therapists into their assigned group. Children received child-focused (n=71) or context-focused intervention (n=57) over 6 months, returning to their regular therapy schedule and approach between 6 and 9 months. The primary outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI). Secondary outcome measures included the Gross Motor Function Measure (GMFM-66), range of motion of hip abduction, popliteal angle and ankle dorsiflexion, the Assessment of Preschool Children's Participation (APCP), and the Family Empowerment Scale (FES). Outcome evaluators were masked to group assignment and completed assessments at baseline, 6 months, and 9 months. Ten children did not complete the full intervention, six in the child group and four in context group. GMFCS levels for children in the study were level I (n=37), level II (n=23), level III (n=21), level IV (n=21), and level V (n=26). There were no significant differences at baseline between the treatment groups for GMFCS level, parental education, or parental income. For the PEDI, there was no significant difference between the treatment groups, except for a small effect (p<0.03) on the Caregiver Assistance Mobility subscale between baseline and 9 months. The mean scores of both groups changed significantly on the Functional Skills Scales (p<0.001) and Caregiver Assistance Scales (p<0.02) of the PEDI after the 6-month intervention. There was no additional statistically significant change on the PEDI during the follow-up period from 6 to 9 months. A subgroup effect was found for age (p<0.001), with children younger than 3 years changing significantly more than older children. GMFCS level at baseline did not influence the amount of change on the PEDI scales. There were no significant differences between the treatment groups on the GMFM, range of motion measures, APCP or FES assessments. For the GMFM, there was a significant change over time from baseline to 6 months (p<0.001) and no significant change between 6 and 9 months. There was no adverse side effect as range of motion did not decrease in either group. Hip abduction increased significantly (p<0.01) at the 9-month assessment for both groups. For the APCP, significant changes for both treatment groups were found between baseline and 6 months for play intensity (p<0.04), physical activity intensity and diversity (p<0.001), and total score intensity (p<0.01). This study shows that child- or context-focused therapy approaches are equally effective and that frequency of intervention may be a critical component of successful intervention. Further evaluation is required to identify the various 'dose-response' relations of amount of treatment and changes in functional abilities. © The Authors. Developmental Medicine & Child Neurology © 2011 Mac Keith Press.

Level of motivation in mastering challenging tasks in children with cerebral palsy.

PubMed

Majnemer, Annette; Shevell, Michael; Law, Mary; Poulin, Chantal; Rosenbaum, Peter

2010-12-01

the aim of this study was to describe and identify factors associated with motivation in children with cerebral palsy (CP). children with CP were recruited for this cross-sectional study. Children were assessed using the Leiter Intelligence Test, the Gross Motor Function Measure, and the Vineland Adaptive Behavior Scale. Parents completed the Dimensions of Mastery Questionnaire (DMQ) and questionnaires on demographics, child behaviour, and family functioning. the parents of 74 children (46 males, 28 females; mean age 9y 2mo, SD 2y 1mo, range 5y 10mo-12y 11mo) completed the DMQ. Just over half of the children (39/74) were classified at Gross Motor Function Classification System (GMFCS) level I, with 13 classified at GMFCS level II, one at level III, six at level IV, and 14 at level V; one child was not classified. The most common diagnoses were spastic hemiplegia and quadriplegia (23 each), followed by diplegia (14). The highest motivation scores were obtained for the dimensions of mastery pleasure and social persistence and the lowest for persistence with motor or cognitive tasks. Age and sex were not predictive of scores on the DMQ. Higher IQ (r=0.41), better motor ability (r=0.43), and fewer limitations in self-care, communication, and socialization (r=0.44-0.53) were positively associated with motivation total score. A negative impact of the child's disability on the family was associated with lower motivation (r=-0.44). Positive social behaviours were positively correlated with motivation (r=0.38-0.66), whereas hyperactivity and peer problems were negatively associated. high motivation was associated with fewer activity limitations and behavioural problems and reduced family burden. Low motivation may adversely influence a child's functional potential and the effectiveness of interventions. Strategies focusing on the child, peers, adults, or activities are proposed to enhance the children's motivation to engage in more challenging activities.

Development and initial validation of the assessment of caregiver experience with neuromuscular disease.

PubMed

Matsumoto, Hiroko; Clayton-Krasinski, Debora A; Klinge, Stephen A; Gomez, Jaime A; Booker, Whitney A; Hyman, Joshua E; Roye, David P; Vitale, Michael G

2011-01-01

Orthopaedic intervention can have a wide range of functional and psychosocial effects on children with neuromuscular disease (NMD). In the multihandicapped child (Gross Motor Classification System IV/V), functional status, pain, psychosocial function, and health-related quality of life also have effects on the families of these child. The purpose of this study is to report the development and initial validation of an outcomes instrument specifically designed to assess the caregiver impact experienced by parents raising severely affected NMD children: the Assessment of Caregiver Experience with Neuromuscular Disease (ACEND). In the first part of this prospective study, 61 children with NMD and their parents were administered a range of earlier validated pediatric health measures. A framework technique was used to select the most appropriate and relevant subset of questions from this large set. Sensitivity analyses guided the development of a master question list measuring caregiver impact, excluding items with low relevance, and modifying unclear questions. In the second part of the study, the ACEND was administered to the caregivers of 46 children with moderate-to-severe NMD. Statistical analyses were conducted to determine validity of the instrument. The resulting ACEND instrument included 2 domains, 7 subdomains, and 41 items. Domain 1, examining physical impact, includes 4 subdomains: feeding/grooming/dressing (6 items), sitting/play (5 items), transfers (5 items), and mobility (7 items). Domain 2, which examines general caregiver impact, included 3 subdomains: time (4 items), emotion (9 items), and finance (5 items). Mean overall relevance rating was 6.21 ± 0.37 and clarity rating was 6.68 ± 0.52 (scale 0 to 7). Multiple floor effects in patients with GMFCS V and ceiling effects in patients with GMFCS III were identified almost exclusively in motor-based items. Virtually no floor or ceiling effects were identified in the time, emotion or finance domains across GMFCS level. The initial validation demonstrated that ACEND is a valid, disease-specific measure to quantify experience on caregivers of children with NMD. Larger groups of patients across NMD disease type are currently being tested to strengthen validity findings. Additionally, the ACEND is now being administered before and after orthopaedic interventions to determine responsiveness, which is critical to health outcomes research. LEVEL OF EVIDENCE/RELEVANCE: IIc.

Inactive and sedentary lifestyles amongst ambulatory adolescents and young adults with cerebral palsy

PubMed Central

2014-01-01

Background To assess physical behaviour, including physical activity and sedentary behaviour, of ambulatory adolescents and young adults with cerebral palsy (CP). We compared participant physical behaviour to that of able-bodied persons and assessed differences related to Gross Motor Functioning Classification System (GMFCS) level and CP distribution (unilateral/bilateral). Methods In 48 ambulatory persons aged 16 to 24 years with spastic CP and in 32 able-bodied controls, physical behaviour was objectively determined with an accelerometer-based activity monitor. Total duration, intensity and type of physical activity were assessed and sedentary time was determined (lying and sitting). Furthermore, distribution of walking bouts and sitting bouts was specified. Results Adolescents and young adults with CP spent 8.6% of 24 hours physically active and 79.5% sedentary, corresponding with respectively 123 minutes and 1147 minutes per 24 hours. Compared to able-bodied controls, persons with CP participated 48 minutes less in physical activities (p < 0.01) and spent 80 minutes more sedentary per 24 hours (p < 0.01). Physical behaviour was not different between persons with GMFCS level I and II and only number of short sitting bouts were significantly more prevalent in persons with bilateral CP compared to unilateral CP (p < 0.05). Conclusions Ambulatory adolescents and young adults with CP are less physically active and spend more time sedentary compared to able-bodied persons, suggesting that this group may be at increased risk for health problems related to less favourable physical behaviour. Trial registration Nederlands trial register: NTR1785 PMID:24708559

Parents' Experiences and Perceptions when Classifying their Children with Cerebral Palsy: Recommendations for Service Providers.

PubMed

Scime, Natalie V; Bartlett, Doreen J; Brunton, Laura K; Palisano, Robert J

2017-08-01

This study investigated the experiences and perceptions of parents of children with cerebral palsy (CP) when classifying their children using the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS). The second aim was to collate parents' recommendations for service providers on how to interact and communicate with families. A purposive sample of seven parents participating in the On Track study was recruited. Semi-structured interviews were conducted orally and were audiotaped, transcribed, and coded openly. A descriptive interpretive approach within a pragmatic perspective was used during analysis. Seven themes encompassing parents' experiences and perspectives reflect a process of increased understanding when classifying their children, with perceptions of utility evident throughout this process. Six recommendations for service providers emerged, including making the child a priority and being a dependable resource. Knowledge of parents' experiences when using the GMFCS, MACS, and CFCS can provide useful insight for service providers collaborating with parents to classify function in children with CP. Using the recommendations from these parents can facilitate family-provider collaboration for goal setting and intervention planning.

Longitudinal Study of Oropharyngeal Dysphagia in Preschool Children With Cerebral Palsy.

PubMed

Benfer, Katherine A; Weir, Kelly A; Bell, Kristie L; Ware, Robert S; Davies, Peter S; Boyd, Roslyn N

2016-04-01

To determine changes in prevalence and severity of oropharyngeal dysphagia (OPD) in children with cerebral palsy (CP) and the relationship to health outcomes. Longitudinal cohort study. Community and tertiary institutions. Children (N=53, 33 boys) with a confirmed diagnosis of CP assessed first at 18 to 24 months (Assessment 1: mean age ± SD, 22.9±2.9 mo corrected age; Gross Motor Function Classification System [GMFCS]: I, n=22; II, n=7; III, n=11; IV, n=5; V, n=8) and at 36 months (Assessment 2). Not applicable. OPD was classified using the Dysphagia Disorders Survey (DDS) and signs suggestive of pharyngeal dysphagia. Nutritional status was measured using Z scores for weight, height, and body mass index (BMI). Gross motor skills were classified on GMFCS and motor type/distribution. Prevalence of OPD decreased from 62% to 59% between the ages of 18 to 24 months and 36 months. Thirty percent of children had an improvement in severity of OPD (greater than smallest detectable change), and 4% had worse OPD. Gross motor function was strongly associated with OPD at both assessments, on the DDS (Assessment 1: odds ratio [OR]=20.3, P=.011; Assessment 2: OR=28.9, P=.002), pharyngeal signs (Assessment 1: OR=10.6, P=.007; Assessment 2: OR=15.8, P=.003), and OPD severity (Assessment 1: β=6.1, P<.001; Assessment 2: β=5.5, P<.001). OPD at 18 to 24 months was related to health outcomes at 36 months: low Z scores for weight (adjusted β=1.2, P=.03) and BMI (adjusted β=1.1, P=.048), and increased parent stress (adjusted OR=1.1, P=.049). Classification and severity of OPD remained relatively stable between 18 to 24 months and 36 months. Gross motor function was the best predictor of OPD. These findings contribute to developing more effective screening processes that consider critical developmental transitions that are anticipated to present challenges for children from each of the GMFCS levels. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Long-term outcomes five years after selective dorsal rhizotomy

PubMed Central

Nordmark, Eva; Josenby, Annika Lundkvist; Lagergren, Jan; Andersson, Gert; Strömblad, Lars-Göran; Westbom, Lena

2008-01-01

Background Selective dorsal rhizotomy (SDR) is a well accepted neurosurgical procedure performed for the relief of spasticity interfering with motor function in children with spastic cerebral palsy (CP). The goal is to improve function, but long-term outcome studies are rare. The aims of this study were to evaluate long-term functional outcomes, safety and side effects during five postoperative years in all children with diplegia undergoing SDR combined with physiotherapy. Methods This study group consisted of 35 children, consecutively operated, with spastic diplegia, of which 26 were Gross Motor Function Classification System (GMFCS) levels III–V. Mean age was 4.5 years (range 2.5–6.6). They were all assessed by the same multidisciplinary team at pre- and at 6, 12, 18 months, 3 and 5 years postoperatively. Clinical and demographic data, complications and number of rootlets cut were prospectively registered. Deep tendon reflexes and muscle tone were examined, the latter graded with the modified Ashworth scale. Passive range of motion (PROM) was measured with a goniometer. Motor function was classified according to the GMFCS and measured with the Gross Motor Function Measure (GMFM-88) and derived into GMFM-66. Parent's opinions about the children's performance of skills and activities and the amount of caregiver assistance were measured with Pediatric Evaluation Disability Inventory (PEDI). Results The mean proportion of rootlets cut in S2-L2 was 40%. Muscle tone was immediately reduced in adductors, hamstrings and dorsiflexors (p < 0.001) with no recurrence of spasticity over the 5 years. For GMFCS-subgroups I–II, III and IV–V significant improvements during the five years were seen in PROM for hip abduction, popliteal angle and ankle dorsiflexion (p = 0.001), capacity of gross motor function (GMFM) (p = 0.001), performance of functional skills and independence in self-care and mobility (PEDI) (p = 0.001). Conclusion SDR is a safe and effective method for reducing spasticity permanently without major negative side effects. In combination with physiotherapy, in a group of carefully selected and systematically followed young children with spastic diplegia, it provides lasting functional benefits over a period of at least five years postoperatively. PMID:19077294

myTREEHOUSE Self-Concept Assessment: preliminary psychometric analysis of a new self-concept assessment for children with cerebral palsy.

PubMed

Cheong, Sau Kuan; Lang, Cathryne P; Hemphill, Sheryl A; Johnston, Leanne M

2017-06-01

To evaluate the preliminary validity and reliability of the myTREEHOUSE Self-Concept Assessment for children with cerebral palsy (CP) aged 8 to 12 years. The myTREEHOUSE Self-Concept Assessment includes 26 items divided into eight domains, assessed across three Performance Perspectives (Personal, Social, and Perceived) and an additional Importance Rating. Face and content validity was assessed by semi-structured interviews with seven expert professionals regarding the assessment construct, content, and clinical utility. Reliability was assessed with 50 children aged 8 to 12 years with CP (29 males, 21 females; mean age 10y 2mo; Gross Motor Function Classification System [GMFCS] level I=35, II=8, III=5, IV=1; mean Wechsler Intelligence Scale for Children - Fourth Edition [WISC-IV]=104), whose data was used to calculate internal consistency of the scale, and a subset of 35 children (20 males, 15 females; mean age 10y 5mo; GMFCS level I=26, II=4, III=4, IV=1; mean WISC-IV=103) who participated in test-retest reliability within 14 to 28 days. Face and content validity was supported by positive expert feedback, with only minor adjustments suggested to clarify the wording of some items. After these amendments, strong internal consistency (Cronbach's α 0.84-0.91) and moderate to good test-retest reliability (intraclass correlation coefficient 0.64-0.75) was found for each component. The myTREEHOUSE Self-Concept Assessment is a valid and reliable assessment of self-concept for children with CP aged 8 to 12 years. © 2017 Mac Keith Press.

Reliability and Applicability of the Bayley Scale of Infant Development-II for Children With Cerebral Palsy.

PubMed

Lee, Ji Hyun; Lim, Hye Kyung; Park, Eunyoung; Song, Junyoung; Lee, Hee Song; Ko, Jooyeon; Kim, Minyoung

2013-04-01

To obtain reliability and applicability of the Korean version Bayley Scale of Infant Development-II (BSID-II) in evaluating the developmental status of children with cerebral palsy (CP). The inter-rater reliability of BSID-II scores from 68 children with CP (46 boys and 22 girls; mean age, 32.54±16.76 months; age range, 4 to 78 months) was evaluated by 10 pediatric occupational therapists. Patients were classified in several ways according to age group, typology, and the severity of motor impairment by the level of the Gross Motor Function Classification System (GMFCS). The measures were performed by video analysis, and the results of intraclass correlation (ICC) were obtained for each of the above classifications. To evaluate the clinical applicability of BSID-II for CP, its correlation with the Gross Motor Function Measure (GMFM), which has been known as the standard motor assessment for CP, was investigated. ICC was 0.99 for the Mental scale and 0.98 for the Motor scale in all subjects. The values of ICC ranged from 0.92 to 0.99 for each age group, 0.93 to 0.99 for each typology, and 0.99 to 1.00 for each GMFCS level. A strong positive correlation was found between the BSID-II Motor raw score and the GMFM total score (r=0.84, p<0.001), and a moderate correlation was observed between the BSID-II Mental raw score and the GMFM total score (r=0.65, p<0.001). The Korean version of BSID-II is a reliable tool to measure the functional status of children with CP. The raw scores of BSID-II showed a great correlation with GMFM, indicating validity of this measure for children with CP on clinical basis.

Apolipoprotein E polymorphisms and severity of cerebral palsy: a cross-sectional study in 255 children in Norway

PubMed Central

LIEN, ESPEN; ANDERSEN, GURO L; BAO, YONGDE; GORDISH-DRESSMAN, HEATHER; SKRANES, JON S; VIK, TORSTEIN; BLACKMAN, JAMES A

2012-01-01

Aim The aim of this study was to examine whether the presence of the apolipoprotein E (ApoE) allele APOEε4 is associated with less severe manifestations of cerebral palsy (CP), consistent with the suggested beneficial effect of this allele on neurodevelopment in children. Method ApoE genotyping was performed on buccal epithelial cells from 255 children (141 males 114 females; mean age 12y, SD 2y 3mo, range 9–17y) recorded in the Cerebral Palsy Register of Norway. The main outcome measure of CP severity was the Gross Motor Function Classification System (GMFCS). Secondary outcome measures were fine motor function, epilepsy, and the need for gastrostomy tube feeding (GTF). Results There was no association between the APOEε4 genotype and GMFCS levels (odds ratio [OR] 1.15; 95% confidence interval [CI] 0.66–1.99). However, the APOEε4 genotype was more often present among children with epilepsy (OR 2.2; 95% CI 1.1–4.2) and/or receiving GTF (OR 2.7; 95% CI 1.1–6.6). Among children with unilateral CP, the presence of APOEε4 was associated with more severe fine motor impairment (OR 2.6; 95% CI 1.3–6.9). Interpretation Our main hypothesis that APOEε4 would have a protective effect on neurodevelopment was not supported. Instead, subgroup analyses suggested an adverse effect of the APOEε4 genotype on the developing brain after injury. PMID:23384326

Motor Control of the Lower Extremity Musculature in Children with Cerebral Palsy

ERIC Educational Resources Information Center

Arpin, David J.; Stuberg, Wayne; Stergiou, Nicholas; Kurz, Max J.

2013-01-01

The aim of this investigation was to quantify the differences in torque steadiness and variability of the muscular control in children with cerebral palsy (CP) and typically developing (TD) children. Fifteen children with CP (age = 14.2 [plus or minus] 0.7 years) that had a Gross Motor Function Classification System (GMFCS) score of I-III and 15…

Feasibility and Reliability of the Modified Berg Balance Scale in Persons with Severe Intellectual and Visual Disabilities

ERIC Educational Resources Information Center

Waninge, A.; van Wijck, R.; Steenbergen, B.; van der Schans, C. P.

2011-01-01

Background: The purpose of this study was to determine the feasibility and reliability of the modified Berg Balance Scale (mBBS) in persons with severe intellectual and visual disabilities (severe multiple disabilities, SMD) assigned Gross Motor Function Classification System (GMFCS) grades I and II. Method: Thirty-nine participants with SMD and…

Bone mineral density and nutritional status in children with quadriplegic cerebral palsy.

PubMed

Alvarez Zaragoza, Citlalli; Vasquez Garibay, Edgar Manuel; García Contreras, Andrea A; Larrosa Haro, Alfredo; Romero Velarde, Enrique; Rea Rosas, Alejandro; Cabrales de Anda, José Luis; Vega Olea, Israel

2018-03-04

This study demonstrated the relationship of low bone mineral density (BMD) with the degree of motor impairment, method of feeding, anthropometric indicators, and malnutrition in children with quadriplegic cerebral palsy (CP). The control of these factors could optimize adequate bone mineralization, avoid the risk of osteoporosis, and would improve the quality of life. The purpose of the study is to explore the relationship between low BMD and nutritional status in children with quadriplegic CP. A cross-sectional analytical study included 59 participants aged 6 to 18 years with quadriplegic CP. Weight and height were obtained with alternative measurements, and weight/age, height/age, and BMI/age indexes were estimated. The BMD measurement obtained from the lumbar spine was expressed in grams per square centimeter and Z score (Z). Unpaired Student's t tests, chi-square tests, odds ratios, Pearson's correlations, and linear regressions were performed. The mean of BMD Z score was lower in adolescents than in school-aged children (p = 0.002). Patients with low BMD were at the most affected levels of the Gross Motor Function Classification System (GMFCS). Participants at level V of the GMFCS were more likely to have low BMD than levels III and IV [odds ratio (OR) = 5.8 (confidence interval [CI] 95% 1.4, 24.8), p = 0.010]. There was a higher probability of low BMD in tube-feeding patients [OR = 8.6 (CI 95% 1.0, 73.4), p = 0.023]. The probability of low BMD was higher in malnourished children with weight/age and BMI indices [OR = 11.4 (1.3, 94), p = 0.009] and [OR = 9.4 (CI 95% 1.1, 79.7), p = 0.017], respectively. There was a significant relationship between low BMD, degree of motor impairment, method of feeding, and malnutrition. Optimizing these factors could reduce the risk of osteopenia and osteoporosis and attain a significant improvement of quality of life in children with quadriplegic CP.

Measuring Mobility Limitations in Children with Cerebral Palsy: Content and Construct Validity of a Mobility Questionnaire (MobQues)

ERIC Educational Resources Information Center

Van Ravesteyn, Nicolien T.; Scholtes, Vanessa A.; Becher, Jules G.; Roorda, Leo D.; Verschuren, Olaf; Dallmeijer, Annet J.

2010-01-01

Aim: The objective of this study was to assess the validity of a mobility questionnaire (MobQues) that was developed to measure parent-reported mobility limitations in children with cerebral palsy (CP). Method: The parents of 439 children with CP (256 males and 183 females; age range 2-18y; Gross Motor Function Classification System [GMFCS] levels…

Morphometric analysis of the femur in cerebral palsy: 3-dimensional CT study.

PubMed

Gose, Shinichi; Sakai, Takashi; Shibata, Toru; Murase, Tsuyoshi; Yoshikawa, Hideki; Sugamoto, Kazuomi

2010-09-01

The cause of hip disorder in cerebral palsy (CP) has been thought to involve muscle imbalance, flexion, and adduction contracture of the hip joint, acetabular dysplasia, and femoral growth abnormalities. The aim of this study was to quantitatively evaluate the 3-dimensional femoral geometry and subluxation/dislocation of the hip in spastic CP using 3D-CT reconstructed images of the pelvis and the femur, focusing on the femoral growth abnormalities in CP. Between June 2006 and September 2009, 186 hips in 93 bilateral spastic CP patients, including spastic diplegia (SD) in 73 patients and spastic quadriplegia (SQ) in 20 patients, who had not received any surgical treatment, were investigated using 3D-CT at our hospital. There were 59 boys and 34 girls with an average age of 5.3 years (range: 2.6 to 6.8 y). As an index for the femoral geometry, the neck-shaft angle, the femoral anteversion, and the femoral offset were 3-dimensionally measured. The center of the acetabulum and the femoral head were determined to calculate the CT migration percentage as the distance between these centers divided by the femoral head diameter. To elucidate the factors related to hip subluxation/dislocation, the relationships between the neck-shaft angle, the femoral anteversion, the femoral offset, and the CT migration percentage were investigated. The mean neck-shaft angle was 150.4+/-9.4 degrees (range: 129.4 to 173.2 degrees). The mean femoral anteversion was 44.4+/-13.6 degrees (range: 5.8 to 84.0 degrees). The mean CT migration percentage was 22.4+/-22.7% (range: 3 to 129%). There was positive correlation between the CT migration percentage and the neck-shaft angle (r=0.49). Hips with large CT migration percentage tended to show coxa valga. There was an inverse correlation between the neck-shaft angle and the femoral offset (r=-0.90), but no correlation between the CT migration percentage and the femoral anteversion (r=0.26), between the femoral offset and the femoral anteversion (r=-0.25), or between the neck-shaft angle and the femoral anteversion (r=0.23). The neck-shaft angle, the femoral anteversion, and the CT migration percentage were significantly larger, and the femoral offset was significantly smaller, in patients with the Gross Motor Functional Classification System (GMFCS) level IV/V (nonwalking children) and SQ type, than in patients with GMFCS level II/III (mostly walking children) and SD type. The 3-dimensional femoral geometry in CP patients can be analyzed quantitatively using 3D-CT regardless of the abnormal spastic posture. Our data indicate that 3-dimensional evaluation is accurate and useful for analysis of the femur and acetabulum in CP, and that the extent of coxa valga and femoral anteversion is more severe in the patients with GMFCS level IV/V and SQ type. Level IV.

Amount and focus of physical therapy and occupational therapy for young children with cerebral palsy.

PubMed

Palisano, Robert J; Begnoche, Denise M; Chiarello, Lisa A; Bartlett, Doreen J; McCoy, Sarah Westcott; Chang, Hui-Ju

2012-11-01

The aims of this study were to describe physical therapy (PT) and occupational therapy (OT) services for a cohort of 399 children with cerebral palsy (CP), 2-6 years old, residing in the United States and Canada. Parents completed a services questionnaire by telephone interview. Therapists classified children's Gross Motor Function Classification System (GMFCS) level. Mean minutes per month of PT and OT were greater for children receiving services in both an educational and clinic setting. Mean minutes per month of PT and OT were greater for children in levels IV-V than children in level I and greater for children in the United States than children in Canada. Parents reported that interventions focused a moderate to great extent on primary impairments, secondary impairments, activity, and structured play activities, a moderate extent on environmental modifications and equipment; and a moderate to small extent on self-care routines. The results support the importance of coordination of PT and OT services.

Functional Communication Profiles in Children with Cerebral Palsy in Relation to Gross Motor Function and Manual and Intellectual Ability.

PubMed

Choi, Ja Young; Park, Jieun; Choi, Yoon Seong; Goh, Yu Ra; Park, Eun Sook

2018-07-01

The aim of the present study was to investigate communication function using classification systems and its association with other functional profiles, including gross motor function, manual ability, intellectual functioning, and brain magnetic resonance imaging (MRI) characteristics in children with cerebral palsy (CP). This study recruited 117 individuals with CP aged from 4 to 16 years. The Communication Function Classification System (CFCS), Viking Speech Scale (VSS), Speech Language Profile Groups (SLPG), Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and intellectual functioning were assessed in the children along with brain MRI categorization. Very strong relationships were noted among the VSS, CFCS, and SLPG, although these three communication systems provide complementary information, especially for children with mid-range communication impairment. These three communication classification systems were strongly related with the MACS, but moderately related with the GMFCS. Multiple logistic regression analysis indicated that manual ability and intellectual functioning were significantly related with VSS and CFCS function, whereas only intellectual functioning was significantly related with SLPG functioning in children with CP. Communication function in children with a periventricular white matter lesion (PVWL) varied widely. In the cases with a PVWL, poor functioning was more common on the SLPG, compared to the VSS and CFCS. Very strong relationships were noted among three communication classification systems that are closely related with intellectual ability. Compared to gross motor function, manual ability seemed more closely related with communication function in these children. © Copyright: Yonsei University College of Medicine 2018.

Avascular necrosis in children with cerebral palsy after reconstructive hip surgery

PubMed Central

Phillips, L.; Hesketh, K.; Schaeffer, E. K.; Andrade, J.; Farr, J.; Mulpuri, K.

2017-01-01

Abstract Purpose Progressive hip displacement is one of the most common orthopaedic pathologies in children with cerebral palsy (CP). Reconstructive hip surgery has become the standard treatment of care. Reported avascular necrosis (AVN) rates for hip reconstructive surgery in these patients vary widely in the literature. The purpose of this study is to identify the frequency and associated risk factors of AVN for reconstructive hip procedures. Methods A retrospective analysis was performed of 70 cases of reconstructive hip surgery in 47 children with CP, between 2009 and 2013. All 70 cases involved varus derotation osteotomy (VDRO), with 60% having combined VDRO and pelvic osteotomies (PO), and 21% requiring open reductions. Mean age at time of surgery was 8.82 years and 90% of patients were Gross Motor Function Classification System (GMFCS) 4 and 5. Radiographic dysplasia parameters were analysed at selected intervals, to a minimum of one year post-operatively. Severity of AVN was classified by Kruczynski's method. Bivar- iate statistical analysis was conducted using Chi-square test and Student's t-test. Results There were 19 (27%) noted cases of AVN, all radio- graphically identifiable within the first post-operative year. The majority of AVN cases (63%) were mild to moderate in severity. Pre-operative migration percentage (MP) (p = 0.0009) and post-operative change in MP (p = 0.002) were the most significant predictors of AVN. Other risk factors were: GMFCS level (p = 0.031), post-operative change in NSA (p = 0.02) and concomitant adductor tenotomy (0.028). Conclusion AVN was observed in 27% of patients. Severity of displacement correlates directly with AVN risk and we suggest that hip reconstruction, specifically VDRO, be performed early in the 'hip at risk' group to avoid this complication. PMID:29081846

Avascular necrosis in children with cerebral palsy after reconstructive hip surgery.

PubMed

Phillips, L; Hesketh, K; Schaeffer, E K; Andrade, J; Farr, J; Mulpuri, K

2017-10-01

Progressive hip displacement is one of the most common orthopaedic pathologies in children with cerebral palsy (CP). Reconstructive hip surgery has become the standard treatment of care. Reported avascular necrosis (AVN) rates for hip reconstructive surgery in these patients vary widely in the literature. The purpose of this study is to identify the frequency and associated risk factors of AVN for reconstructive hip procedures. A retrospective analysis was performed of 70 cases of reconstructive hip surgery in 47 children with CP, between 2009 and 2013. All 70 cases involved varus derotation osteotomy (VDRO), with 60% having combined VDRO and pelvic osteotomies (PO), and 21% requiring open reductions. Mean age at time of surgery was 8.82 years and 90% of patients were Gross Motor Function Classification System (GMFCS) 4 and 5. Radiographic dysplasia parameters were analysed at selected intervals, to a minimum of one year post-operatively. Severity of AVN was classified by Kruczynski's method. Bivar- iate statistical analysis was conducted using Chi-square test and Student's t-test. There were 19 (27%) noted cases of AVN, all radio- graphically identifiable within the first post-operative year. The majority of AVN cases (63%) were mild to moderate in severity. Pre-operative migration percentage (MP) (p = 0.0009) and post-operative change in MP (p = 0.002) were the most significant predictors of AVN. Other risk factors were: GMFCS level (p = 0.031), post-operative change in NSA (p = 0.02) and concomitant adductor tenotomy (0.028). AVN was observed in 27% of patients. Severity of displacement correlates directly with AVN risk and we suggest that hip reconstruction, specifically VDRO, be performed early in the 'hip at risk' group to avoid this complication.

Neurogenic Lower Urinary Tract Dysfunction in Adults with Cerebral Palsy: Outcomes following a Conservative Management Approach.

PubMed

Goldfarb, Robert A; Pisansky, Andrew; Fleck, Joseph; Hoversten, Patrick; Cotter, Katherine J; Katorski, Jenna; Liberman, Daniel; Elliott, Sean P

2016-04-01

Cerebral palsy is characterized by motor impairment following injury to the developing brain. Neurogenic lower urinary tract dysfunction is estimated to affect at least a third of children with cerebral palsy. However there are limited data as patients transition to adulthood. We sought to describe the symptoms, sequelae and management of neurogenic lower urinary tract dysfunction in adults with cerebral palsy. We retrospectively reviewed the charts of adult patients with cerebral palsy between 2011 and 2014. Patients with prior bladder reconstruction or catheterization based bladder drainage were excluded from study. Cerebral palsy severity was determined using GMFCS (Gross Motor Function Classification System). A conservative evaluation and treatment paradigm was used. Noninvasive treatments were encouraged. Specifically clean intermittent catheterization, which is often not feasible, is avoided unless urinary retention, hydronephrosis or refractory lower urinary tract symptoms develop. There were 121 patients included in final analysis. Median age was 25 and 61 patients (50%) had GMFCS level V. Noninvasive management failed in 28 of 121 patients (23%) as defined by hydronephrosis in 9, persistent urinary retention in 10 and refractory lower urinary tract symptoms/incontinence in 9. Urethral clean intermittent catheterization was poorly tolerated. Of all patients 25% showed evidence of urolithiasis during the study period. Surgical intervention was rare and associated with significant morbidity. Adults with cerebral palsy may present with variable signs and symptoms of neurogenic lower urinary tract dysfunction. Conservative treatment was successful in more than 75% of patients. Clean intermittent catheterization was poorly tolerated in patients in whom conservative treatment failed. Surgical intervention was rarely indicated and it should be reserved for select individuals. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Correlation Between Fractional Anisotropy and Motor Outcomes in One-Year-Old Infants with Periventricular Brain Injury

PubMed Central

Madhavan, Sangeetha; Campbell, Suzann K.; Campise-Luther, Rose; Gaebler-Spira, Deborah; Zawacki, Laura; Clark, April; Boynewicz, Kara; Kale, Dipti; Bulanda, Michelle; Yu, Jinsheng; Sui, Yi; Zhou, Xiaohong Joe

2014-01-01

Purpose To determine whether motor outcomes of an exercise intervention beginning at 2 months corrected age (CA) in children with periventricular brain injury (PBI) are correlated with fractional anisotropy (FA) measures derived from diffusion tensor imaging (DTI) at 12 months CA. Materials and Methods DTI was performed in eight infants with PBI who were randomly assigned to kicking and treadmill stepping exercise or a no-training condition. Development was assessed using the Alberta Infant Motor Scale (AIMS) and the Gross Motor Function Classification System (GMFCS). FA values were derived from regions of interest (ROI) in the middle third of the posterior limb of the internal capsule (PLIC) and the posterior thalamic radiation (PTR). Results Significant correlations were observed between motor development and FA measures. For PLIC, the correlation coefficients were 0.82 between FA and AIMS, and -0.92 between FA and GMFCS, while for PTR the corresponding correlation coefficients were 0.73 and -0.80, respectively. Conclusion Results of this study suggest that quantitative evaluation of white matter tracts using DTI at 12 months CA may be useful for assessment of brain plasticity in children. PMID:24136687

Correlation between fractional anisotropy and motor outcomes in one-year-old infants with periventricular brain injury.

PubMed

Madhavan, Sangeetha; Campbell, Suzann K; Campise-Luther, Rose; Gaebler-Spira, Deborah; Zawacki, Laura; Clark, April; Boynewicz, Kara; Kale, Dipti; Bulanda, Michelle; Yu, Jinsheng; Sui, Yi; Zhou, Xiaohong Joe

2014-04-01

To determine whether motor outcomes of an exercise intervention beginning at 2 months corrected age (CA) in children with periventricular brain injury (PBI) are correlated with fractional anisotropy (FA) measures derived from diffusion tensor imaging (DTI) at 12 months CA. DTI was performed in eight infants with PBI who were randomly assigned to kicking and treadmill stepping exercise or a no-training condition. Development was assessed using the Alberta Infant Motor Scale (AIMS) and the Gross Motor Function Classification System (GMFCS). FA values were derived from regions of interest (ROIs) in the middle third of the posterior limb of the internal capsule (PLIC) and the posterior thalamic radiation (PTR). Significant correlations were observed between motor development and FA measures. For PLIC, the correlation coefficients were 0.82 between FA and AIMS, and -0.92 between FA and GMFCS, while for PTR the corresponding correlation coefficients were 0.73 and -0.80, respectively. Results of this study suggest that quantitative evaluation of white matter tracts using DTI at 12 months CA may be useful for assessment of brain plasticity in children. Copyright © 2013 Wiley Periodicals, Inc.

Correlation of quantitative sensorimotor tractography with clinical grade of cerebral palsy.

PubMed

Trivedi, Richa; Agarwal, Shruti; Shah, Vipul; Goyel, Puneet; Paliwal, Vimal K; Rathore, Ram K S; Gupta, Rakesh K

2010-08-01

The purpose of this study was to determine whether tract-specific diffusion tensor imaging measures in somatosensory and motor pathways correlate with clinical grades as defined using the Gross Motor Function Classification System (GMFCS) in cerebral palsy (CP) children. Quantitative diffusion tensor tractography was performed on 39 patients with spastic quadriparesis (mean age = 8 years) and 14 age/sex-matched controls. All patients were graded on the basis of GMFCS scale into grade II (n = 12), grade IV (n = 22), and grade V (n = 5) CP and quantitative analysis reconstruction of somatosensory and motor tracts performed. Significant inverse correlation between clinical grade and fractional anisotropy (FA) was observed in both right and left motor and sensory tracts. A significant direct correlation of mean diffusivity values from both motor and sensory tracts was also observed with clinical grades. Successive decrease in FA values was observed in all tracts except for left motor tracts moving from age/sex-matched controls to grade V through grades II and IV. We conclude that white matter tracts from both the somatosensory and the motor cortex play an important role in the pathophysiology of motor disability in patients with CP.

Prevalence of cerebral palsy in Uganda: a population-based study.

PubMed

Kakooza-Mwesige, Angelina; Andrews, Carin; Peterson, Stefan; Wabwire Mangen, Fred; Eliasson, Ann Christin; Forssberg, Hans

2017-12-01

Few population-based studies of cerebral palsy have been done in low-income and middle-income countries. We aimed to examine cerebral palsy prevalence and subtypes, functional impairments, and presumed time of injury in children in Uganda. In this population-based study, we used a nested, three-stage, cross-sectional method (Iganga-Mayuge Health and Demographic Surveillance System [HDSS]) to screen for cerebral palsy in children aged 2-17 years in a rural eastern Uganda district. A specialist team confirmed the diagnosis and determined the subtype, motor function (according to the Gross Motor Function Classification System [GMFCS]), and possible time of brain injury for each child. Triangulation and interviews with key village informants were used to identify additional cases of suspected cerebral palsy. We estimated crude and adjusted cerebral palsy prevalence. We did χ 2 analyses to examine differences between the group screened at stage 1 and the entire population and regression analyses to investigate associations between the number of cases and age, GMFCS level, subtype, and time of injury. We used data from the March 1, 2015, to June 30, 2015, surveillance round of the Iganga-Mayuge HDSS. 31 756 children were screened for cerebral palsy, which was confirmed in 86 (19%) of 442 children who screened positive in the first screening stage. The crude cerebral palsy prevalence was 2·7 (95% CI 2·2-3·3) per 1000 children, and prevalence increased to 2·9 (2·4-3·6) per 1000 children after adjustment for attrition. The prevalence was lower in older (8-17 years) than in younger (<8 years) children. Triangulation added 11 children to the cohort. Spastic unilateral cerebral palsy was the most common subtype (45 [46%] of 97 children) followed by bilateral cerebral palsy (39 [40%] of 97 children). 14 (27%) of 51 children aged 2-7 years had severe cerebral palsy (GMFCS levels 4-5) compared with only five (12%) of 42 children aged 8-17 years. Few children (two [2%] of 97) diagnosed with cerebral palsy were born preterm. Post-neonatal events were the probable cause of cerebral palsy in 24 (25%) of 97 children. Cerebral palsy prevalence was higher in rural Uganda than in high-income countries (HICs), where prevalence is about 1·8-2·3 cases per 1000 children. Children younger than 8 years were more likely to have severe cerebral palsy than older children. Fewer older children than younger children with cerebral palsy suggested a high mortality in severely affected children. The small number of preterm-born children probably resulted from low preterm survival. About five times more children with post-neonatal cerebral palsy in Uganda than in HICs suggested that cerebral malaria and seizures were prevalent risk factors in this population. Swedish Research Council, Promobilia. Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Reliability and validity of Edinburgh visual gait score as an evaluation tool for children with cerebral palsy.

PubMed

Del Pilar Duque Orozco, Maria; Abousamra, Oussama; Church, Chris; Lennon, Nancy; Henley, John; Rogers, Kenneth J; Sees, Julieanne P; Connor, Justin; Miller, Freeman

2016-09-01

Assessment of gait abnormalities in cerebral palsy (CP) is challenging, and access to instrumented gait analysis is not always feasible. Therefore, many observational gait analysis scales have been devised. This study aimed to evaluate the interobserver reliability, intraobserver reliability, and validity of Edinburgh visual gait score (EVGS). Video of 30 children with spastic CP were reviewed by 7 raters (10 children each in GMFCS levels I, II, and III, age 6-12 years). Three observers had high level of experience in gait analysis (10+ years), two had medium level (2-5 years) and two had no previous experience (orthopedic fellows). Interobserver reliability was evaluated using percentage of complete agreement and kappa values. Criterion validity was evaluated by comparing EVGS scores with 3DGA data taken from the same video visit. Interobserver agreement was 60-90% and Kappa values were 0.18-0.85 for the 17 items in EVGS. Reliability was higher for distal segments (foot/ankle/knee 63-90%; trunk/pelvis/hip 60-76%), with greater experience (high 66-91%, medium 62-90%, no-experience 41-87%), with more EVGS practice (1st 10 videos 52-88%, last 10 videos 64-97%) and when used with higher functioning children (GMFCS I 65-96%, II 58-90%, III 35-65%). Intraobserver agreement was 64-92%. Agreement between EVGS and 3DGA was 52-73%. We believe that having EVGS as part of the standardized gait evaluation is helpful in optimizing the visual scoring. EVGS can be a supportive tool that adds quantitative data instead of only qualitative assessment to a video only gait evaluation. Copyright © 2016 Elsevier B.V. All rights reserved.

Predicting functional communication ability in children with cerebral palsy at school entry.

PubMed

Coleman, Andrea; Weir, Kelly; Ware, Robert S; Boyd, Roslyn

2015-03-01

To explore the value of demographic, environmental, and early clinical characteristics in predicting functional communication in children with cerebral palsy (CP) at school entry. Data are from an Australian prospective longitudinal study of children with CP. Children assessed at 18 to 24 and 48 to 60 months corrected age were included in the study. Functional communication was classified at 48 to 60 months using the Communication Function Classification System (CFCS). Predictive variables included communication skills at 18 to 24 months, evaluated using the Communication and Symbolic Behavioural Scales Developmental Profile (CSBS-DP) Infant-Toddler Checklist. Early Gross Motor Function Classification System (GMFCS), Manual Ability Classification System, and motor type and distribution were evaluated by two physiotherapists. Demographic and comorbid variables were obtained through parent interview with a paediatrician or rehabilitation specialist. A total of 114 children (76 males, 38 females) were included in the study. At 18 to 24 months the mean CSBS-DP was 84.9 (SD 19.0). The CFCS distribution at 48 to 60 months was I=36(32%), II=25(22%), III=20(18%), IV=19(17%), and V=14(12%). In multivariable regression analysis, only CSBS-DP (p<0.01) and GMFCS (p<0.01) at 18 to 24 months were predictors of functional communication at school entry. Body structure and function and not environmental factors impact functional communication at school entry in children with CP. This provides valuable guidance for early screening, parent education, and future planning of intervention programs to improve functional communication. © 2014 Mac Keith Press.

Predicting respiratory hospital admissions in young people with cerebral palsy.

PubMed

Blackmore, Amanda Marie; Bear, Natasha; Blair, Eve; Langdon, Katherine; Moshovis, Lisa; Steer, Kellie; Wilson, Andrew C

2018-03-19

To determine the early predictors of respiratory hospital admissions in young people with cerebral palsy (CP). A 3-year prospective cohort study using linked data. Children and young people with CP, aged 1 to 26 years. Self-reported and carer-reported respiratory symptoms were linked to respiratory hospital admissions (as defined by the International Statistical Classification of Diseases and Related Health Problems 10th Revision codes) during the following 3 years. 482 participants (including 289 males) were recruited. They were aged 1 to 26 years (mean 10 years, 10 months; SD 5 years, 11 months) at the commencement of the study, and represented all Gross Motor Function Classification Scale (GMFCS) levels. During the 3-year period, 55 (11.4%) participants had a total of 186 respiratory hospital admissions, and spent a total of 1475 days in hospital. Statistically significant risk factors for subsequent respiratory hospital admissions over 3 years in univariate analyses were GMFCS level V, at least one respiratory hospital admission in the year preceding the survey, oropharyngeal dysphagia, seizures, frequent respiratory symptoms, gastro-oesophageal reflux disease, at least two courses of antibiotics in the year preceding the survey, mealtime respiratory symptoms and nightly snoring. Most risk factors for respiratory hospital admissions are potentially modifiable. Early identification of oropharyngeal dysphagia and the management of seizures may help prevent serious respiratory illness. One respiratory hospital admission should trigger further evaluation and management to prevent subsequent respiratory illness. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Higher Levels of Caregiver Strain Perceived by Indian Mothers of Children and Young Adults with Cerebral Palsy Who have Limited Self-Mobility.

PubMed

Prakash, V; Patel, Anjali M; Hariohm, K; Palisano, Robert J

2017-02-01

Describe and compare the caregiver strain experienced among Indian mothers of children and young adults with cerebral palsy (CP) living in low resource settings. 62 consecutive children and young adults with spastic CP (mean age 6.0 ± 4.5, range 2-21) and their parents were recruited from an outpatient physiotherapy department for this cross-sectional study. Ability to walk was classified using the Gross Motor Function Classification System and mother's caregiver strain was measured using caregiver strain index (CSI). Mothers of children and young adults who have limited self-mobility perceived higher caregiver strain (mean CSI score 12.0 ± 1.3, p < 0.05) than mothers of children who can walk (mean CSI score 4.5 ± 3.0, p < 0.05). All 46 mothers of children and youth in GMFCS levels IV and V reported high levels of caregiver stress compared with only three of 16 mothers of children and youth who walk (levels I and II). Physiotherapists and occupational therapists serving children and youth with CP are encouraged to partner with families to identify goals for ease of caregiving, activity, and participation at home and in the community.

Effect of cerebrolysin on gross motor function of children with cerebral palsy: a clinical trial.

PubMed

Nasiri, Jafar; Safavifar, Faezeh

2017-06-01

Gross motor dysfunction is considered as the most challenging problem in cerebral palsy (CP). It is proven that improvement of gross motor function could reduce CP-related disabilities and provide better quality of life in this group of patients. Therefore, the aim of this trial is to evaluate the effectiveness of cerebrolysin (CBL) on gross motor function of children with CP who are undergoing treatment. In this clinical trial study, paediatric patients aged 18-75 months with spastic diplegic or quadriplegic cerebral palsy, who were under rehabilitation therapy, were selected and randomly allocated in control and CBL groups. Patients in CBL group underwent treatment with standard rehabilitation therapy plus CBL. The latter was administrated intramuscularly as a single daily dose of 0.1 cc/kg for 10 days and then continued weekly for 4 months. Gross motor function of participants in the two studied groups, before and after trial, was evaluated and compared using the validated Persian version of gross motor function classification system-expanded and revised (GMFCS-E&R). During this trial, 108 patients with CP were evaluated for eligibility. From these, 50 patients were enrolled and randomly allocated in the CBL and control groups. Four months after trial, the mean level of GMFCS decreased significantly in the two groups (P < 0.05). However, it was significantly lower in the CBL group than in the control group (2.1 vs. 3.16, P < 0.05). The results of this trial indicated that CBL could improve gross motor function in patients with CP. This finding is consistent with neurotrophic and neuroprotective effects of CBL, which have been reported in various clinical trials in other neurological disorders. Further studies are recommended to establish the value of continued neuroprotection and to determine the pharmacokinetics/dynamics of CBL in this group of patients.

Perceptual visual dysfunction, physical impairment and quality of life in Bangladeshi children with cerebral palsy.

PubMed

Mitry, D; Williams, C; Northstone, K; Akter, A; Jewel, J; Khan, N; Muhit, M; Gilbert, C E; Bowman, R

2016-09-01

Cerebral palsy (CP) is the most common cause of motor disability in children and is often accompanied by sensory and/or cognitive impairment. The aim of this study was to characterise visual acuity impairment, perceptual visual dysfunction (PVD) and physical disability in a community-based sample of Bangladeshi children with CP and to assess the impact of these factors on the quality of life of the children. A key informant study was used to recruit children with CP from Sirajganj district. Gross Motor Function Classification System (GMFCS) levels and visual impairment were assessed by a physiotherapist and an optometrist, respectively. Assessments of visual perception were performed and standardised questionnaires were administered to each child's main carer to elicit indicators of PVD and parent-reported health-related quality of life. A generalised linear regression analysis was conducted to assess the determinants of the quality of life scores. 180 children were recruited. The median age was 8 years (IQR: 6-11 years); 112 (62%) were male; 57 (32%) had visual acuity impairment and 95 (53%) had some parent-reported PVD. In analyses adjusted for age, sex, GMFCS and acuity impairment, visual attention (p<0.001) and recognition/navigation (p<0.001) were associated with total health-related quality of life, and there were similar trends for total PVD score (p=0.006) and visual search (p=0.020). PVD is an important contributor in reducing quality of life in children with CP, independent of motor disability and acuity impairment. Better characterisation of PVD is important to help design interventions for affected children, which may improve their quality of life. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A Trunk Support System to Identify Posture Control Mechanisms in Populations Lacking Independent Sitting

PubMed Central

Goodworth, Adam D.; Wu, Yen-Hsun; Felmlee, Duffy; Dunklebarger, Ellis; Saavedra, Sandra

2016-01-01

Populations with moderate-to-severe motor control impairments often exhibit degraded trunk control and/or lack the ability to sit unassisted. These populations need more research, yet their underdeveloped trunk control complicates identification of neural mechanisms behind their movements. The purpose of this study was to overcome this barrier by developing the first multi-articulated trunk support system to identify visual, vestibular, and proprioception contributions to posture in populations lacking independent sitting. The system provided external stability at a user-specific level on the trunk, so that body segments above the level of support required active posture control. The system included a tilting surface (controlled via servomotor) as a stimulus to investigate sensory contributions to postural responses. Frequency response and coherence functions between the surface tilt and trunk support were used to characterize system dynamics and indicated that surface tilts were accurately transmitted up to 5Hz. Feasibility of collecting kinematic data in participants lacking independent sitting was demonstrated in two populations: two typically developing infants, ~2-8 months, in a longitudinal study (8 sessions each) and four children with moderate-to-severe cerebral palsy (GMFCS III-V). Adaptability in the system was assessed by testing 16 adults (ages 18-63). Kinematic responses to continuous pseudorandom surface tilts were evaluated across 0.046–2Hz and qualitative feedback indicated that the trunk support and stimulus were comfortable for all subjects. Concepts underlying the system enable both research for, and rehabilitation in, populations lacking independent sitting. PMID:27046877

Social Attitudes toward Cerebral Palsy and Potential Uses in Medical Education Based on the Analysis of Motion Pictures.

PubMed

Jóźwiak, Marek; Chen, Brian Po-Jung; Musielak, Bartosz; Fabiszak, Jacek; Grzegorzewski, Andrzej

2015-01-01

This study presents how motion pictures illustrate a person with cerebral palsy (CP), the social impact from the media, and the possibility of cerebral palsy education by using motion pictures. 937 motion pictures were reviewed in this study. With the criteria of nondocumentary movies, possibility of disability classification, and availability, the total number of motion pictures about CP was reduced to 34. The geographical distribution of movie number ever produced is as follows: North America 12, Europe 11, India 2, East Asia 6, and Australia 3. The CP incidences of different motor types in real world and in movies, respectively, are 78-86%, 65% (Spastic); 1.5-6%, 9% (Dyskinetic); 6.5-9%, 26% (Mixed); 3%, 0% (Ataxic); 3-4%, 0% (Hypotonic). The CP incidences of different Gross Motor Function Classification System (GMFCS) levels in real world and in movies, respectively, are 40-51%, 47% (Level I + II); 14-19%, 12% (Level III); 34-41%, 41% (Level IV + V). Comparisons of incidence between the real world and the movies are surprisingly matching. Motion pictures honestly reflect the general public's point of view to CP patients in our real world. With precise selection and medical professional explanations, motion pictures can play the suitable role making CP understood more clearly.

Family ecology of young children with cerebral palsy.

PubMed

LaForme Fiss, A; Chiarello, L A; Bartlett, D; Palisano, R J; Jeffries, L; Almasri, N; Chang, H-J

2014-07-01

Family ecology in early childhood may influence children's activity and participation in daily life. The aim of this study was to describe family functioning, family expectations of their children, family support to their children, and supports for families of young children with cerebral palsy (CP) based on children's gross motor function level. Participants were 398 children with CP (mean age = 44.9 months) and their parents residing in the USA and Canada. Parents completed four measures of family ecology, the Family Environment Scale (FES), Family Expectations of Child (FEC), Family Support to Child (FSC) and Family Support Scale (FSS). The median scores on the FES indicated average to high family functioning and the median score on the FSS indicated that families had helpful family supports. On average, parents reported high expectations of their children on the FEC and strong support to their children on the FSC. On the FES, higher levels of achievement orientation were reported by parents of children in Gross Motor Function Classification System (GMFCS) level II than parents of children in level I, and higher levels of control were reported by parents of children in level I than parents of children in level IV. On the FEC, parents of children with limited gross motor function (level V) reported lower expectations than parents of children at all other levels. Family ecology, including family strengths, expectations, interests, supports and resources, should be discussed when providing interventions and supports for young children with CP and their families. © 2013 John Wiley & Sons Ltd.

Evaluation of group versus individual physiotherapy following lower limb intra-muscular Botulinum Toxin-Type A injections for ambulant children with cerebral palsy: A single-blind randomized comparison trial.

PubMed

Thomas, Rachel E; Johnston, Leanne M; Sakzewski, Leanne; Kentish, Megan J; Boyd, Roslyn N

2016-01-01

This study aimed to evaluate efficacy of group (GRP) versus individual (IND) physiotherapy rehabilitation following lower limb intramuscular injections of Botulinum Toxin-Type A (BoNT-A) for ambulant children with cerebral palsy (CP). Following lower limb BoNT-A injections, 34 children were randomly allocated to GRP (n=17; mean age 7y8m SD 2.0; 13 males; Gross Motor Function Classification System (GMFCS) I=5, II=8, III=4) or IND physiotherapy (n=17; mean age 8y7m SD 2.0; 11 males; GMFCS I=9, II=5, III=3). Primary outcomes were the Canadian Occupational Performance Measure (COPM) and Edinburgh Visual Gait Score (EVGS) assessed at baseline, 10 and 26 weeks post intervention. There were no baseline differences between groups. GRP intervention had greater, but not clinically meaningful, improvement in COPM satisfaction (estimated mean difference EMD 1.7, 95% CI 0.4-3.1; p<0.01) at 26 weeks. Both groups demonstrated clinically significant improvements in COPM performance and satisfaction, but minimal change in quality of gait (EVGS). Six hours of direct physiotherapy (either GRP or IND) with an additional indirect dose (median 16 episodes) of individualized home programme activities following lower limb BoNT-A injections, however, was inadequate to drive clinically meaningful changes in lower limb motor outcomes. Copyright © 2016 Elsevier Ltd. All rights reserved.

Obstructive sleep apnea in children with cerebral palsy and epilepsy.

PubMed

Garcia, John; Wical, Beverly; Wical, William; Schaffer, Leah; Wical, Thomas; Wendorf, Heather; Roiko, Samuel

2016-10-01

To examine the risk of obstructive sleep apnea (OSA) in children with cerebral palsy (CP) and/or epilepsy. This cross-sectional study employs the Pediatric Sleep Questionnaire (PSQ), the Gross Motor Function Classification System (GMFCS), and chart review to identify symptoms of OSA in children presenting to a multi-specialty pediatric healthcare institution. Two-hundred and fifteen patients were grouped into those with epilepsy (n=54), CP (n=18), both (n=55), and neither (comparison group, n=88). The comparison group comprised children with developmental disabilities but not children with typical development. Significantly increased PSQ scores (indicating increased risk of OSA) were found among children with CP (58%) and CP with epilepsy (67%) than among the comparison group (27%; p<0.001 and p<0.0001 respectively). Children with both CP and epilepsy had a greater number of increased PSQ scores compared with CP alone (p<0.05). Increased PSQ scores were observed with increasing CP severity as measured using the GMFCS. The PSQ identified more children at risk of OSA (46%) than did the medical record review for symptoms of OSA (8.2%, p<0.001). Children with CP of greater severity or comorbid epilepsy are at increased risk of OSA. This study supports the routine questionnaire-based assessment for OSA as a regular part of the care of all children with CP, especially in those with more severe CP and those with epilepsy. © 2016 Mac Keith Press.

Predicting equipment needs of children with cerebral palsy using the Gross Motor Function Classification System: a cross-sectional study.

PubMed

Novak, Iona; Smithers-Sheedy, Hayley; Morgan, Cathy

2012-01-01

Children with cerebral palsy (CP) routinely use assistive equipment to improve their independence. Specialist equipment is expensive and therefore not always available to the child when needed. The aim of this study was to determine whether the assistive equipment needs of children with CP and the associated costs could be predicted. A cross-sectional study using a chart audit was completed. Two hundred forty-two children met eligibility criteria and were included in the study. Data abstracted from files pertained to the child's CP, associated impairments and assistive equipment prescribed. The findings were generated using linear regression modelling. Gross Motor Function Classification System (GMFCS) level [B = 3.01 (95% CI, 2.36-3.57), p = 0.000] and the presence of epilepsy [B = 2.35 (95% CI, 0.64-4.06), p = 0.008] predicted the prescription of assistive equipment. The more severely affected the gross motor function impairment, the more equipment that was required and the more the equipment cost. The equipment needs of children with CP can be predicted for the duration of childhood. This information may be useful for families and for budget and service planning.

A home-based body weight supported treadmill training program for children with cerebral palsy: A case series.

PubMed

Kenyon, Lisa K; Westman, Marci; Hefferan, Ashley; McCrary, Peter; Baker, Barbara J

2017-07-01

Contemporary approaches to the treatment of cerebral palsy (CP) advocate a task-specific approach that emphasizes repetition and practice of specific tasks. Recent studies suggest that body-weight-supported treadmill training (BWSTT) programs may be beneficial in clinical settings. The purposes of this case series were to explore the outcomes and feasibility of a home-based BWSTT program for three children with CP. Three children with CP at Gross Motor Function Classification System (GMFCS) Levels III or IV participated in this case series. Examination included the Functional Assessment Questionnaire (FAQ), the 10-meter walk test, the Gross Motor Function Measure (GMFM-66), and the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT). A harness system was used to conduct the BWSTT program over an 8-12 week period. All of the families reported enjoying the BWSTT program and found the harness easy to use. Participant 2 increased from a 2 to a 4 on the FAQ, while Participant 3 increased from a 6 to a 7. Two of the participants demonstrated post-intervention improvements in functional mobility. In addition to mobility outcomes, future research should explore the potential health benefits of a home-based BWSTT program.

A multiple camera tongue switch for a child with severe spastic quadriplegic cerebral palsy.

PubMed

Leung, Brian; Chau, Tom

2010-01-01

The present study proposed a video-based access technology that facilitated a non-contact tongue protrusion access modality for a 7-year-old boy with severe spastic quadriplegic cerebral palsy (GMFCS level 5). The proposed system featured a centre camera and two peripheral cameras to extend coverage of the frontal face view of this user for longer durations. The child participated in a descriptive case study. The participant underwent 3 months of tongue protrusion training while the multiple camera tongue switch prototype was being prepared. Later, the participant was brought back for five experiment sessions where he worked on a single-switch picture matching activity, using the multiple camera tongue switch prototype in a controlled environment. The multiple camera tongue switch achieved an average sensitivity of 82% and specificity of 80%. In three of the experiment sessions, the peripheral cameras were associated with most of the true positive switch activations. These activations would have been missed by a centre-camera-only setup. The study demonstrated proof-of-concept of a non-contact tongue access modality implemented by a video-based system involving three cameras and colour video processing.

Does Nintendo Wii Balance Board improve standing balance? A randomized controlled trial in children with cerebral palsy.

PubMed

Gatica-Rojas, Valeska; Méndez-Rebolledo, Guillermo; Guzman-Muñoz, Eduardo; Soto-Poblete, Alex; Cartes-Velásquez, Ricardo; Elgueta-Cancino, Edith; Cofré Lizama, L Eduardo

2017-08-01

Evidence on the effect of systemic exercise programs to improve the standing balance with the Nintendo Wii system is very limited and its post-treatment effectiveness is unknown in cerebral palsy (CP) patients. Primary aim was to compare the effect of Nintendo Wii balance board (Wii-therapy) and standard physiotherapy (SPT), on the performance of standing balance in children and adolescents with CP. Secondary aim was to determine the post-treatment effectiveness of Wii-therapy and SPT. Two-arm, matched-pairs, parallel-groups, randomized, controlled clinical trial. Outpatient Rehabilitation Centre in the city of Talca. Patients with CP type spastic hemiplegia (SHE) and spastic diplegia (SDI), aged 7 to 14 years, and level I or II of GMFCS or GMFCS-ER. Were excluded patients with FSIQ<80, epilepsy, previous surgeries and application of Botulinum Toxin-A in the lower limb, uncorrected vision and hearing disorders. Thirty-two CP patients (10.7±3.2 years old) were randomly assigned to either Wii-therapy (SDI=7; SHE=9) or SPT intervention (SDI=7; SHE=9). In each group, patients received three sessions per week over a period of 6 weeks. Standing balance was assessed at baseline and every 2 weeks. Additionally, two follow-up assessments (4 additional weeks) were performed to determine post-treatment effectiveness. Standing balance was quantified on force platform obtaining the outcomes area of center-of-pressure (CoP) sway (CoPSway), standard deviation in the medial-lateral (SDML) and the anterior-posterior (SDAP) directions, and velocity in both directions (VML and VAP). Compared to SPT, Wii-therapy significantly reduced the CoPSway (P=0.02) and SDAP in the eyes-open condition (P=0.01). However, the effects wane after 2-4 weeks. Post-hoc analysis revealed that only SHE children benefited from Wii-therapy. Wii-therapy was better than SPT in improving standing balance in patients with CP, but improves the balance only in SHE patients. Also, Wii-therapy effectiveness waned 2-4 weeks after the end the intervention. A systematic exercise program like Wii-therapy using the Nintendo Wii Balance Board device can be considered to improves the standing balance in patients with CP, specifically in the SHE type. This program is easy to transfer to physiotherapists and rehabilitation centers.

Social Attitudes toward Cerebral Palsy and Potential Uses in Medical Education Based on the Analysis of Motion Pictures

PubMed Central

Jóźwiak, Marek; Chen, Brian Po-Jung; Musielak, Bartosz; Fabiszak, Jacek; Grzegorzewski, Andrzej

2015-01-01

This study presents how motion pictures illustrate a person with cerebral palsy (CP), the social impact from the media, and the possibility of cerebral palsy education by using motion pictures. 937 motion pictures were reviewed in this study. With the criteria of nondocumentary movies, possibility of disability classification, and availability, the total number of motion pictures about CP was reduced to 34. The geographical distribution of movie number ever produced is as follows: North America 12, Europe 11, India 2, East Asia 6, and Australia 3. The CP incidences of different motor types in real world and in movies, respectively, are 78–86%, 65% (Spastic); 1.5–6%, 9% (Dyskinetic); 6.5–9%, 26% (Mixed); 3%, 0% (Ataxic); 3-4%, 0% (Hypotonic). The CP incidences of different Gross Motor Function Classification System (GMFCS) levels in real world and in movies, respectively, are 40–51%, 47% (Level I + II); 14–19%, 12% (Level III); 34–41%, 41% (Level IV + V). Comparisons of incidence between the real world and the movies are surprisingly matching. Motion pictures honestly reflect the general public's point of view to CP patients in our real world. With precise selection and medical professional explanations, motion pictures can play the suitable role making CP understood more clearly. PMID:26257472

Association between isometric muscle strength and gait joint kinetics in adolescents and young adults with cerebral palsy.

PubMed

Dallmeijer, A J; Baker, R; Dodd, K J; Taylor, N F

2011-03-01

The purpose of this study was to determine the association between isometric muscle strength of the lower limbs and gait joint kinetics in adolescents and young adults with cerebral palsy (CP). Twenty-five participants (11 males) with bilateral spastic CP, aged 14-22 years (mean: 18.9, sd: 2.0 yr) and Gross Motor Function Classification System (GMFCS) level II (n=19) and III (n=6) were tested. Hand held dynamometry was used to measure isometric strength (expressed in Nm/kg) of the hip, knee, and ankle muscles using standardized testing positions and procedures. 3D gait analysis was performed with a VICON system to calculate joint kinetics in the hip, knee and ankle during gait. Ankle peak moments exceeded by far the levels of isometric strength of the plantar flexors, while the knee and hip peak moments were just at or below maximal isometric strength of knee and hip muscles. Isometric muscle strength showed weak to moderate correlations with peak ankle and hip extension moment and power during walking. Despite considerable muscle weakness, joint moment curves were similar to norm values. Results suggest that passive stretch of the muscle-tendon complex of the triceps surae contributes to the ankle moment during walking and that muscle strength assessment may provide additional information to gait kinetics. Copyright © 2010 Elsevier B.V. All rights reserved.

Cerebral palsy after neonatal encephalopathy: do neonates with suspected asphyxia have worse outcomes?

PubMed

Garfinkle, Jarred; Wintermark, Pia; Shevell, Michael I; Oskoui, Maryam

2016-02-01

We sought to investigate how brain injury and severity, and neurological subtype of cerebral palsy (CP) differed in term-born children with CP after neonatal encephalopathy, between those with suspected birth asphyxia and those without. Using the Canadian CP Registry, which included 1001 children, those with CP born at ≥ 36 wks after moderate or severe neonatal encephalopathy, were dichotomized according to the presence or absence of suspected birth asphyxia. Gross Motor Function Classification System (GMFCS) scores, neurological subtypes, comorbidities, and magnetic resonance imaging findings were compared. Of the 147 term-born children with CP (82 males, 65 females; median age 37 months, interquartile range [IQR] 26-52.5) who after moderate or severe neonatal encephalopathy had the required outcome data, 61 (41%) met criteria for suspected birth asphyxia. They had a higher frequency of non-ambulatory GMFCS status (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.72-6.8), spastic quadriplegia (OR 2.8, 95% CI 1.4-5.6), non-verbal communication skills impairment (OR 4.2, 95% CI 2.0-8.6), isolated deep grey matter injury (OR 4.1, 95% CI 1.8-9.5), a lower frequency of spastic hemiplegia (OR 0.17, 95% CI 0.07-0.42), focal injury (OR 0.20; 95% CI 0.04-0.93), and more comorbidities (p=0.017) than those who did not meet criteria. Term-born children who develop CP after neonatal encephalopathy with suspected birth asphyxia have a greater burden of disability than those without suspected birth asphyxia. © 2015 Mac Keith Press.

Gross motor function is an important predictor of daily physical activity in young people with bilateral spastic cerebral palsy.

PubMed

Bania, Theofani A; Taylor, Nicholas F; Baker, Richard J; Graham, H Kerr; Karimi, Leila; Dodd, Karen J

2014-12-01

The aim of the study was to describe daily physical activity levels of adolescents and young adults with bilateral spastic cerebral palsy (CP) and to identify factors that help predict these levels. Daily physical activity was measured using an accelerometer-based activity monitor in 45 young people with bilateral spastic CP (23 males, 22 females; mean age 18y 6mo [SD 2y 5mo] range 16y 1mo-20y 11mo); classified as Gross Motor Function Classification System (GMFCS) level II or III and with contractures of <20° at hip and knee. Predictor variables included demographic characteristics (age, sex, weight) and physical characteristics (gross motor function, lower limb muscle strength, 6min walk distance). Data were analyzed using the information-theoretic approach, using the Akaike information criterion (AIC) and linear regression. Daily activity levels were low compared with published norms. Gross Motor Function Measure Dimension-E (GMFM-E; walking, running, and jumping) was the only common predictor variable in models that best predicted energy expenditure, number of steps, and time spent sitting/lying. GMFM Dimension-D (standing) and bilateral reverse leg press strength contributed to the models that predicted daily physical activity. Adolescents and young adults with bilateral spastic CP and mild to moderate walking disabilities have low levels of daily activity. The GMFM-E was an important predictor of daily physical activity. © 2014 Mac Keith Press.

Profile of refractive errors in cerebral palsy: impact of severity of motor impairment (GMFCS) and CP subtype on refractive outcome.

PubMed

Saunders, Kathryn J; Little, Julie-Anne; McClelland, Julie F; Jackson, A Jonathan

2010-06-01

To describe refractive status in children and young adults with cerebral palsy (CP) and relate refractive error to standardized measures of type and severity of CP impairment and to ocular dimensions. A population-based sample of 118 participants aged 4 to 23 years with CP (mean 11.64 +/- 4.06) and an age-appropriate control group (n = 128; age, 4-16 years; mean, 9.33 +/- 3.52) were recruited. Motor impairment was described with the Gross Motor Function Classification Scale (GMFCS), and subtype was allocated with the Surveillance of Cerebral Palsy in Europe (SCPE). Measures of refractive error were obtained from all participants and ocular biometry from a subgroup with CP. A significantly higher prevalence and magnitude of refractive error was found in the CP group compared to the control group. Axial length and spherical refractive error were strongly related. This relation did not improve with inclusion of corneal data. There was no relation between the presence or magnitude of spherical refractive errors in CP and the level of motor impairment, intellectual impairment, or the presence of communication difficulties. Higher spherical refractive errors were significantly associated with the nonspastic CP subtype. The presence and magnitude of astigmatism were greater when intellectual impairment was more severe, and astigmatic errors were explained by corneal dimensions. Conclusions. High refractive errors are common in CP, pointing to impairment of the emmetropization process. Biometric data support this In contrast to other functional vision measures, spherical refractive error is unrelated to CP severity, but those with nonspastic CP tend to demonstrate the most extreme errors in refraction.

Gastrostomy feeding in cerebral palsy: enough and no more.

PubMed

Vernon-Roberts, Angharad; Wells, Jonathan; Grant, Hugh; Alder, Nicola; Vadamalayan, Babu; Eltumi, Muftah; Sullivan, Peter B

2010-12-01

gastrostomy feeding children with spastic quadriplegic cerebral palsy (SQCP) improves weight gain but may cause excess deposition of body fat. This study was designed to investigate whether weight gain could be achieved without an adverse effect on body composition by using a low-energy feed in gastrostomy-fed children with SQCP. ourteen children (seven male; seven female; median age 2y; range 10mo-11y) with SQCP were studied, 13 of whom were classified as Gross Motor Function Classification Score (GMFCS) level V and one as GMFCS level IV. Children were eligible for the study if they weighed between 8 and 30kg with a diagnosis of severe SQCP and significant feeding difficulties in whom a clinical decision had been made to insert a gastrostomy feeding tube. The feed used in the study had an energy concentration of 0.75kcal/mL (Nutrini Low Energy Multi Fibre). Assessments were performed before gastrostomy insertion (baseline) and after 6months, and included body composition, growth, nutritional intake, and gastrointestinal symptoms. there was a significant increase in weight (median difference 1.9kg; 95% confidence interval [CI] 0.85-3.03kg; p=0.012), mid-upper arm circumference (median difference 1.45cm; 95% CI -0.36cm to 3.47cm; p=0.043), and lower leg length (median difference 1.62cm; 95% CI 0.44-3.95cm; p=0.012) over the 6 months. There was no significant increase in fat mass index (median diff 1.21, 95% CI -1.15 to 2.94, p=0.345) or fat free mass index (median diff -1.43, 95% CI -1.15 to 2.94, p=0.249). Micronutrient levels remained within reference ranges with the exception of elevated chromium. The median percentage intake of the estimated average requirements for energy (kcal) was 43% at the beginning of the study and 48.8% after 6 months on the low-energy feed. children with SQCP who are fed a low-energy, micronutrient-complete, high-fibre feed continue to grow even with energy intakes below 75% of the estimated average requirements. This was not associated with a disproportionate rise in fat mass or fat percentage, and the majority of micronutrient levels remained within the reference range.

Botulinum toxin injections for chronic sialorrhoea in children are effective regardless of the degree of neurological dysfunction: A single tertiary institution experience.

PubMed

Mahadevan, Murali; Gruber, Maayan; Bilish, Darin; Edwards, Kathryn; Davies-Payne, David; van der Meer, Graeme

2016-09-01

To determine the effectiveness of submandibular salivary gland Botulinum Toxin Type-A (BTX-A) injection in the treatment of drooling in children with varying degrees of neurological dysfunction. A retrospective review of pre- and post-procedure drooling frequency and severity scores of patients receiving BTX-A between January 2008 and January 2013. Stratification to different subgroups of neurological impairment was performed according to Gross Motor Function Classification System (GMFCS) score. Drooling severity was assessed using Thomas-Stonell and Greenberg symptom questionnaires administered at time of initial consultation and 3 months after treatment. 48 sets of BTX-A injections in 26 patients with an average age of 9.45 years (range 7 months-18 years) were included in the study. Marked improvement in drooling was seen in 60.4% of patients, a marginal or brief improvement was seen in 20.8% and there was no improvement in 18.8%. No adverse events were reported following any of the BTX-A injections. BTX-A was safe and effective in the eight patients with pre-existing swallowing dysfunction. Subsequent drooling surgery was performed in 15 (57.7%) of the cohort, all 15 patients responded to BTX-A injections. In patients with Cerebral Palsy, there was no correlation between the severity of the neurological dysfunction as measured by the Gross Motor Function Classification System (GMFCS) score and the response to BTX-A treatment. Injection of BTX-A to the submandibular glands of children with neurological disorders is a safe procedure and results in a reduction in drooling in the majority of patients. Children with severe neurological dysfunction respond to BTX-A injections as effectively as their less impaired peers and the degree of response does not appear to be associated with the severity of neurological disability. BTX-A injection is a good initial procedure when drooling surgery is being considered. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Correlations between risk factors and functional evolution in patients with spastic quadriplegia

PubMed Central

Rogoveanu, OC; Tuțescu, NC; Kamal, D; Alexandru, DO; Kamal, C; Streba, L; Trăistaru, MR

2016-01-01

Cerebral palsy is the most common cause of developing neuro-motor disability in children, in many cases, the triggering cause remaining unknown. Quadriplegia is the most severe spastic cerebral palsy, characterized by severe mental retardation and bi-pyramidal syndrome. The purpose of this paper was to demonstrate the importance of knowing the risk factors and the psychosomatic ones, determining to what extent they influence the functional evolution in patients diagnosed with spastic quadriplegia. 23 children diagnosed with spastic quadriplegia were included in the study, being aged between 1 year and half and 12 years. Patients were assessed at baseline (T1), at one year (T2) and after two years at the end of the study (T3). Patients received a comprehensive rehabilitation program for the motor and sensory deficits throughout the study. Initially, a comprehensive evaluation (etiopathogenic, clinical and functional) that started from a thorough medical history of children (the older ones), was conducted but chose parents to identify the risk factors, and a complete physical exam. At each assessment, joint and muscle balance was conducted. To assess functionality, the gross motor function classification systems (GMFCS) and manual ability (MACS) were used. Many risk factors that were classified according to the timeline in prenatal factors, perinatal and postnatal, were identified from a thorough history. A direct correlation was noticed between the decrease of coarse functionality and manual ability, both initially and in dynamic and low APGAR scores, low gestational age, low birth weight and a higher body mass index of the mother. A direct link was observed between the gross motor function and the manual ability. A significant improvement in the MACS score was noticed in patients with a better GMFCS score. PMID:27453749

Correlations between risk factors and functional evolution in patients with spastic quadriplegia.

PubMed

Rogoveanu, O C; Tuțescu, N C; Kamal, D; Alexandru, D O; Kamal, C; Streba, L; Trăistaru, M R

2016-01-01

Cerebral palsy is the most common cause of developing neuro-motor disability in children, in many cases, the triggering cause remaining unknown. Quadriplegia is the most severe spastic cerebral palsy, characterized by severe mental retardation and bi-pyramidal syndrome. The purpose of this paper was to demonstrate the importance of knowing the risk factors and the psychosomatic ones, determining to what extent they influence the functional evolution in patients diagnosed with spastic quadriplegia. 23 children diagnosed with spastic quadriplegia were included in the study, being aged between 1 year and half and 12 years. Patients were assessed at baseline (T1), at one year (T2) and after two years at the end of the study (T3). Patients received a comprehensive rehabilitation program for the motor and sensory deficits throughout the study. Initially, a comprehensive evaluation (etiopathogenic, clinical and functional) that started from a thorough medical history of children (the older ones), was conducted but chose parents to identify the risk factors, and a complete physical exam. At each assessment, joint and muscle balance was conducted. To assess functionality, the gross motor function classification systems (GMFCS) and manual ability (MACS) were used. Many risk factors that were classified according to the timeline in prenatal factors, perinatal and postnatal, were identified from a thorough history. A direct correlation was noticed between the decrease of coarse functionality and manual ability, both initially and in dynamic and low APGAR scores, low gestational age, low birth weight and a higher body mass index of the mother. A direct link was observed between the gross motor function and the manual ability. A significant improvement in the MACS score was noticed in patients with a better GMFCS score.

Drooling, saliva production, and swallowing in cerebral palsy.

PubMed

Senner, Jill E; Logemann, Jerilyn; Zecker, Steven; Gaebler-Spira, Deborah

2004-12-01

Fourteen participants (six females, eight males) ranging in age from 7 years 11 months to 18 years 2 months (mean 11y 7mo) with a confirmed diagnosis of spastic cerebral palsy (CP) were included in the study. Participants included those who drooled (CP+, n=14); age- and sex-matched children with spastic CP who were dry to mild and never to infrequent droolers (CP-, n=14) as well as typically developing peers (CTRL, n=14) served as controls. Frequency of swallowing was measured by using simultaneous cervical ausculation and videotaping of the head and neck. Saliva production was measured with the Saxon test, a simple gauze-chewing procedure. In addition, Pediatric Evaluation of Disability Inventory (PEDI), Test of Nonverbal Intelligence-3 (TONI-3), dysarthria severity scale, and Gross Motor Function Classification System (GMFCS) scores were obtained for each participant. Both groups of participants with CP tended to swallow less frequently than typically developing participants and tended to produce less saliva than typically developing controls; however, these differences were not statistically significant. No correlation was found between amount of saliva produced and amount drooled (r=0.245). An analysis of variance (ANOVA) conducted on the PEDI functional skills mean scores indicated significant differences between the three groups (F(2,39)=23.522,p<0.0001). Likewise, an ANOVA conducted on the TONI-3 scores revealed statistically significant differences between the three groups (F(2,39)=31.761, p<0.0001). A Spearman's rho correlation indicated that GMFCS scores were not significantly correlated with drooling severity (Spearman's rho correlation=0.3951,p=0.037). Drooling severity was found to be positively correlated with dysarthria severity (Spearman's rho correlation=0.82,p<0.0001). These findings suggest that drooling in patients with CP is related to swallowing difficulties rather than hypersalivation.

Energy expenditure during standing in children with cerebral palsy: A brief report1.

PubMed

Saxena, Shikha; Kumaran, Senthil; Rao, Bhamini K

2016-09-02

The aim of the study was to estimate the energy expenditure (EE) during a quiet standing task in children with bilateral spastic CP (BSCP) in comparison with typically developing (TD) children, using gas analyzer. The study was an observational cross-sectional study of children with BSCP (Gross Motor Function Classification System [GMFCS] levels II and III; n = 30; 10 males, 20 females; mean weight 27.46 kgs; mean age 10 years) and TD children (n = 30; 16 males, 14 females; mean weight 25.35 kgs; mean age 9 years, 9 months). The energy expenditure during quiet standing task was measured by using Cosmed K4b2 gas analyzer and expressed in terms of peak oxygen consumption (VO2 max, ml/kg body weight/min). Children with BSCP expended 1.4 times higher energy during standing than TD children (p< 0.0001). We identified that standing puts an additional energy demand in ambulant children with BSCP. Findings suggest that both dependant and independent ambulating children with BSCP might need to exert more effort to maintain a static standing position. Therefore, clinicians must evaluate standing position for balance control and energy expenditure to evaluate the efficiency of physical therapy and rehabilitation.

Biomechanics of Submaximal Recumbent Cycling in Adolescents With and Without Cerebral Palsy

PubMed Central

Johnston, Therese E; Barr, Ann E; Lee, Samuel CK

2011-01-01

Background and Purpose The purpose of this study was to compare the biomechanics of recumbent cycling between adolescents with cerebral palsy (CP) classified at Gross Motor Function Classification System (GMFCS) levels III and IV and adolescents with typical development (TD). Subjects Twenty subjects, ages (X̄±SD) 15.2±1.6 years (10 with TD, 10 with CP), participated. Methods Lower-extremity kinematics and muscle activity were measured at 30 and 60 rpm while subjects pedaled on a recumbent cycle. Energy expenditure and perceived exertion were measured during a 5-minute test, and efficiency was calculated. Noncircular data were analyzed with analyses of variance. Circular data were analyzed using circular t tests. Results Differences were found between groups for joint kinematics for all motions. Subjects with CP displayed earlier onsets and later offsets of muscle activity, increased co-contraction of agonist and antagonist muscles, and decreased efficiency compared with subjects with TD. There were no differences in perceived exertion. Discussion and Conclusion Differences in cycling biomechanics between children with CP and children with TD may be due to decreased strength and motor control in the children with CP. PMID:17405804

[Refractive errors in patients with cerebral palsy].

PubMed

Mrugacz, Małgorzata; Bandzul, Krzysztof; Kułak, Wojciech; Poppe, Ewa; Jurowski, Piotr

2013-04-01

Ocular changes are common in patients with cerebral palsy (CP) and they exist in about 50% of cases. The most common are refractive errors and strabismus disease. The aim of the paper was to estimate the relativeness between refractive errors and neurological pathologies in patients with selected types of CP. MATERIAL AND METHODS. The subject of the analysis was showing refractive errors in patients within two groups of CP: diplegia spastica and tetraparesis, with nervous system pathologies taken into account. Results. This study was proven some correlations between refractive errors and type of CP and severity of the CP classified in GMFCS scale. Refractive errors were more common in patients with tetraparesis than with diplegia spastica. In the group with diplegia spastica more common were myopia and astigmatism, however in tetraparesis - hyperopia.

Gait phenotypes in paediatric hereditary spastic paraplegia revealed by dynamic time warping analysis and random forests

PubMed Central

Martín-Gonzalo, Juan Andrés; Rodríguez-Andonaegui, Irene; López-López, Javier; Pascual-Pascual, Samuel Ignacio

2018-01-01

The Hereditary Spastic Paraplegias (HSP) are a group of heterogeneous disorders with a wide spectrum of underlying neural pathology, and hence HSP patients express a variety of gait abnormalities. Classification of these phenotypes may help in monitoring disease progression and personalizing therapies. This is currently managed by measuring values of some kinematic and spatio-temporal parameters at certain moments during the gait cycle, either in the doctor´s surgery room or after very precise measurements produced by instrumental gait analysis (IGA). These methods, however, do not provide information about the whole structure of the gait cycle. Classification of the similarities among time series of IGA measured values of sagittal joint positions throughout the whole gait cycle can be achieved by hierarchical clustering analysis based on multivariate dynamic time warping (DTW). Random forests can estimate which are the most important isolated parameters to predict the classification revealed by DTW, since clinicians need to refer to them in their daily practice. We acquired time series of pelvic, hip, knee, ankle and forefoot sagittal angular positions from 26 HSP and 33 healthy children with an optokinetic IGA system. DTW revealed six gait patterns with different degrees of impairment of walking speed, cadence and gait cycle distribution and related with patient’s age, sex, GMFCS stage, concurrence of polyneuropathy and abnormal visual evoked potentials or corpus callosum. The most important parameters to differentiate patterns were mean pelvic tilt and hip flexion at initial contact. Longer time of support, decreased values of hip extension and increased knee flexion at initial contact can differentiate the mildest, near to normal HSP gait phenotype and the normal healthy one. Increased values of knee flexion at initial contact and delayed peak of knee flexion are important factors to distinguish GMFCS stages I from II-III and concurrence of polyneuropathy. PMID:29518090

Exploring issues of participation among adolescents with cerebral palsy: what's important to them?

PubMed

Livingston, Michael H; Stewart, Debra; Rosenbaum, Peter L; Russell, Dianne J

2011-08-01

The purpose of this cross-sectional study was to determine what participation issues are important to adolescents with cerebral palsy (CP). Two hundred and three adolescents with CP (mean age 16.0 ± 1.8 years) were assessed using the Canadian Occupational Performance Measure (COPM). This was done through semistructured interviews by trained physical and occupational therapists. Adolescents responded either directly (n = 144) or through a parent or a caregiver (n = 59) if they were unable to communicate. Issues were extracted from completed questionnaires and coded under three COPM categories (self-care, productivity, and leisure) and 16 subcategories. There was no association between the total number of issues identified and gender (p = .99), age (p = .88), type of respondent (adolescents versus parent) (p = .27), Gross Motor Function Classification System (GMFCS) level (p = .93), or 66-item Gross Motor Function Measure (GMFM-66) score (p = .45). The issues identified most frequently were related to active leisure (identified by 57% of participants), mobility (55%), school (48%), and socialization (44%). Interventions aimed at improving participation among adolescents with physical disabilities, such as CP, should be directed towards these four key areas. Health care professionals should also recognize and consider the interaction of person and environment when addressing issues related to participation.

Theory of mind, emotional and social functioning, and motor severity in children and adolescents with dystonic cerebral palsy.

PubMed

Adegboye, Dolapo; Sterr, Annette; Lin, Jean-Pierre; Owen, Tamsin J

2017-05-01

This cross-sectional study aimed to investigate whether children and adolescents with dystonic cerebral palsy (CP) present with emotional and social difficulties along side motor limitations. Twenty-two verbal and nonverbal children and adolescents with dystonic CP were compared with a normative sample of twenty children and adolescents on measures of theory of mind (ToM), emotion regulation (ER), and social difficulties (SD). Higher social and emotional difficulties were found in the dystonic CP group compared to the control group. Nonverbal participants with dystonic CP were found to present with greater social impairment and lower ToM ability than their verbal counterparts. Emotional regulation and hyperactivity and attentional difficulties (HAD) significantly predicted ToM ability and social difficulties. Lower Gross Motor Function Classification System (GMFCS) level and IQ also contributed to differences in ToM ability. Findings support the need for greater attention to the emotional health and social development of children/adolescents with dystonic CP, along with assessments of motor difficulties in the planning and implementation of interventions and individual care plans. Further research is needed to explore links between motor disorder and mental state understanding in this clinical group. Copyright © 2017 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.

Gross motor function change after multilevel soft tissue release in children with cerebral palsy.

PubMed

Chang, Chia-Hsieh; Chen, Yu-Ying; Yeh, Kuo-Kuang; Chen, Chia-Ling

2017-06-01

Improving motor function is a major goal of therapy for children with cerebral palsy (CP). However, changes in motor function after orthopedic surgery for gait disorders are seldom discussed. This study aimed to evaluate the postoperative changes in gross motor function and to investigate the prognostic factors for such changes. We prospectively studied 25 children with CP (4-12 years) who were gross motor function classification system (GMFCS) level II to IV and and underwent bilateral multilevel soft-tissue release for knee flexion gait. Patients were evaluated preoperatively and at 6 weeks and 3 and 6 months postoperatively for Gross Motor Function Measure (GMFM-66), range of motion, spasticity, and selective motor control. The associations between change in GMFM-66 score and possible factors were analyzed. 25 children with gross motor function level II to IV underwent surgery at a mean age of 8.6 years (range, 4-12 years). Mean GMFM-66 score decreased from 55.9 at baseline to 54.3 at 6-weeks postoperatively and increased to 57.5 at 6-months postoperatively (p < 0.05). Regression analysis revealed better gross motor function level and greater surgical reduction of spasticity were predictors for decreased GMFM-66 score at 6-weeks postoperatively. Younger age was a predictor for increased GMFM-66 score at 6-months postoperatively. Reduction of contracture and spasticity and improvement of selective motor control were noted after surgery in children with CP. However, a down-and-up course of GMFM-66 score was noted. It is emphasized that deterioration of motor function in children with ambulatory ability and the improvement in young children after orthopedic surgery for gait disorders. case series, therapeutic study, level 4. Copyright © 2017 Chang Gung University. Published by Elsevier B.V. All rights reserved.

Determinants of responsiveness to botulinum toxin, casting, and bracing in the treatment of spastic equinus in children with cerebral palsy.

PubMed

Yap, Rita; Majnemer, Annette; Benaroch, Thierry; Cantin, Marie-Andree

2010-02-01

The objective was to determine whether specific intrinsic (age, pattern of cerebral palsy [CP], child's motivation) and extrinsic (number of treatments, parenting stress) characteristics were associated with responsiveness to botulinum toxin A (BoNT-A) injections in children with CP 3 months after injection into the gastrocnemius muscle. Children with hemiplegia or diplegia recruited from a BoNT-A programme were evaluated before and 3 months following injection of BoNT-A into the gastrocnemius. Outcome measures included muscle tone, range of motion, gait pattern, level of ambulation, gross motor function, and functional independence. Determinants of responsiveness to BoNT-A considered were age, number of treatments, distribution of CP, parenting stress, and motivation. Thirty-one children were recruited (17 males, 14 females)--22 with hemiplegia and nine with diplegia. Twenty-eight were classified at Gross Motor Function Classification System (GMFCS) level I and three at level III. The mean age was 6 years 4 months (SD 2y 11mo). Younger age (p=0.015) and fewer number (p=0.024) of BoNT-A treatments were associated with greater change in gross motor function. Child's motivation and parenting stress were significantly associated with improvements in muscle tone (p=0.006-0.017), passive range of motion (p=0.008-0.033), gait pattern (p=0.005-0.042), level of ambulation (p=0.001-0.043), and functional independence (p=0.004-0.027). The results indicate that child, family, and treatment characteristics influence the degree of responsiveness to BoNT-A treatment. The contribution of contextual factors (personal and environmental) on responsiveness may be underappreciated in children with CP.

Therapeutic effects of a horse riding simulator in children with cerebral palsy.

PubMed

Silva e Borges, Maria Beatriz; Werneck, Maria José da Silva; da Silva, Maria de Lourdes; Gandolfi, Lenora; Pratesi, Riccardo

2011-10-01

To evaluate the efficacy of horse ridding simulator on the sitting postural control of children with spastic diplegia. Forty children were randomly divided in a group using the simulator (RS) and a group performing conventional physical therapy (CT). FScan/Fmat equipment was used to register maximal displacement in antero-posterior (AP) and medio-lateral (ML) directions with children in sitting position. At the pre and post intervention stage both groups were classified according to the Gross Motor Function Classification System (GMFCS) and, after intervention, by the AUQEI questionnaire (Autoquestionnaire Qualité de vie Enfant Image). Comparison between groups disclosed statistically significant pos-intervention improvement both in the AP (p<0.0001) as in the ML (p<0.0069) direction in the RS group. The horse ridding simulator produced significant improvement in the postural control of children in sitting position, additionally showing a higher motor functionality and a better acceptance of the therapeutic intervention.

Effect of Depth and Duration of Cooling on Death or Disability at Age 18 Months Among Neonates With Hypoxic-Ischemic Encephalopathy: A Randomized Clinical Trial.

PubMed

Shankaran, Seetha; Laptook, Abbot R; Pappas, Athina; McDonald, Scott A; Das, Abhik; Tyson, Jon E; Poindexter, Brenda B; Schibler, Kurt; Bell, Edward F; Heyne, Roy J; Pedroza, Claudia; Bara, Rebecca; Van Meurs, Krisa P; Huitema, Carolyn M Petrie; Grisby, Cathy; Devaskar, Uday; Ehrenkranz, Richard A; Harmon, Heidi M; Chalak, Lina F; DeMauro, Sara B; Garg, Meena; Hartley-McAndrew, Michelle E; Khan, Amir M; Walsh, Michele C; Ambalavanan, Namasivayam; Brumbaugh, Jane E; Watterberg, Kristi L; Shepherd, Edward G; Hamrick, Shannon E G; Barks, John; Cotten, C Michael; Kilbride, Howard W; Higgins, Rosemary D

2017-07-04

Hypothermia for 72 hours at 33.5°C for neonatal hypoxic-ischemic encephalopathy reduces death or disability, but rates continue to be high. To determine if cooling for 120 hours or to a temperature of 32.0°C reduces death or disability at age 18 months in infants with hypoxic-ischemic encephalopathy. Randomized 2 × 2 factorial clinical trial in neonates (≥36 weeks' gestation) with hypoxic-ischemic encephalopathy at 18 US centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network between October 2010 and January 2016. A total of 364 neonates were randomly assigned to 4 hypothermia groups: 33.5°C for 72 hours (n = 95), 32.0°C for 72 hours (n = 90), 33.5°C for 120 hours (n = 96), or 32.0°C for 120 hours (n = 83). The primary outcome was death or moderate or severe disability at 18 to 22 months of age adjusted for center and level of encephalopathy. Severe disability included any of Bayley Scales of Infant Development III cognitive score less than 70, Gross Motor Function Classification System (GMFCS) level of 3 to 5, or blindness or hearing loss despite amplification. Moderate disability was defined as a cognitive score of 70 to 84 and either GMFCS level 2, active seizures, or hearing with amplification. The trial was stopped for safety and futility in November 2013 after 364 of the planned 726 infants were enrolled. Among 347 infants (95%) with primary outcome data (mean age at follow-up, 20.7 [SD, 3.5] months; 42% female), death or disability occurred in 56 of 176 (31.8%) cooled for 72 hours and 54 of 171 (31.6%) cooled for 120 hours (adjusted risk ratio, 0.92 [95% CI, 0.68-1.25]; adjusted absolute risk difference, -1.0% [95% CI, -10.2% to 8.1%]) and in 59 of 185 (31.9%) cooled to 33.5°C and 51 of 162 (31.5%) cooled to 32.0°C (adjusted risk ratio, 0.92 [95% CI, 0.68-1.26]; adjusted absolute risk difference, -3.1% [95% CI, -12.3% to 6.1%]). A significant interaction between longer and deeper cooling was observed (P = .048), with primary outcome rates of 29.3% at 33.5°C for 72 hours, 34.5% at 32.0°C for 72 hours, 34.4% at 33.5°C for 120 hours, and 28.2% at 32.0°C for 120 hours. Among term neonates with moderate or severe hypoxic-ischemic encephalopathy, cooling for longer than 72 hours, cooling to lower than 33.5°C, or both did not reduce death or moderate or severe disability at 18 months of age. However, the trial may be underpowered, and an interaction was found between longer and deeper cooling. These results support the current regimen of cooling for 72 hours at 33.5°C. clinicaltrials.gov Identifier: NCT01192776.

Responsiveness of the ACTIVLIM-CP questionnaire measuring global activity performance in children with cerebral palsy.

PubMed

Paradis, Julie; Arnould, Carlyne; Thonnard, Jean-Louis; Houx, Laëtitia; Pons-Becmeur, Christelle; Renders, Anne; Brochard, Sylvain; Bleyenheuft, Yannick

2018-06-04

To investigate the responsiveness of the ACTIVLIM-CP questionnaire after two evidence-based interventions for children with cerebral palsy (CP). Seventy-five children with CP either participated in an intensive motor-skill learning intervention (hand-arm bimanual intensive therapy including lower extremities [HABIT-ILE], n=47) or received botulinum neurotoxin-A (BoNT-A) injection(s) into lower extremities combined with conventional physical therapy (n=28). All children were assessed three times: at baseline (T 0 ; before HABIT-ILE/the day of BoNT-A injection), at T 1 (last day of HABIT-ILE/6wks after BoNT-A injection), and at follow-up (T 2 ; 3-4mo after the beginning of intervention). Parents completed ACTIVLIM-CP and three other activity questionnaires. Responsiveness was analysed using group (based on intervention), subgroup (based on gross motor function level), and individual approaches. For the HABIT-ILE group, significant improvements in ACTIVLIM-CP were observed for the T 0 -T 1 period (p<0.001) but not for the T 1 -T 2 period. No significant changes were found in the BoNT-A group during assessments (p=0.84). In the subgroup analysis for the HABIT-ILE group (T 0 -T 1 ), greater changes were demonstrated for children in Gross Motor Function Classification System levels III and IV (p<0.001, effect size=1.36). The individual approach was congruent with the group approach. ACTIVLIM-CP demonstrated high responsiveness after HABIT-ILE, showing that this scale may be used to investigate global activity performance in clinical trials focusing on improving daily life activities. Good responsiveness of ACTIVLIM-CP questionnaire during intensive motor-skill learning intervention. Higher responsiveness for children in Gross Motor Function Classification System (GMFCS) levels III and IV versus I and II after intensive intervention. ACTIVLIM-CP is useful to identify children improving their performance after botulinum neurotoxin-A injection. © 2018 Mac Keith Press.

Energy expenditure in adults with cerebral palsy playing Wii Sports.

PubMed

Hurkmans, Henri L; van den Berg-Emons, Rita J; Stam, Henk J

2010-10-01

To determine energy expenditure of adults with bilateral spastic cerebral palsy while playing Wii Sports tennis and boxing. Cross-sectional study. University medical center. Five men and 3 women with bilateral spastic cerebral palsy and ambulatory ability (Gross Motor Function Classification System level I or II) participated. The mean participant age ± SD was 36±7 years. Exclusion criteria were comorbidities that affected daily physical activity and fitness, contraindications to exercise, or inability to understand study instructions owing to cognitive disorders or language barriers. Participants played Wii Sports tennis and boxing, each for 15 minutes in random order. By using a portable gas analyzer, we assessed energy expenditure by oxygen uptake (Vo(2)) while sitting and during Wii Sports game play. Energy expenditure is expressed in metabolic equivalents (METs), which were calculated as Vo(2) during Wii Sports play divided by Vo(2) during sitting. Mean ± SD energy expenditure during Wii Sports game play was 4.5±1.1METs for tennis and 5.0±1.1METs for boxing (P=.024). All participants attained energy expenditures greater than 3METs, and 2 participants attained energy expenditures greater than 6METs while playing Wii Sports tennis or boxing. Both Wii Sports tennis and boxing seem to provide at least moderate-intensity exercise in adults with bilateral spastic cerebral palsy (GMFCS level I or II). These games, therefore, may be useful as treatment to promote more active and healthful lifestyles in these patients. Further research is needed to determine the energy expenditures of other physically disabled patient groups while playing active video games, and to determine the effectiveness of these games in improving health and daily activity levels. Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Effects of interactive games on motor performance in children with spastic cerebral palsy

PubMed Central

AlSaif, Amer A.; Alsenany, Samira

2015-01-01

[Purpose] Motor control and muscle strength impairments are the prime reasons for motor behavior disorders in children with spastic cerebral palsy. These impairments lead to histological changes in muscle growth and the learning of motor skills. Therefore, such children experience reduced muscle force generation and decreased muscle flexibility. We investigated the effect of training with Nintendo Wii Fit games on motor performance in children with spastic cerebral palsy. [Subjects and Methods] Forty children with cerebral palsy spastic diplegia aged 6–10 years diagnosed with level-3 functional capabilities according to the Gross Motor Classification System (GMFCS) were enrolled. Participants were divided randomly into equal groups: group (A) that practiced with the Nintendo Wii Fit game for at least 20 minutes/day for 12 weeks and group (B) that underwent no training (control group). The Movement Assessment Battery for Children-2 (mABC-2) was used to assess motor performance, because it mainly involves motor tasks very similar to those involved in playing Nintendo Wii Fit games, e.g., goal-directed arm movements, balancing, and jumping. [Results] There were significant improvements in the subscales of the motor performance test of those who practiced with the Nintendo Wii, while the control group showed no significant changes. [Conclusion] Using motion interactive games in home rehabilitation is feasible for children with cerebral palsy. PMID:26180367

Effects of interactive games on motor performance in children with spastic cerebral palsy.

PubMed

AlSaif, Amer A; Alsenany, Samira

2015-06-01

[Purpose] Motor control and muscle strength impairments are the prime reasons for motor behavior disorders in children with spastic cerebral palsy. These impairments lead to histological changes in muscle growth and the learning of motor skills. Therefore, such children experience reduced muscle force generation and decreased muscle flexibility. We investigated the effect of training with Nintendo Wii Fit games on motor performance in children with spastic cerebral palsy. [Subjects and Methods] Forty children with cerebral palsy spastic diplegia aged 6-10 years diagnosed with level-3 functional capabilities according to the Gross Motor Classification System (GMFCS) were enrolled. Participants were divided randomly into equal groups: group (A) that practiced with the Nintendo Wii Fit game for at least 20 minutes/day for 12 weeks and group (B) that underwent no training (control group). The Movement Assessment Battery for Children-2 (mABC-2) was used to assess motor performance, because it mainly involves motor tasks very similar to those involved in playing Nintendo Wii Fit games, e.g., goal-directed arm movements, balancing, and jumping. [Results] There were significant improvements in the subscales of the motor performance test of those who practiced with the Nintendo Wii, while the control group showed no significant changes. [Conclusion] Using motion interactive games in home rehabilitation is feasible for children with cerebral palsy.

Effects of whole-body vibration training on physical function, bone and muscle mass in adolescents and young adults with cerebral palsy.

PubMed

Gusso, Silmara; Munns, Craig F; Colle, Patrícia; Derraik, José G B; Biggs, Janene B; Cutfield, Wayne S; Hofman, Paul L

2016-03-03

We performed a clinical trial on the effects of whole-body vibration training (WBVT) on muscle function and bone health of adolescents and young adults with cerebral palsy. Forty participants (11.3-20.8 years) with mild to moderate cerebral palsy (GMFCS II-III) underwent 20-week WBVT on a vibration plate for 9 minutes/day 4 times/week at 20 Hz (without controls). Assessments included 6-minute walk test, whole-body DXA, lower leg pQCT scans, and muscle function (force plate). Twenty weeks of WBVT were associated with increased lean mass in the total body (+770 g; p = 0.0003), trunk (+410 g; p = 0.004), and lower limbs (+240 g; p = 0.012). Bone mineral content increased in total body (+48 g; p = 0.0001), lumbar spine (+2.7 g; p = 0.0003), and lower limbs (+13 g; p < 0.0001). Similarly, bone mineral density increased in total body (+0.008 g/cm(2); p = 0.013), lumbar spine (+0.014 g/cm(2); p = 0.003), and lower limbs (+0.023 g/cm(2); p < 0.0001). Participants reduced the time taken to perform the chair test, and improved the distance walked in the 6-minute walk test by 11% and 35% for those with GMFCS II and III, respectively. WBVT was associated with increases in muscle mass and bone mass and density, and improved mobility of adolescents and young adults with cerebral palsy.

The effect of different physiotherapy interventions in post-BTX-A treatment of children with cerebral palsy.

PubMed

Desloovere, K; De Cat, J; Molenaers, G; Franki, I; Himpens, E; Van Waelvelde, H; Fagard, K; Van den Broeck, C

2012-01-01

To distinguish the effects of different physiotherapeutic programs in a post BTX-A regime for children with Cerebral Palsy (CP). Retrospective, controlled intervention study. A group of 38 children (X¯ = 7y7m, GMFCS I-III, 27 bilateral, 11 unilateral CP) receiving an individually defined Neurodevelopment Treatment (NDT) program, was matched and compared to a group of children with the same age, GMFCS and diagnosis, receiving more conventional physiotherapy treatment. All patients received selective tone-reduction by means of multilevel BTX-A injections and adequate follow-up treatment, including physiotherapy. Three-dimensional gait analyses and clinical examination was performed pre and two months post-injection. Treatment success was defined using the Goal Attainment Scale (GAS). Both groups' mean converted GAS scores were above 50. The average converted GAS score was higher in the group of children receiving NDT than in the group receiving conventional physiotherapy (p < 0.05). In the NDT group, overall treatment success was achieved in 76% of the goals, compared to 67% of the goals defined for the conventional physiotherapy group. Especially for the goals based on gait analyses (p < 0.05) and in the group of children with bilateral CP (p < 0.05), treatment success was higher in the NDT group. In a post-BTX-A regime, the short-term effects of an NDT approach are more pronouncedthan these from a conventional physiotherapy approach. Copyright © 2011 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.

Effect of Depth and Duration of Cooling on Death or Disability at Age 18 Months Among Neonates With Hypoxic-Ischemic Encephalopathy

PubMed Central

Laptook, Abbot R.; Pappas, Athina; McDonald, Scott. A.; Das, Abhik; Tyson, Jon E.; Poindexter, Brenda B.; Schibler, Kurt; Bell, Edward F.; Heyne, Roy J.; Pedroza, Claudia; Bara, Rebecca; Van Meurs, Krisa P.; Huitema, Carolyn M. Petrie; Grisby, Cathy; Devaskar, Uday; Ehrenkranz, Richard A.; Harmon, Heidi M.; Chalak, Lina F.; DeMauro, Sara B.; Garg, Meena; Hartley-McAndrew, Michelle E.; Khan, Amir M.; Walsh, Michele C.; Ambalavanan, Namasivayam; Brumbaugh, Jane E.; Watterberg, Kristi L.; Shepherd, Edward G.; Hamrick, Shannon E. G.; Barks, John; Cotten, C. Michael; Kilbride, Howard W.; Higgins, Rosemary D.

2017-01-01

Importance Hypothermia for 72 hours at 33.5°C for neonatal hypoxic-ischemic encephalopathy reduces death or disability, but rates continue to be high. Objective To determine if cooling for 120 hours or to a temperature of 32.0°C reduces death or disability at age 18 months in infants with hypoxic-ischemic encephalopathy. Design, Setting, and Participants Randomized 2 × 2 factorial clinical trial in neonates (≥36 weeks’ gestation) with hypoxic-ischemic encephalopathy at 18 US centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network between October 2010 and January 2016. Interventions A total of 364 neonates were randomly assigned to 4 hypothermia groups: 33.5°C for 72 hours (n = 95), 32.0°C for 72 hours (n = 90), 33.5°C for 120 hours (n = 96), or 32.0°C for 120 hours (n = 83). Main Outcomes and Measures The primary outcome was death or moderate or severe disability at 18 to 22 months of age adjusted for center and level of encephalopathy. Severe disability included any of Bayley Scales of Infant Development III cognitive score less than 70, Gross Motor Function Classification System (GMFCS) level of 3 to 5, or blindness or hearing loss despite amplification. Moderate disability was defined as a cognitive score of 70 to 84 and either GMFCS level 2, active seizures, or hearing with amplification. Results The trial was stopped for safety and futility in November 2013 after 364 of the planned 726 infants were enrolled. Among 347 infants (95%) with primary outcome data (mean age at follow-up, 20.7 [SD, 3.5] months; 42% female), death or disability occurred in 56 of 176 (31.8%) cooled for 72 hours and 54 of 171 (31.6%) cooled for 120 hours (adjusted risk ratio, 0.92 [95% CI, 0.68-1.25]; adjusted absolute risk difference, −1.0% [95% CI, −10.2% to 8.1%]) and in 59 of 185 (31.9%) cooled to 33.5°C and 51 of 162 (31.5%) cooled to 32.0°C (adjusted risk ratio, 0.92 [95% CI, 0.68-1.26]; adjusted absolute risk difference, −3.1% [95% CI, −12.3% to 6.1%]). A significant interaction between longer and deeper cooling was observed (P = .048), with primary outcome rates of 29.3% at 33.5°C for 72 hours, 34.5% at 32.0°C for 72 hours, 34.4% at 33.5°C for 120 hours, and 28.2% at 32.0°C for 120 hours. Conclusions and Relevance Among term neonates with moderate or severe hypoxic-ischemic encephalopathy, cooling for longer than 72 hours, cooling to lower than 33.5°C, or both did not reduce death or moderate or severe disability at 18 months of age. However, the trial may be underpowered, and an interaction was found between longer and deeper cooling. These results support the current regimen of cooling for 72 hours at 33.5°C. Trial Registration clinicaltrials.gov Identifier: NCT01192776 PMID:28672318

Subtalar fusion for pes valgus in cerebral palsy: results of a modified technique in the setting of single event multilevel surgery.

PubMed

Shore, Benjamin J; Smith, Katherine R; Riazi, Arash; Symons, Sean B V; Khot, Abhay; Graham, Kerr

2013-06-01

We studied the use of cortico-cancellous circular allograft combined with cannulated screw fixation for the correction of dorsolateral peritalar subluxation in a series of children with bilateral spastic cerebral palsy undergoing single event multilevel surgery. Forty-six children who underwent bilateral subtalar fusion between January 1999 and December 2004 were retrospectively reviewed. Gait laboratory records, Gross Motor Function Classification System (GMFCS) levels, Functional Mobility Scale (FMS) scores, and radiographs were reviewed. The surgical technique used an Ollier type incision with a precut cortico-cancellous allograft press-fit into the prepared sinus tarsi. One or two 7.3 mm fully threaded cancellous screws were used to fix the subtalar joint. Radiographic analysis included preoperative and postoperative standing lateral radiographs measuring the lateral talocalcaneal angle, lateral talo-first metatarsal angle, and navicular cuboid overlap. Fusion rate was assessed with radiographs >12 months after surgery. The mean patient age was 12.9 years (range, 7.8 to 18.4 y) with an average follow-up of 55 months. Statistically significant improvement postoperatively was found for all 3 radiographic indices: lateral talocalcaneal angle, mean improvement 20 degrees (95% CI, 17.5-22.1; P<0.001); lateral talo-first metatarsal angle, mean improvement 21 degrees (95% CI, 19.2-23.4; P<0.001); and navicular cuboid overlap, mean improvement 29% (95% CI, 25.7%-32.6%; P<0.001). FMS improved across all patients, with Gross Motor Function Classification System III children experiencing a 70% improvement across all 3 FMS distances (5, 50, and 500 m). All 3 radiographic measures improved significantly (P<0.001). Fusion was achieved in 45 patients and there were no wound complications. With this study, we demonstrate significant improvement in radiographic segmental alignment and overall function outcome with this modified subtalar fusion technique. We conclude that this technique is an effective complement for children with dorsolateral peritalar subluxation undergoing single event multilevel surgery. Level IV.

Social adjustment of children with cerebral palsy in mainstream classes: peer perception.

PubMed

Nadeau, Line; Tessier, Réjean

2006-05-01

The aim of this study was to describe the social experience of children with cerebral palsy (CP) in mainstream classes in Canada and compare it with that of their classmates without disability. The CP group included 25 females and 35 males (mean age 10 y 5 mo [SD 0.95], range 10 y 4 mo-10 y 10 mo) diagnosed as having hemiplegia (n=44) or diplegia (n=16) and classified as Level I on the Gross Motor Function Classification System (GMFCS). Fifty-seven comparison children, born at term and without any motor and/or sensory impairment, were recruited from the classes of the children with CP during a school visit (mean age 10 y 3 mo, [SD 1.0], range 10 y-10 y 6 mo). They were matched to children with CP for sex, age, parents' education level, and family income. Social adjustment measures (social status, reciprocated friendships, social isolation, aggression, sociability/leadership, and verbal and/or physical victimization) were obtained by conducting a class-wide sociometric interview (n=943) in the classes of the children with CP. Findings showed that children with CP (specifically females with CP and irrespective of their type of disability) had fewer reciprocated friendships, exhibited fewer sociable/leadership behaviours, and were more isolated and victimized by their peers than their classmates without a disability. This seems to suggest that females and males with CP are perceived differently from their peers in a mainstreaming context. The discussion addresses the issue of age- and sex-related differences and provides avenues of intervention relating to personal and environmental factors that could facilitate or interfere with the social experience of children with CP in a mainstream environment.

Relationships between developmental profiles and ambulatory ability in A follow-up study of preschool children with spastic quadriplegic cerebral palsy.

PubMed

Chen, Chia-Ling; Chen, Chung-Yao; Lin, Keh-Chung; Chen, Kai-Hua; Wu, Ching-Yi; Lin, Chu-Hsu; Liu, Wen-Yu; Hsu, Hung-Chih

2010-01-01

To investigate the follow-up course of developmental profiles in preschool children with spastic quadriplegic (SQ) cerebral palsy (CP) who had varying ambulatory abilities. Forty-eight children with SQ CP between 1 and 5 years old were classified into 2 groups, the ambulatory and non-ambulatory groups, based on Gross Motor Function Classification System (GMFCS) levels during the initial assessment. The developmental profiles, consisting of development quotients (DQs) of 8 domains, were evaluated during the initial assessment and the final assessment one year later. The DQ change index (%) was calculated as 100% X (final DQ-initial DQ)/initial DQ. The DQs of all developmental domains in the non-ambulatory group were lower than those in the ambulatory group on both initial and final assessments (p<0.01). As indicated by the DQ change indices, most DQs in the ambulatory group decreased slightly, whereas those in the non-ambulatory group decreased considerably (p<0.05). Furthermore, fine motor function increased proportionally with age in the ambulatory group, but not in the non-ambulatory group. The DQs of the developmental profiles varied in preschool CP children with different ambulatory abilities. The course of developmental profiles in preschool children with SQ CP evolves with age and relates to the degree of ambulatory function. Knowledge of these developmental profiles may be helpful in understanding, predicting, and managing the developmental problems of these children.

The impacts of hinged and solid ankle-foot orthoses on standing and walking in children with spastic diplegia.

PubMed

Dalvand, Hamid; Dehghan, Leila; Feizi, Awat; Hosseini, Seyed Ali; Amirsalari, Susan

2013-01-01

The purpose of this study was to examine the impacts of hinged and solid anklefoot orthoses (AFOs) on standing and walking abilities in children with spastic diplegia. In a quasi-experimental design, 30 children with spastic diplegia, aged 4-6 years were recruited. They were matched in terms of age, IQ, and level of GMFCS E&R. Children were randomly assigned into 3 groups: a hinged AFO group (n=10) plus occupational therapy (OT), a solid AFO group (n=10) plus OT, a control group who used only OT for three months. Gross motor abilities were measured using Gross Motor Measure Function (GMFM). We obtained statistically significant differences in the values between baseline and after treatment in all groups. The groups were also significantly different in total GMFM after intervention. Furthermore, there were differences between hinged AFOs and solid AFOs groups, and between hinged AFOs and control groups. We concluded that gross motor function was improved in all groups; however, hinged AFOs group appears to improve the gross motor function better than solid AFOs and control groups.

Effects of whole-body vibration training on physical function, bone and muscle mass in adolescents and young adults with cerebral palsy

PubMed Central

Gusso, Silmara; Munns, Craig F; Colle, Patrícia; Derraik, José G B; Biggs, Janene B; Cutfield, Wayne S; Hofman, Paul L

2016-01-01

We performed a clinical trial on the effects of whole-body vibration training (WBVT) on muscle function and bone health of adolescents and young adults with cerebral palsy. Forty participants (11.3–20.8 years) with mild to moderate cerebral palsy (GMFCS II–III) underwent 20-week WBVT on a vibration plate for 9 minutes/day 4 times/week at 20 Hz (without controls). Assessments included 6-minute walk test, whole-body DXA, lower leg pQCT scans, and muscle function (force plate). Twenty weeks of WBVT were associated with increased lean mass in the total body (+770 g; p = 0.0003), trunk (+410 g; p = 0.004), and lower limbs (+240 g; p = 0.012). Bone mineral content increased in total body (+48 g; p = 0.0001), lumbar spine (+2.7 g; p = 0.0003), and lower limbs (+13 g; p < 0.0001). Similarly, bone mineral density increased in total body (+0.008 g/cm2; p = 0.013), lumbar spine (+0.014 g/cm2; p = 0.003), and lower limbs (+0.023 g/cm2; p < 0.0001). Participants reduced the time taken to perform the chair test, and improved the distance walked in the 6-minute walk test by 11% and 35% for those with GMFCS II and III, respectively. WBVT was associated with increases in muscle mass and bone mass and density, and improved mobility of adolescents and young adults with cerebral palsy. PMID:26936535

Physiotherapeutic interventions and physical activity for children in Northern Sweden with cerebral palsy: a register study from equity and gender perspectives.

PubMed

Degerstedt, Frida; Wiklund, Maria; Enberg, Birgit

Young people with disabilities, especially physical disabilities, report worse health than others. This may be because of the disability, lower levels of physical activity, and discrimination. For children with cerebral palsy, access to physiotherapy and physical activity is a crucial prerequisite for good health and function. To date, there is limited knowledge regarding potential gender bias and inequity in habilitation services. To map how physiotherapeutic interventions (PTI), physical leisure activity, and physical education are allocated for children with cerebral palsy regarding sex, age, level of gross motor function, and county council affiliation. This was done from a gender and equity perspective. A register study using data from the Cerebral Palsy follow-Up Program (CPUP). Data included 313 children ≤18 years with cerebral palsy from the five northern counties in Sweden during 2013. Motor impairment of the children was classified according to the expanded and revised Gross Motor Function Classification System (GMFCS). In three county councils, boys received more physiotherapy interventions and received them more frequently than girls did. Differences between county councils were seen for frequency and reasons for physiotherapy interventions (p < 0.001). The physiotherapist was involved more often with children who had lower motor function and with children who had low physical leisure activity. Children with lower motor function level participated in physical leisure activity less often than children with less motor impairment (p < 0.001). Boys participated more frequently in physical education than did girls (p = 0.028). Gender and county council affiliation affect the distribution of physiotherapy interventions for children with cerebral palsy, and there are associations between gender and physical activity. Thus, the intervention is not always determined by the needs of the child or the degree of impairment. A gender-bias is indicated. Further studies are needed to ensure fair interventions.

Physiotherapeutic interventions and physical activity for children in Northern Sweden with cerebral palsy: a register study from equity and gender perspectives

PubMed Central

Degerstedt, Frida; Wiklund, Maria; Enberg, Birgit

2017-01-01

ABSTRACT Background: Young people with disabilities, especially physical disabilities, report worse health than others. This may be because of the disability, lower levels of physical activity, and discrimination. For children with cerebral palsy, access to physiotherapy and physical activity is a crucial prerequisite for good health and function. To date, there is limited knowledge regarding potential gender bias and inequity in habilitation services. Objectives: To map how physiotherapeutic interventions (PTI), physical leisure activity, and physical education are allocated for children with cerebral palsy regarding sex, age, level of gross motor function, and county council affiliation. This was done from a gender and equity perspective. Methods: A register study using data from the Cerebral Palsy follow-Up Program (CPUP). Data included 313 children ≤18 years with cerebral palsy from the five northern counties in Sweden during 2013. Motor impairment of the children was classified according to the expanded and revised Gross Motor Function Classification System (GMFCS). Results: In three county councils, boys received more physiotherapy interventions and received them more frequently than girls did. Differences between county councils were seen for frequency and reasons for physiotherapy interventions (p < 0.001). The physiotherapist was involved more often with children who had lower motor function and with children who had low physical leisure activity. Children with lower motor function level participated in physical leisure activity less often than children with less motor impairment (p < 0.001). Boys participated more frequently in physical education than did girls (p = 0.028). Conclusion: Gender and county council affiliation affect the distribution of physiotherapy interventions for children with cerebral palsy, and there are associations between gender and physical activity. Thus, the intervention is not always determined by the needs of the child or the degree of impairment. A gender-bias is indicated. Further studies are needed to ensure fair interventions. PMID:28219314

Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a randomized trial.

PubMed

Wallen, Margaret; Ziviani, Jenny; Naylor, Olivia; Evans, Ruth; Novak, Iona; Herbert, Robert D

2011-12-01

Conventional constraint-based therapies are intensive and demanding to implement, particularly for children. Modified forms of constraint-based therapies that are family-centred may be more acceptable and feasible for families of children with cerebral palsy (CP)-but require rigorous evaluation using randomized trials. The aim of this study was to determine the effects of modified constraint-induced therapy compared with intensive occupational therapy on activities of daily living and upper limb outcomes in children with hemiplegic CP. In this assessor-blinded pragmatic randomized trial, 50 children (27 males, 23 females; age range 19 mo-7 y 10 mo) with hemiplegic CP were randomized using a concealed allocation procedure to one of two 8-week interventions: intensive occupational therapy (n = 25), or modified constraint-induced therapy (n = 25). Manual Ability Classification System (MACS) levels of the participants were, level I n = 2, II n = 37, III n = 8, and level IV n = 1; Gross Motor Function Classification System (GMFCS) levels were, level I n = 33, level II n = 15, and level III n = 1. Participants were recruited through three specialist CP centres in Australia and randomized between January 2008 and April 2010. Children randomized to modified constraint-induced therapy wore a mitt on the unaffected hand for 2 hours each day, during which time the children participated in targeted therapy. The primary outcome was the Canadian Occupational Performance Measure (COPM--measured on a 10-point scale) at completion of therapy. Other outcome measures were Goal Attainment Scaling, Assisting Hand Assessment, Pediatric Motor Activity Log, Modified Ashworth Scale, Modified Tardieu Scale, and a parent questionnaire. Assessments were carried out at 10 weeks and 6 months following randomization. All participants were included in the analysis. Between-group differences for all outcomes were neither clinically important nor statistically significant. The mean difference in COPM was 0.3 (95% confidence interval [CI] -0.8 to 1.4; p=0.61) and mean difference in COPM satisfaction was 0.1 (95% CI -1.1 to 1.2; p=0.90). Minor adverse events were reported by five of the 25 participants in the modified constraint-induced therapy group and by one of the 25 in the intensive occupational therapy group. All adverse events were related to participants' lack of acceptance of therapy. Modified constraint-induced therapy is no more effective than intensive occupational therapy for improving completion of activities of daily living or upper limb function in children with hemiplegic CP. © The Authors. Developmental Medicine & Child Neurology © 2011 Mac Keith Press.

Are we there yet? Evaluating commercial grade brain-computer interface for control of computer applications by individuals with cerebral palsy.

PubMed

Taherian, Sarvnaz; Selitskiy, Dmitry; Pau, James; Claire Davies, T

2017-02-01

Using a commercial electroencephalography (EEG)-based brain-computer interface (BCI), the training and testing protocol for six individuals with spastic quadriplegic cerebral palsy (GMFCS and MACS IV and V) was evaluated. A customised, gamified training paradigm was employed. Over three weeks, the participants spent two sessions exploring the system, and up to six sessions playing the game which focussed on EEG feedback of left and right arm motor imagery. The participants showed variable inconclusive results in the ability to produce two distinct EEG patterns. Participant performance was influenced by physical illness, motivation, fatigue and concentration. The results from this case study highlight the infancy of BCIs as a form of assistive technology for people with cerebral palsy. Existing commercial BCIs are not designed according to the needs of end-users. Implications for Rehabilitation Mood, fatigue, physical illness and motivation influence the usability of a brain-computer interface. Commercial brain-computer interfaces are not designed for practical assistive technology use for people with cerebral palsy. Practical brain-computer interface assistive technologies may need to be flexible to suit individual needs.

Accuracy of skinfold and bioelectrical impedance assessments of body fat percentage in ambulatory individuals with cerebral palsy.

PubMed

Oeffinger, Donna J; Gurka, Matthew J; Kuperminc, Michelle; Hassani, Sahar; Buhr, Neeley; Tylkowski, Chester

2014-05-01

This study assessed the accuracy of measurements of body fat percentage in ambulatory individuals with cerebral palsy (CP) from bioelectrical impedance analysis (BIA) and skinfold equations. One hundred and twenty-eight individuals (65 males, 63 females; mean age 12y, SD 3, range 6-18y) with CP (Gross Motor Function Classification System [GMFCS] levels I (n=6), II (n=46), and III (n=19) participated. Body fat percentage was estimated from (1) BIA using standing height and estimated heights (knee height and tibial length) and (2) triceps and subscapular skinfolds using standard and CP-specific equations. All estimates of body fat percentage were compared with body fat percentage from dual-energy X-ray absorptiometry (DXA) scans. Differences between DXA, BIA, and skinfold body fat percentage were analyzed by comparing mean differences. Agreement was assessed by Bland-Altman plots and concordance correlation coefficients (CCC). BMI was moderately correlated with DXA (Pearson's r=0.53). BIA body fat percentage was significantly different from DXA when using estimated heights (95% confidence intervals [CIs] do not contain 0) but not standing height (95% CI -1.9 to 0.4). CCCs for all BIA comparisons indicated good to excellent agreement (0.75-0.82) with DXA. Body fat percentage from skinfold measurements and CP-specific equations was not significantly different from DXA (mean 0.8%; SD 5.3%; 95% CI -0.2 to 1.7) and demonstrated strong agreement with DXA (CCC 0.86). Accurate measures of body fat percentage can be obtained using BIA and two skinfold measurements (CP-specific equations) in ambulatory individuals with CP. These findings should encourage assessments of body fat in clinical and research practices. © 2013 Mac Keith Press.

Reliability and Validity of Objective Measures of Physical Activity in Youth With Cerebral Palsy Who Are Ambulatory.

PubMed

O'Neil, Margaret E; Fragala-Pinkham, Maria; Lennon, Nancy; George, Ameeka; Forman, Jeffrey; Trost, Stewart G

2016-01-01

Physical therapy for youth with cerebral palsy (CP) who are ambulatory includes interventions to increase functional mobility and participation in physical activity (PA). Thus, reliable and valid measures are needed to document PA in youth with CP. The purpose of this study was to evaluate the inter-instrument reliability and concurrent validity of 3 accelerometer-based motion sensors with indirect calorimetry as the criterion for measuring PA intensity in youth with CP. Fifty-seven youth with CP (mean age=12.5 years, SD=3.3; 51% female; 49.1% with spastic hemiplegia) participated. Inclusion criteria were: aged 6 to 20 years, ambulatory, Gross Motor Function Classification System (GMFCS) levels I through III, able to follow directions, and able to complete the full PA protocol. Protocol activities included standardized activity trials with increasing PA intensity (resting, writing, household chores, active video games, and walking at 3 self-selected speeds), as measured by weight-relative oxygen uptake (in mL/kg/min). During each trial, participants wore bilateral accelerometers on the upper arms, waist/hip, and ankle and a portable indirect calorimeter. Intraclass coefficient correlations (ICCs) were calculated to evaluate inter-instrument reliability (left-to-right accelerometer placement). Spearman correlations were used to examine concurrent validity between accelerometer output (activity and step counts) and indirect calorimetry. Friedman analyses of variance with post hoc pair-wise analyses were conducted to examine the validity of accelerometers to discriminate PA intensity across activity trials. All accelerometers exhibited excellent inter-instrument reliability (ICC=.94-.99) and good concurrent validity (rho=.70-.85). All accelerometers discriminated PA intensity across most activity trials. This PA protocol consisted of controlled activity trials. Accelerometers provide valid and reliable measures of PA intensity among youth with CP. © 2016 American Physical Therapy Association.

Nutritional status of children with cerebral palsy in Turkey.

PubMed

Tüzün, Emine Handan; Güven, Duygu Korkem; Eker, Levent; Elbasan, Bülent; Bülbül, Selda Fatma

2013-03-01

The aim of this study was to assess the nutritional status, and provide information regarding anthropometric measurements of cerebral-palsied children living in the city of Ankara, Turkey. A total of 447 children with cerebral palsy (CP) were participated in this cross-sectional study. Participants were assessed for functional motor impairment by the gross motor function classification system (GMFCS). Assesment of nutritional status was based on the triceps skinfold thickness (TSF), arm fat area (AFA) estimates derived from TSF and mid-upper arm circumference measurements. TSF and AFA Z-scores were computed using reference data. Cerebral-palsied children had lower TSF and AFA Z-scores compared to reference data from healthy children. The prevalence of underweight and overweight among boys was 8.3 and 9.5%, respectively, whereas it was 19.0 and 0.5% for girls. Underweight was more prevalent in the low functioning children than in moderate functioning children. The findings of this study indicate that cerebral-palsied children face nutritional challenges. Underweight is more prevalent than overweight among cerebral-palsied children. To optimize the outcomes of rehabilitation and prevention efforts, an understanding of the heterogeneity of nutritional status among children with CP is required.

Personal and environmental factors contributing to participation in romantic relationships and sexual activity of young adults with cerebral palsy.

PubMed

Wiegerink, Diana J H G; Stam, Henk J; Ketelaar, Marjolijn; Cohen-Kettenis, Peggy T; Roebroeck, Marij E

2012-01-01

To study determinants of romantic relationships and sexual activity of young adults with cerebral palsy (CP), focusing on personal and environmental factors. A cohort study was performed with 74 young adults (46 men; 28 women) aged 20-25 years (SD 1.4) with CP (49% unilateral CP, 76% GMFCS level I, 85% MACS level I). All participants were of normal intelligence. Romantic relationships, sexual activity (outcome measures), personal and environmental factors (associated factors) were assessed. Associations were analyzed using logistic regression analyses. More females than males with CP were in a current romantic relationship. Self-esteem, sexual esteem and feelings of competence regarding self-efficacy contributed positively to having current romantic relationships. A negative parenting style contributed negatively. Age and gross motor functioning explained 20% of the variance in experience with intercourse. In addition, sexual esteem and taking initiative contributed significantly to intercourse experience. For young adults with CP personal factors (20-35% explained variances) seem to contribute more than environmental factors (9-12% explained variances) to current romantic relationships and sexual experiences. We advice parents and professionals to focus on self-efficacy, self-esteem and sexual self-esteem in development of young adults with CP. [ • The severity of gross motor functioning contributed somewhat to sexual activities, but not to romantic relationships.• High self-efficacy, self-esteem and sexual self-esteem can facilitate involvement in romantic and sexual relationships for young adults with CP.

Development of Child and Family-Centered Engagement Guidelines for Clinical Administration of the Challenge to Measure Advanced Gross Motor Skills: A Qualitative Study.

PubMed

Gibson, Barbara E; Mistry, Bhavnita; Wright, F Virginia

2017-07-28

This article describes a qualitative study aimed at producing child-centered guidelines for the administration of a measure of children's advanced gross motor skills, the Challenge. The purpose of the guidelines is to promote collaborative interpretation and application of results. The study was conducted in three Canadian cities and included 31 children with cerebral palsy (GMFCS Level I or II) ages 8 to 18 and one parent/caregiver per child (N = 62 participants). Following Challenge administration, each child and one of their caregivers took part in separate qualitative interviews. Analyses were oriented to exploring understandings of the purposes of testing, impressions of the child's performance, and perceptions of how results might inform activity choices and interventions. Three themes were generated: investments in doing well; I know my child/myself; and caregivers' interpretations of child's performance. Themes were then integrated with principles of child and family-centered care to develop The Challenge Engagement Guidelines directed at reducing test anxiety and enhancing shared decision making. The Guidelines are the first of their kind to integrate child and family-centered principles into the administration protocol of a motor measure. Although developed for the Challenge, the principles have applicability to other rehabilitation measures.

Femoral anteversion assessment: Comparison of physical examination, gait analysis, and EOS biplanar radiography.

PubMed

Westberry, David E; Wack, Linda I; Davis, Roy B; Hardin, James W

2018-05-01

Multiple measurement methods are available to assess transverse plane alignment of the lower extremity. This study was performed to determine the extent of correlation between femoral anteversion assessment using simultaneous biplanar radiographs and three-dimensional modeling (EOS imaging), clinical hip rotation by physical examination, and dynamic hip rotation assessed by gait analysis. Seventy-seven patients with cerebral palsy (GMFCS Level I and II) and 33 neurologically typical children with torsional abnormalities completed a comprehensive gait analysis with same day biplanar anterior-posterior and lateral radiographs and three-dimensional transverse plane assessment of femoral anteversion. Correlations were determined between physical exam of hip rotation, EOS imaging of femoral anteversion, and transverse plane hip kinematics for this retrospective review study. Linear regression analysis revealed a weak relationship between physical examination measures of hip rotation and biplanar radiographic assessment of femoral anteversion. Similarly, poor correlation was found between clinical evaluation of femoral anteversion and motion assessment of dynamic hip rotation. Correlations were better in neurologically typical children with torsional abnormalities compared to children with gait dysfunction secondary to cerebral palsy. Dynamic hip rotation cannot be predicted by physical examination measures of hip range of motion or from three-dimensional assessment of femoral anteversion derived from biplanar radiographs. Copyright © 2018 Elsevier B.V. All rights reserved.

Systematic review and meta-analysis of the effect of equine assisted activities and therapies on gross motor outcome in children with cerebral palsy.

PubMed

Tseng, Sung-Hui; Chen, Hung-Chou; Tam, Ka-Wai

2013-01-01

To evaluate the literature on the efficacy of equine assisted activities and therapies (EAAT) on gross motor outcomes representing the ICF component of body functions and activity in children with cerebral palsy (CP). We conducted a systematic review and meta-analysis of randomized controlled trials and observational studies of hippotherapy (HPOT) and therapeutic horseback riding (TR) for children with spastic CP. Gross motor outcomes, assessed via muscle activity and muscle tone, gait, posture and Gross Motor Function Measures (GMFM) were evaluated. Five TR studies and nine HPOT studies were included. Our meta-analysis indicated that short-term HPOT (total riding time 8-10 min) significantly reduced asymmetrical activity of the hip adductor muscles. HPOT could improve postural control in children with spastic CP, GMFCS level < 5. However, the evidence did not show a statistically significant effect on GMFM after long-term HPOT or TR (total riding time, 8-22 h) in children with spastic CP. This systematic review found insufficient evidence to support the claim that long-term TR or HPOT provide a significant benefit to children with spastic CP. We found no statistically significant evidence of either therapeutic effect or maintenance effects on the gross motor activity status in CP children.

Acute functional deterioration in a child with cerebral palsy

PubMed Central

Smyth, Elizabeth; Kaliaperumal, Chandrasekaran; Leonard, Jane; Caird, John

2012-01-01

We describe a case of acute functional deterioration in a 13-year-old girl with severe spastic diplegia (GMFCS III) and a new diagnosis of diffuse intrinsic pontine glioma (DIPG). She presented with acute deterioration in mobility and motor function over 1 month, which was associated with dysarthria, dysphagia and behavioural change. Her mother had noticed subtle functional deterioration over the 2 months prior to this. Her physiotherapist who was concerned about her acute functional deterioration referred her for emergency review. Neurological imaging revealed a diffuse pontine lesion consistent with DIPG. She was subsequently referred to oncology. She deteriorated further, clinically, over the next few days and following discussion with the team; her family opted for palliative treatment, given the poor prognosis associated with DIPG. PMID:23257647

Construct Validity and Reliability of the SARA Gait and Posture Sub-scale in Early Onset Ataxia

PubMed Central

Lawerman, Tjitske F.; Brandsma, Rick; Verbeek, Renate J.; van der Hoeven, Johannes H.; Lunsing, Roelineke J.; Kremer, Hubertus P. H.; Sival, Deborah A.

2017-01-01

Aim: In children, gait and posture assessment provides a crucial marker for the early characterization, surveillance and treatment evaluation of early onset ataxia (EOA). For reliable data entry of studies targeting at gait and posture improvement, uniform quantitative biomarkers are necessary. Until now, the pediatric test construct of gait and posture scores of the Scale for Assessment and Rating of Ataxia sub-scale (SARA) is still unclear. In the present study, we aimed to validate the construct validity and reliability of the pediatric (SARAGAIT/POSTURE) sub-scale. Methods: We included 28 EOA patients [15.5 (6–34) years; median (range)]. For inter-observer reliability, we determined the ICC on EOA SARAGAIT/POSTURE sub-scores by three independent pediatric neurologists. For convergent validity, we associated SARAGAIT/POSTURE sub-scores with: (1) Ataxic gait Severity Measurement by Klockgether (ASMK; dynamic balance), (2) Pediatric Balance Scale (PBS; static balance), (3) Gross Motor Function Classification Scale -extended and revised version (GMFCS-E&R), (4) SARA-kinetic scores (SARAKINETIC; kinetic function of the upper and lower limbs), (5) Archimedes Spiral (AS; kinetic function of the upper limbs), and (6) total SARA scores (SARATOTAL; i.e., summed SARAGAIT/POSTURE, SARAKINETIC, and SARASPEECH sub-scores). For discriminant validity, we investigated whether EOA co-morbidity factors (myopathy and myoclonus) could influence SARAGAIT/POSTURE sub-scores. Results: The inter-observer agreement (ICC) on EOA SARAGAIT/POSTURE sub-scores was high (0.97). SARAGAIT/POSTURE was strongly correlated with the other ataxia and functional scales [ASMK (rs = -0.819; p < 0.001); PBS (rs = -0.943; p < 0.001); GMFCS-E&R (rs = -0.862; p < 0.001); SARAKINETIC (rs = 0.726; p < 0.001); AS (rs = 0.609; p = 0.002); and SARATOTAL (rs = 0.935; p < 0.001)]. Comorbid myopathy influenced SARAGAIT/POSTURE scores by concurrent muscle weakness, whereas comorbid myoclonus predominantly influenced SARAKINETIC scores. Conclusion: In young EOA patients, separate SARAGAIT/POSTURE parameters reveal a good inter-observer agreement and convergent validity, implicating the reliability of the scale. In perspective of incomplete discriminant validity, it is advisable to interpret SARAGAIT/POSTURE scores for comorbid muscle weakness. PMID:29326569

Feeding and gastrointestinal problems in children with cerebral palsy.

PubMed

Erkin, Gulten; Culha, Canan; Ozel, Sumru; Kirbiyik, Eylem Gulsen

2010-09-01

The aim of our study was to identify feeding and gastrointestinal system (GIS) problems in children with cerebral palsy (CP), and to evaluate the relationship between these problems and the severity of CP. A total of 120 children with CP were enrolled consecutively into the study (67 males, 53 females; mean age: 6.0±2.4 years; range: 2-12 years). The children were classified according to the Swedish classification as diplegic, hemiplegic, or quadriplegic. Severity of CP was classified based on the Gross Motor Function Classification System. The amount of time that the caregiver allocated to mealtimes, modifications of the food, as well as feeding and GIS problems was evaluated. Feeding dysfunction was classified as mild, moderate, or severe. Comparisons of GIS and feeding disorders and the severity of CP were carried out using χ test. The results indicated lack of appetite in 46 of the 120 children (38.3%), sialorrhea in 37 (30.8%), constipation in 30 (25%), difficulty in swallowing in 23 (19.2%), and feeding dysfunction in 26 (21.7%). On the basis of the Gross Motor Function Classification System (GMFCS), the incidence of GIS problems and feeding dysfunction was found to be significantly higher in the children classified in the severe group. The time taken to consume meals was significantly longer among children with feeding dysfunction. Feeding and GIS problems are frequent in children with CP, and more marked in those with severe CP. Approximately one fourth of children with CP suffer from feeding dysfunction, and more time has to be allocated to consume meals.

Questionnaire about the adverse events and side effects following botulinum toxin A treatment in patients with cerebral palsy.

PubMed

Blaszczyk, Izabela; Foumani, Nazli Poorsafar; Ljungberg, Christina; Wiberg, Mikael

2015-11-06

Botulinum toxin A (BoNT-A) injections for treatment of spasticity in patients with cerebral palsy (CP) have been used for about two decades. The treatment is considered safe but a low frequency of adverse events (AE) has been reported. A good method to report AEs is necessary to verify the safety of the treatment. We decided to use an active surveillance of treatment-induced harm using a questionnaire we created. We studied the incidence of reported AEs and side effects in patients with CP treated with BoNT-A. We investigated the relationship between the incidence of AEs or side effects and gender, age, weight, total dose, dose per body weight, Gross Motor Function Classification System (GMFCS) and number of treated body parts. Seventy-four patients with CP participated in our study. In 54 (51%) of 105 BoNT-A treatments performed in 45 (61%) patients, there were 95 AEs and side effects reported, out of which 50 were generalized and/or focal distant. Severe AEs occurred in three patients (4%), and their BoNT-A treatment was discontinued. Consecutive collection of the AE and side-effect incidence using our questionnaire can increase the safety of BoNT-A treatment in patients with CP.

Sleep disturbances in preschool age children with cerebral palsy: a questionnaire study.

PubMed

Romeo, Domenico M; Brogna, Claudia; Musto, Elisa; Baranello, Giovanni; Pagliano, Emanuela; Casalino, Tiziana; Ricci, Daniela; Mallardi, Maria; Sivo, Serena; Cota, Francesco; Battaglia, Domenica; Bruni, Oliviero; Mercuri, Eugenio

2014-09-01

The study aimed to analyze (i) the prevalence of sleep disorders in pre-school children with cerebral palsy (CP) using the Sleep Disturbance Scale for Children (SDSC), (ii) the possible association with motor, cognitive and behavioral problems, and (iii) the possible differences with typically developing children matched for age and gender. One-hundred children with CP (age range: 3-5 years, mean: 3.8 years) were assessed using the SDSC, the Gross Motor Function Classification System (GMFCS), the Wechsler Preschool and Primary Scale of Intelligence, and the Child Behaviour Check List (CBCL) to assess sleep, motor, cognitive, and behavioral problems, respectively. Further 100 healthy children matched for age and sex were assessed using the SDSC. An abnormal total sleep score was found in 13% of children with CP while 35% had an abnormal score on at least one SDSC factor. SDSC total score was significantly associated with pathological internalizing scores on CBCL and active epilepsy on multivariate analysis. CP group reported higher significant median scores on SDSC total, parasomnias, and difficulty in initiating and maintaining sleep factors. In pre-school children sleep disorders are more common in children with CP than in healthy control group and are often associated with epilepsy and behavioral problems. Copyright © 2014 Elsevier B.V. All rights reserved.

Neurodevelopmental long-term outcome in children with hydrocephalus requiring neonatal surgical treatment.

PubMed

Melot, A; Labarre, A; Vanhulle, C; Rondeau, S; Brasseur, M; Gilard, V; Castel, H; Marret, S; Proust, F

2016-04-01

To assess long-term neurodevelopmental outcome in children with hydrocephalus requiring neurosurgical treatment during the neonatal period. This prospective longitudinal population-based study included 43 children with neonatal shunted hydrocephalus. The 43 children were prospectively reviewed in the presence of their parents at the outpatient clinic. Cognitive and motor outcomes were assessed respectively using different Wechsler scales according to age and Gross Motor Function Classification System (GMFCS). Postoperative MRI was routinely performed. The mean gestational age at birth of the 43 consecutive children with neonatal hydrocephalus (sex ratio M/F: 1.39) was 34.5±5.4 weeks of gestation. At mean follow-up of 10.4±4 years, mean total IQ was 73±27.7, with equivalent results in mean verbal and mean performance IQ. Of the 33 children with IQ evaluation, 18 presented an IQ≥85 (41.9%). Efficiency in walking without a mobility device (GMFCS≤2) was obtained in 37 children (86%). Only severity of postoperative ventricular dilation was significantly associated with unfavorable outcome (Evans index>0.37; odds ratio: 0.16, P=0.03). This information could be provided to those families concerned who often experience anxiety when multi-disciplinary management of neonatal hydrocephalus is required. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Achilles tendon moment arm length is smaller in children with cerebral palsy than in typically developing children.

PubMed

Kalkman, Barbara M; Bar-On, Lynn; Cenni, Francesco; Maganaris, Constantinos N; Bass, Alfie; Holmes, Gill; Desloovere, Kaat; Barton, Gabor J; O'Brien, Thomas D

2017-05-03

When studying muscle and whole-body function in children with cerebral palsy (CP), knowledge about both internal and external moment arms is essential since they determine the mechanical advantage of a muscle over an external force. Here we asked if Achilles tendon moment arm (MA AT ) length is different in children with CP and age-matched typically developing (TD) children, and if MA AT can be predicted from anthropometric measurements. Sixteen children with CP (age: 10y 7m±3y, 7 hemiplegia, 12 diplegia, GMFCS level: I (11) and II (8)) and twenty TD children (age: 10y 6m±3y) participated in this case-control study. MA AT was calculated at 20° plantarflexion by differentiating calcaneus displacement with respect to ankle angle. Seven anthropometric variables were measured and related to MA AT . We found normalized MA AT to be 15% (∼7mm) smaller in children with CP compared to TD children (p=0.003). MA AT could be predicted by all anthropometric measurements with tibia length explaining 79% and 72% of variance in children with CP and TD children, respectively. Our findings have important implications for clinical decision making since MA AT influences the mechanical advantage about the ankle, which contributes to movement function and is manipulated surgically. Copyright © 2017 Elsevier Ltd. All rights reserved.

Intra-operatively measured spastic semimembranosus forces of children with cerebral palsy.

PubMed

Yucesoy, Can A; Temelli, Yener; Ateş, Filiz

2017-10-01

The knee kept forcibly in a flexed position is typical in cerebral palsy. Using a benchmark, we investigate intra-operatively if peak spastic hamstring force is measured in flexed knee positions. This tests the assumed shift of optimal length due to adaptation of spastic muscle and a decreasing force trend towards extension. Previously we measured spastic gracilis (GRA) and semitendinosus (ST) forces. Presently, we studied spastic semimembranosus (SM) and tested the following hypotheses: spastic SM forces are (1) high in flexed and (2) low in extended positions. We compared the data to those of GRA and ST to test (3) if percentages of peak force produced in flexed positions are different. During muscle lengthening surgery of 8 CP patients (9years, 4months; GMFCS levels=II-IV; limbs tested=13) isometric SM forces were measured from flexion (120°) to full extension (0°). Spastic SM forces were low in flexed knee positions (only 4.2% (3.4%) and 10.7% (9.7%) of peak force at KA=120° and KA=90° respectively, indicating less force production compared to the GRA or ST) and high in extended knee positions (even 100% of peak force at KA=0°). This indicates an absence of strong evidence for a shift of optimal muscle length of SM towards flexion. Copyright © 2017 Elsevier Ltd. All rights reserved.

A retrospective review to assess whether spinal fusion and scoliosis correction improved activity and participation for children with Angelman syndrome.

PubMed

Sewell, Mathew David; Wallace, Charles; Gibson, Alex; Noordeen, Hilali; Tucker, Stewart; Molloy, Sean; Lehovsky, Jan

2016-10-01

This study investigates outcome of scoliosis treatment for 11 children with Angelman syndrome (AS), with particular focus on activity, participation and the musculoskeletal factors that may affect these outcomes. Retrospective review of medical records, radiographs and questionnaires administered to caregivers of 11 children (8M:3F) with AS and scoliosis. Six underwent observational treatment during childhood and five underwent spinal fusion. The Activities Scale for Kids (ASKp) questionnaire was used to measure activity and participation. Questionnaire and radiographic data were recorded over a 2 year period. In the observational group, scoliosis increased from 31° to 46°. Mean ASKp decreased from 13.8 to 11.9 (p = 0.06). In the operative group, scoliosis decreased from 68° to 29°. Mean ASKp increased from 11.4 to 15.9 (p < 0.01). There was also a reduction in spinal-related pain and mean number of hospital admissions for chest infection. However, there was a 60% major complication rate. There was no difference in mobility, GMFCS level, feeding or communication in either group before or after treatment. In children with significant scoliosis and AS, spinal fusion was associated with a small improvement in activity and participation, reduction in pain and a decrease in frequency of severe chest infections. Non-operative treatment resulted in progression of scoliosis during childhood and decrease in activity.

Evaluation of Functional Electrical Stimulation to Assist Cycling in Four Adolescents with Spastic Cerebral Palsy

PubMed Central

Harrington, Ann Tokay; McRae, Calum G. A.; Lee, Samuel C. K.

2012-01-01

Introduction. Adolescents with cerebral palsy (CP) often have difficulty participating in exercise at intensities necessary to improve cardiovascular fitness. Functional electrical stimulation- (FES-) assisted cycling is proposed as a form of exercise for adolescents with CP. The aims of this paper were to adapt methods and assess the feasibility of applying FES cycling technology in adolescents with CP, determine methods of performing cycling tests in adolescents with CP, and evaluate the immediate effects of FES assistance on cycling performance. Materials/Methods. Four participants (12–14 years old; GMFCS levels III-IV) participated in a case-based pilot study of FES-assisted cycling in which bilateral quadriceps muscles were activated using surface electrodes. Cycling cadence, power output, and heart rate were collected. Results. FES-assisted cycling was well tolerated (n = 4) and cases are presented demonstrating increased cadence (2–43 rpm), power output (19–70%), and heart rates (4-5%) and decreased variability (8–13%) in cycling performance when FES was applied, compared to volitional cycling without FES assistance. Some participants (n = 2) required the use of an auxiliary hub motor for assistance. Conclusions. FES-assisted cycling is feasible for individuals with CP and may lead to immediate improvements in cycling performance. Future work will examine the potential for long-term fitness gains using this intervention. PMID:22685479

Cerebral palsy in a total population of 4-11 year olds in southern Sweden. Prevalence and distribution according to different CP classification systems.

PubMed

Westbom, Lena; Hagglund, Gunnar; Nordmark, Eva

2007-12-05

The aim of this study was to investigate the prevalence of cerebral palsy (CP) as well as to characterize the CP population, its participation in a secondary prevention programme (CPUP) and to validate the CPUP database. The study population was born 1990-1997 and resident in Skåne/Blekinge on Jan 1st 2002. Multiple sources were used. Irrespective of earlier diagnoses, neuropaediatrician and other professional medical records were evaluated for all children at the child habilitation units. The CPUP database and diagnosis registers at hospital departments were searched for children with CP or psychomotor retardation, whose records were then evaluated. To enhance early prevention, CP/probable CP was searched for also in children below four years of age born 1998-2001. The prevalence of CP was 2.4/1,000 (95% CI 2.1-2.6) in children 4-11 years of age born in Sweden, excluding post-neonatally acquired CP. Children born abroad had a higher prevalence of CP with more severe functional limitations. In the total population, the prevalence of CP was 2.7/1,000 (95% CI 2.4-3.0) and 48% were GMFCS-level I (the mildest limitation of gross motor function). One third of the children with CP, who were born or had moved into the area after a previous study in 1998, were not in the CPUP database. The subtype classification in the CPUP database was adjusted in the case of every fifth child aged 4-7 years not previously reviewed. The prevalence of CP and the subtype distribution did not differ from that reported in other studies, although the proportion of mild CP tended to be higher. The availability of a second opinion about the classification of CP/CP subtypes is necessary in order to keep a CP register valid, as well as an active search for undiagnosed CP among children with other impairments.

The integration of probabilistic information during sensorimotor estimation is unimpaired in children with Cerebral Palsy

PubMed Central

Sokhey, Taegh; Gaebler-Spira, Deborah; Kording, Konrad P.

2017-01-01

Background It is important to understand the motor deficits of children with Cerebral Palsy (CP). Our understanding of this motor disorder can be enriched by computational models of motor control. One crucial stage in generating movement involves combining uncertain information from different sources, and deficits in this process could contribute to reduced motor function in children with CP. Healthy adults can integrate previously-learned information (prior) with incoming sensory information (likelihood) in a close-to-optimal way when estimating object location, consistent with the use of Bayesian statistics. However, there are few studies investigating how children with CP perform sensorimotor integration. We compare sensorimotor estimation in children with CP and age-matched controls using a model-based analysis to understand the process. Methods and findings We examined Bayesian sensorimotor integration in children with CP, aged between 5 and 12 years old, with Gross Motor Function Classification System (GMFCS) levels 1–3 and compared their estimation behavior with age-matched typically-developing (TD) children. We used a simple sensorimotor estimation task which requires participants to combine probabilistic information from different sources: a likelihood distribution (current sensory information) with a prior distribution (learned target information). In order to examine sensorimotor integration, we quantified how participants weighed statistical information from the two sources (prior and likelihood) and compared this to the statistical optimal weighting. We found that the weighing of statistical information in children with CP was as statistically efficient as that of TD children. Conclusions We conclude that Bayesian sensorimotor integration is not impaired in children with CP and therefore, does not contribute to their motor deficits. Future research has the potential to enrich our understanding of motor disorders by investigating the stages of motor processing set out by computational models. Therapeutic interventions should exploit the ability of children with CP to use statistical information. PMID:29186196

Pediatric endurance and limb strengthening for children with cerebral palsy (PEDALS) – a randomized controlled trial protocol for a stationary cycling intervention

PubMed Central

Fowler, Eileen G; Knutson, Loretta M; DeMuth, Sharon K; Sugi, Mia; Siebert, Kara; Simms, Victoria; Azen, Stanley P; Winstein, Carolee J

2007-01-01

Background In the past, effortful exercises were considered inappropriate for children with spastic cerebral palsy (CP) due to concern that they would escalate abnormalities including spasticity and abnormal movement patterns. Current scientific evidence indicates that these concerns were unfounded and that therapeutic interventions focused on muscle strengthening can lead to improved functional ability. However, few studies have examined the potential benefits of cardiorespiratory fitness exercises in this patient population. Methods/design The rationale and design of a randomized controlled trial examining the effects of a stationary cycling intervention for children with CP are outlined here. Sixty children with spastic diplegic CP between the ages of 7 and 18 years and Gross Motor Function Classification System (GMFCS) levels of I, II, or III will be recruited for this study. Participants will be randomly assigned to either an intervention (cycling) or a control (no cycling) group. The cycling intervention will be divided into strengthening and cardiorespiratory endurance exercise phases. During the strengthening phase, the resistance to lower extremity cycling will be progressively increased using a uniquely designed limb-loaded mechanism. The cardiorespiratory endurance phase will focus on increasing the intensity and duration of cycling. Children will be encouraged to exercise within a target heart rate (HR) range (70 – 80% maximum HR). Thirty sessions will take place over a 10–12 week period. All children will be evaluated before (baseline) and after (follow-up) the intervention period. Primary outcome measures are: knee joint extensor and flexor moments, or torque; the Gross Motor Function Measure (GMFM); the 600 Yard Walk-Run test and the Thirty-Second Walk test (30 sec WT). Discussion This paper presents the rationale, design and protocol for Pediatric Endurance and Limb Strengthening (PEDALS); a Phase I randomized controlled trial evaluating the efficacy of a stationary cycling intervention for children with spastic diplegic cerebral palsy. PMID:17374171

Long-term neurodevelopmental outcome after selective feticide in monochorionic pregnancies.

PubMed

van Klink, Jmm; Koopman, H M; Middeldorp, J M; Klumper, F J; Rijken, M; Oepkes, D; Lopriore, E

2015-10-01

To assess the incidence of and risk factors for adverse long-term neurodevelopmental outcome in complicated monochorionic pregnancies treated with selective feticide at our centre between 2000 and 2011. Observational cohort study. National referral centre for fetal therapy (Leiden University Medical Centre, the Netherlands). Neurodevelopmental outcome was assessed in 74 long-term survivors. Children, at least 2 years of age, underwent an assessment of neurologic, motor and cognitive development using standardised psychometric tests and the parents completed a behavioural questionnaire. A composite outcome termed neurodevelopmental impairment including cerebral palsy (GMFCS II-V), cognitive and/or motor test score of <70, bilateral blindness or bilateral deafness requiring amplification. A total of 131 monochorionic pregnancies were treated with selective feticide at the Leiden University Medical Centre. Overall survival rate was 88/131 (67%). Long-term outcome was assessed in 74/88 (84%). Neurodevelopmental impairment was detected in 5/74 [6.8%, 95% confidence interval (CI), 1.1-12.5] of survivors. Overall adverse outcome, including perinatal mortality or neurodevelopmental impairment was 48/131 (36.6%). In multivariate analysis, parental educational level was associated with cognitive test scores (regression coefficient B 3.9, 95% CI 1.8-6.0). Behavioural problems were reported in 10/69 (14.5%). Adverse long-term outcome in survivor twins of complicated monochorionic pregnancies treated with selective feticide appears to be more prevalent than in the general population. Cognitive test scores were associated with parental educational level. Neurodevelopmental impairment after selective feticide was detected in 5/74 (6.8%, 95% CI 1.1-12.5) of survivors. © 2015 Royal College of Obstetricians and Gynaecologists.

Picture me playing-a portrait of participation and enjoyment of leisure activities in adolescents with cerebral palsy.

PubMed

Shikako-Thomas, Keiko; Shevell, Michael; Lach, Lucyna; Law, Mary; Schmitz, Norbert; Poulin, Chantal; Majnemer, Annette

2013-03-01

In recent years attention has been paid to the participation levels of children and youth with Cerebral Palsy (CP), particularly the extent to which they have the opportunity to be involved in and enjoy leisure activities. The objective of this study is to describe the level of participation and enjoyment in leisure activities among adolescents with CP and to identify potential differences in participation patterns related to sociodemographic attributes. A cross-sectional design was used. Participants were 175 adolescents 12-20 years old (M=15.3; ±2.2), GMFCS I=55/II=43/III=13/IV=18/V=39 who completed the Children's Assessment of Participation and Enjoyment (CAPE). The types of activities participants engaged in most frequently were social and recreational activities, whereas self-improvement and skill-based activities were least frequent. Social activities were the activities they enjoyed most. In general, participation decreases, as youth grow older. Girls engaged in more self-improvement activities than boys. Adolescents who study in special segregated schools experienced a lower diversity and intensity of engagement in all leisure activity domains. Adolescents who were not ambulatory and those presenting with more severe manual ability limitations participated less in all activity types except skill-based activities. Adolescents with CP place a high value on the ability to engage in activities of their own choosing and on interacting with friends. Engagement in a variety of leisure activities is important for a healthy development. Understanding the leisure patterns and preferences of this population, in addition to the contextual factors, may help in the elaboration of interventions and programs to promote a healthy development for this population. Copyright © 2012 Elsevier Ltd. All rights reserved.

Similarities and differences between infantile and early childhood onset vanishing white matter disease.

PubMed

Zhou, Ling; Zhang, Haihua; Chen, Na; Zhang, Zhongbin; Liu, Ming; Dai, Lifang; Wang, Jingmin; Jiang, Yuwu; Wu, Ye

2018-06-01

Vanishing white matter disease (VWM) is one of the most prevalent inherited leukoencephalopathies in childhood. Infantile VWM is more severe but less understood than the classic early childhood type. We performed a follow-up study on 14 infantile and 26 childhood patients to delineate the natural history and neuroimaging features of VWM. Infantile and childhood patients shared similarities in the incidence of epileptic seizure (35.7 vs. 38.5%) and episodic aggravation (92.9 vs. 84.6%). Developmental delay before disease onset was more common in infantile patients. Motor disability was earlier and more severe in infantile VWM. In survivors with disease durations of 1-3 years, the Gross Motor Function Classification System (GMFCS) was classified as IV-V in 66.7% of infantile and only 29.4% of childhood patients. Kaplan-Meier survival curve analysis indicated that the 5-year survival rates were 21.6 and 91.3% in infantile and childhood VWM, respectively. In terms of MRI, infantile patients showed more extensive involvement and earlier rarefaction, with more common involvement of subcortical white matter, internal capsule, brain stem and dentate nuclei of the cerebellum. Restricted diffusion was more diffuse or extensive in infantile patients. In addition, four novel mutations were identified. In conclusion, we identified some similarities and differences in the natural history and neuroimaging features between infantile and early childhood VWM.

Effect of transcranial direct-current stimulation combined with treadmill training on balance and functional performance in children with cerebral palsy: a double-blind randomized controlled trial.

PubMed

Duarte, Natália de Almeida Carvalho; Grecco, Luanda André Collange; Galli, Manuela; Fregni, Felipe; Oliveira, Cláudia Santos

2014-01-01

Cerebral palsy refers to permanent, mutable motor development disorders stemming from a primary brain lesion, causing secondary musculoskeletal problems and limitations in activities of daily living. The aim of the present study was to determine the effects of gait training combined with transcranial direct-current stimulation over the primary motor cortex on balance and functional performance in children with cerebral palsy. A double-blind randomized controlled study was carried out with 24 children aged five to 12 years with cerebral palsy randomly allocated to two intervention groups (blocks of six and stratified based on GMFCS level (levels I-II or level III).The experimental group (12 children) was submitted to treadmill training and anodal stimulation of the primary motor cortex. The control group (12 children) was submitted to treadmill training and placebo transcranial direct-current stimulation. Training was performed in five weekly sessions for 2 weeks. Evaluations consisted of stabilometric analysis as well as the administration of the Pediatric Balance Scale and Pediatric Evaluation of Disability Inventory one week before the intervention, one week after the completion of the intervention and one month after the completion of the intervention. All patients and two examiners were blinded to the allocation of the children to the different groups. The experimental group exhibited better results in comparison to the control group with regard to anteroposterior sway (eyes open and closed; p<0.05), mediolateral sway (eyes closed; p<0.05) and the Pediatric Balance Scale both one week and one month after the completion of the protocol. Gait training on a treadmill combined with anodal stimulation of the primary motor cortex led to improvements in static balance and functional performance in children with cerebral palsy. Ensaiosclinicos.gov.br/RBR-9B5DH7.

Impact of a virtual reality-based intervention on motor performance and balance of a child with cerebral palsy: a case study

PubMed Central

Pavão, Silvia Leticia; Arnoni, Joice Luiza Bruno; de Oliveira, Alyne Kalyane Câmara; Rocha, Nelci Adriana Cicuto Ferreira

2014-01-01

OBJECTIVE: To verify the effect of an intervention protocol using virtual reality (VR) on the motor performance and balance of a child with cerebral palsy (CP). CASE DESCRIPTION: To comply with the proposed objectives, a 7-year old child with spastic hemiplegic cerebral palsy (CP), GMFCS level I, was submitted to a physiotherapy intervention protocol of 12 45-minute sessions, twice a week, using virtual reality-based therapy. The protocol used a commercially-available console (XBOX(r)360 Kinect(r)) able to track and reproduce body movements on a screen. Prior to the intervention protocol, the child was evaluated using the Motor Development Scale (MDS) and the Pediatric Balance Scale (PBS) in order to assess motor development and balance, respectively. Two baseline assessments with a 2-week interval between each other were carried out for each tool. Then, the child was re-evaluated after the twelfth session. The results showed no changes in the two baseline scores. After the intervention protocol, the child improved his scores in both tools used: the PBS score increased by 3 points, reaching the maximal score, and the MDS increased from a much inferior motor performance to just an inferior motor performance. COMMENTS: The evidence presented in this case supports the use of virtual reality as a promising tool to be incorporated into the rehabilitation process of patients with neuromotor dysfunction. PMID:25511004

Mastery motivation in adolescents with cerebral palsy.

PubMed

Majnemer, Annette; Shikako-Thomas, Keiko; Lach, Lucy; Shevell, Michael; Law, Mary; Schmitz, Norbert

2013-10-01

The aim of this study is to describe motivation in adolescents with cerebral palsy (CP) and factors associated with motivation level. The Dimensions of Mastery Questionnaire (DMQ) measures motivation in mastering challenging tasks and expressive elements. It was completed by 153 parents and 112 adolescents with CP. Adolescents (GMFCS in n=146 - I:50, II:43, III:13, IV:15, V:25) were assessed using the Leiter IQ and Gross Motor Function Measure. Parents completed the Vineland Adaptive Behavior Scale and the Strengths and Difficulties Questionnaire. Motivation scores were highest for mastery pleasure and social persistence with adults and lowest for gross motor and object-oriented persistence. Socio-demographic factors were not strongly correlated with DMQ. Higher gross motor ability (r=0.24-0.52) and fewer activity limitations (r=0.30-0.64, p<.001) were associated with persistence in cognitive, motor and social tasks, but not mastery pleasure. Higher IQ was associated with persistence in object-oriented tasks (r=0.42, p<.001). Prosocial behaviors correlated with high motivation (r=0.39-0.53, p<.001). Adolescents' motivation scores were higher than parents' scores. Adolescents with CP express high mastery pleasure, not related to abilities. High motivation was associated with fewer activity limitations and prosocial behaviors and aspects of family environment. Findings elucidate those at-risk for low motivation, which can influence treatment adherence and participation in challenging but meaningful activities. Copyright © 2013 Elsevier Ltd. All rights reserved.

What makes children with cerebral palsy vulnerable to malnutrition? Findings from the Bangladesh cerebral palsy register (BCPR).

PubMed

Jahan, Israt; Muhit, Mohammad; Karim, Tasneem; Smithers-Sheedy, Hayley; Novak, Iona; Jones, Cheryl; Badawi, Nadia; Khandaker, Gulam

2018-04-16

To assess the nutritional status and underlying risk factors for malnutrition among children with cerebral palsy in rural Bangladesh. We used data from the Bangladesh Cerebral Palsy Register; a prospective population based surveillance of children with cerebral palsy aged 0-18 years in a rural subdistrict of Bangladesh (i.e., Shahjadpur). Socio-demographic, clinical and anthropometric measurements were collected using Bangladesh Cerebral Palsy Register record form. Z scores were calculated using World Health Organization Anthro and World Health Organization AnthroPlus software. A total of 726 children with cerebral palsy were registered into the Bangladesh Cerebral Palsy Register (mean age 7.6 years, standard deviation 4.5, 38.1% female) between January 2015 and December 2016. More than two-third of children were underweight (70.0%) and stunted (73.1%). Mean z score for weight for age, height for age and weight for height were -2.8 (standard deviation 1.8), -3.1 (standard deviation 2.2) and -1.2 (standard deviation 2.3) respectively. Moderate to severe undernutrition (i.e., both underweight and stunting) were significantly associated with age, monthly family income, gross motor functional classification system and neurological type of cerebral palsy. The burden of undernutrition is high among children with cerebral palsy in rural Bangladesh which is augmented by both poverty and clinical severity. Enhancing clinical nutritional services for children with cerebral palsy should be a public health priority in Bangladesh. Implications for Rehabilitation Population-based surveillance data on nutritional status of children with cerebral palsy in Bangladesh indicates substantially high burden of malnutrition among children with CP in rural Bangladesh. Children with severe form of cerebral palsy, for example, higher Gross Motor Function Classification System (GMFCS) level, tri/quadriplegic cerebral palsy presents the highest proportion of severe malnutrition; hence, these vulnerable groups should be focused in designing nutrition intervention and rehabilitation programs. Disability inclusive and focused nutrition intervention programme need to be kept as priority in national nutrition policies and nutrition action plans specially in low- and middle-income countries. Community-based management of malnutrition has the potential to overcome this poor nutritional scenario of children with disability (i.e., cerebral palsy). The global leaders such as World Health Organization, national and international organizations should take this in account and conduct further research to develop nutritional guidelines for this vulnerable group of population.

Transcultural adaptation and validation of the Korean version of Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD).

PubMed

Sung, Ki Hyuk; Kwon, Soon-Sun; Narayanan, Unni G; Chung, Chin Youb; Lee, Kyoung Min; Lee, Seung Yeol; Lee, Damian J; Park, Moon Seok

2015-01-01

The aim of this study was to translate and transculturally adapt the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) questionnaire into Korean language, and to test the reliability and validity, including the internal consistency, known-group validity and factor analysis of the Korean version of the CPCHILD. A Korean version of CPCHILD was produced according to internationally accepted guidelines. For validity testing, 194 consecutive parents or caregivers of children with cerebral palsy (CP) were recruited and completed the questionnaire. Internal consistency, test-retest reliability, and known-groups validity were evaluated and factor analysis was performed to validate the Korean version of the CPCHILD. In terms of internal consistency, a Cronbach's alpha was above 0.90 in all domains of the CPCHILD (range 0.921 to 0.966), except the 5th domain (0.628). In terms of known-groups validity, the total score of the CPCHILD was significantly different according to the Gross Motor Function Classification System (GMFCS) level (p < 0.001). Intra-class correlation coefficient spanned from 0.517 to 0.801. Factor analysis showed that the five-factor solution of the CPCHILD explained 76.7% of the variance with 59.0, 6.5, 5.1, 4.2 and 3.2% of variance by each components number. The Korean version of CPCHILD was found to be a reliable and valid questionnaire of caregivers' perspectives on the health-related quality of life in severely affected children with CP. However, the Korean version of CPCHILD contains some redundant items, and factor analysis suggested a five-domain questionnaire. Implication for Rehabilitation The Korean version of CPCHILD is a reliable, internally consistent, valid instrument for assessing the health-related quality of life in severely affected children with CP from the perspective of caregivers. After the transcultural adaptation and validation of the Korean CPCHILD, it can be reliably used in clinical and research settings to evaluate the health-related quality of life in Korean patients with CP.

The effect of the ketogenic diet on the developing skeleton.

PubMed

Simm, Peter J; Bicknell-Royle, Jillian; Lawrie, Jock; Nation, Judy; Draffin, Kellie; Stewart, Karen G; Cameron, Fergus J; Scheffer, Ingrid E; Mackay, Mark T

2017-10-01

The ketogenic diet (KD) is a medically supervised, high fat, low carbohydrate and restricted protein diet which has been used successfully in patients with refractory epilepsy. Only one published report has explored its effect on the skeleton. We postulated that the KD impairs skeletal health parameters in patients on the KD. Patients commenced on the KD were enrolled in a prospective, longitudinal study, with monitoring of Dual-energy X-ray absorptiometry (DXA) derived bone parameters including bone mineral content and density (BMD). Areal BMD was converted to bone mineral apparent density (BMAD) where possible. Biochemical parameters, including Vitamin D, and bone turnover markers, including osteocalcin, were assessed. Patients were stratified for level of mobility using the gross motor functional classification system (GMFCS). 29 patients were on the KD for a minimum of 6 months (range 0.5-6.5 years, mean 2.1 years). There was a trend towards a reduction in lumbar spine (LS) BMD Z score of 0.1562 (p=0.071) per year and 20 patients (68%) had a lower BMD Z score at the end of treatment. While less mobile patients had lower baseline Z scores, the rate of bone loss on the diet was greater in the more mobile patients (0.28 SD loss per year, p=0.026). Height adjustment of DXA data was possible for 13 patients, with a mean reduction in BMAD Z score of 0.19 SD. Only two patients sustained fractures. Mean urinary calcium-creatinine ratios were elevated (0.77), but only 1 patient developed renal calculi. Children on the KD exhibited differences in skeletal development that may be related to the diet. The changes were independent of height but appear to be exaggerated in patients who are ambulant. Clinicians should be aware of potential skeletal side effects and monitor bone health during KD treatment. Longer term follow up is required to determine adult/peak bone mass and fracture risk throughout life. Crown Copyright © 2017. Published by Elsevier B.V. All rights reserved.

Is head-shaft angle a valuable continuous risk factor for hip migration in cerebral palsy?

PubMed

Chougule, Sanjay; Dabis, John; Petrie, Aviva; Daly, Karen; Gelfer, Yael

2016-12-01

Reimer's migration percentage (MP) is the most established radiographic risk factor for hip migration in cerebral palsy (CP), and it assists surgical decision-making. The head-shaft angle (HSA) measures the valgus of the head and neck in relation to the shaft and may also be a useful predictor of hip migration at a young age. This study first defined normal values and investigated whether the head-shaft angle (HSA) is a continuous risk factor for hip migration in CP. Three hundred and fifty AP pelvic radiographs of 100 consecutive children comprising the hip surveillance programme in our region were analysed for MP and HSA. Inclusion criteria were children with spastic CP and Gross Motor Function Classification System (GMFCS) levels of III-V, along with a minimum follow-up of 5 years. The mean age was 8.8 (range 3-18) years and the mean follow-up time was 7.5 (range 5-10) years. Radiographs of 103 typically developing children (TDC) were selected for the control group. The reliability of the measurements was determined. A random effects analysis was used to assess the relationship between MP and HSA for all data and for MP > 40 %. The TDC cohort had a mean HSA of 157.7° whilst that for the CP cohort was 161.7°. The value declined with age in both groups but remained consistently higher in the CP group. A random effects analysis considering the longitudinal data showed that there was no significant effect of HSA on MP. Similarly, when excluding CP patients with MP < 40 %, there was no significant effect of HSA on MP. This study found no correlation between HSA and hip migration in children with CP in this age group. Using the HSA as a routine radiographic measure in the management pathway across childhood does not offer any added value. Early enrolment onto the hip surveillance programme could offer a better prediction of hip migration using the HSA at a very young age. II retrospective prognostic study.

Medial gastrocnemius and soleus muscle-tendon unit, fascicle, and tendon interaction during walking in children with cerebral palsy.

PubMed

Barber, Lee; Carty, Chris; Modenese, Luca; Walsh, John; Boyd, Roslyn; Lichtwark, Glen

2017-08-01

This study investigates the in vivo function of the medial gastrocnemius and soleus muscle-tendon units (MTU), fascicles, and tendons during walking in children with cerebral palsy (CP) and an equinus gait pattern. Fourteen children with CP (9 males, 5 females; mean age 10y 6mo, standard deviation [SD] 2y 11mo; GMFCS level I=8, II=6), and 10 typically developing (6 males, 4 females; mean age 10y, SD 2y 1mo) undertook full body 3D gait analysis and simultaneous B-mode ultrasound images of the medial gastrocnemius and soleus fascicles during level walking. Fascicle lengths were analysed using a semi-automated tracking algorithm and MTUs using OpenSim. Statistical parametric mapping (two-sample t-test) was used to compare differences between groups (p<0.05). In the CP group medial gastrocnemius fascicles lengthened during mid-stance gait and remained longer into late-stance compared to the typically developing group (p<0.001). CP medial gastrocnemius fascicles shortened less during stance (1.16mm [SD 1.47mm]) compared to the typically developing group (4.48mm [SD 1.94mm], p<0.001). In the CP group the medial gastrocnemius and soleus MTU and tendon were longer during early- and mid-stance (p<0.001). Ankle power during push-off (p=0.015) and positive work (p<0.002) and net work (p<0.001) were significantly lower in the CP group. Eccentric action of the CP medial gastrocnemius muscle fascicles during mid-stance walking is consistent with reduced volume and neuromuscular control of impaired muscle. Reduced ankle push-off power and positive work in the children with CP may be attributed to reduced active medial gastrocnemius fascicle shortening. These findings suggest a reliance on passive force generation for forward propulsion during equinus gait. © 2017 Mac Keith Press.

Three-dimensional evaluation of skeletal deformities of the pelvis and lower limbs in ambulant children with cerebral palsy.

PubMed

Massaad, Abir; Assi, Ayman; Bakouny, Ziad; Sauret, Christophe; Khalil, Nour; Skalli, Wafa; Ghanem, Ismat

2016-09-01

Skeletal abnormalities, affecting posture and walking pattern, increase with motor impairment in children with cerebral palsy (CP). However, it is not known whether these skeletal malalignments occur in children with slight motor impairment. Our aim was to evaluate skeletal malalignment at the level of the pelvis and lower limbs in ambulant children with CP, with slight motor impairment, using a low dose biplanar X-ray technique. Twenty-seven children with spastic CP (mean age: 10.9±4years, 7 Hemiplegia, 20 Diplegia, GMFCS levels I:17, II:10), with no previous treatments at the hips and knees, underwent EOS(®) biplanar X-rays. A control group consisting of 22 typically developing children was also included. Three-dimensional reconstructions of the pelvis and lower limbs were performed in order to calculate 11 radiological parameters related to the pelvis, acetabulum and lower limbs. Pelvic incidence and sacral slope were significantly increased in children with CP compared to TD children (48°±7° vs. 43°±8°, 42°±7° vs. 38°±5°, respectively, p=0.003). Acetabular parameters did not significantly differ between the two groups. Femoral anteversion and neck shaft angle were significantly increased in children with CP (25°±12° vs. 14°±7°, p<0.001; 134°±5° vs. 131°±5°, p=0.005 respectively). No difference was found for tibial torsion. This study showed that even slightly impaired children with CP have an anteverted and abducted femur and present positional and morphological changes of the pelvis in the sagittal plane. The orientation of the acetabulum in 3D seems to not be affected when children with CP present slight motor impairment. Copyright © 2016 Elsevier B.V. All rights reserved.

Avascular necrosis as a complication of the treatment of dislocation of the hip in children with cerebral palsy.

PubMed

Koch, A; Jozwiak, M; Idzior, M; Molinska-Glura, M; Szulc, A

2015-02-01

We investigated the incidence and risk factors for the development of avascular necrosis (AVN) of the femoral head in the course of treatment of children with cerebral palsy (CP) and dislocation of the hip. All underwent open reduction, proximal femoral and Dega pelvic osteotomy. The inclusion criteria were: a predominantly spastic form of CP, dislocation of the hip (migration percentage, MP > 80%), Gross Motor Function Classification System, (GMFCS) grade IV to V, a primary surgical procedure and follow-up of > one year. There were 81 consecutive children (40 girls and 41 boys) in the study. Their mean age was nine years (3.5 to 13.8) and mean follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included measurement of the MP, the acetabular index (AI), the epiphyseal shaft angle (ESA) and the pelvic femoral angle (PFA). The presence and grade of AVN were assessed radiologically according to the Kruczynski classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and Dega osteotomy is an effective form of treatment for children with CP and dislocation of the hip, there were signs of avascular necrosis in about two-thirds of the children. There was a strong correlation between post-operative pain and the severity of the grade of AVN. ©2015 The British Editorial Society of Bone & Joint Surgery.

How are actual needs recognized in the content and goals of written rehabilitation plans?

PubMed

Jeglinsky, Ira; Brogren Carlberg, Eva; Autti-Rämö, Ilona

2014-01-01

The primary aim of the study was to investigate the interrelation between needs and functional difficulties and the therapeutic goals in children with cerebral palsy (CP) as documented in individual written rehabilitation plans. The study was a retrospective cross-sectional register study. The data consisted of randomly chosen register documents for 77 children and adolescents with CP in different predetermined age ranges. The International Classification of Functioning, Disability and Health-Child and Youth version (ICF-CY) was used as a reference for analyzing the content of the written statements. The rehabilitation plans for 70 children, 1-16 years of age, representing all GMFCS levels were analyzed. Goals were not well reflected in the children's needs and functional difficulties. The needs, functional difficulties and goals mainly encompassed the components of body functions and activity/participation. In half of the plans the presence of the parents was mentioned, and the plans were made in multidisciplinary collaboration. The results of this study indicate deficiencies in the content and goals of the written rehabilitation plans. The ICF-CY could serve as a framework to help professionals and parents identify the child's needs and those areas where the goals should be targeted. Implications for Rehabilitation Documenting the child's and family's needs in relation to activity and participation preferences is critical to rehabilitation and intervention planning. Goals, based on the child's needs, should be identified in collaboration with all parties involved, and focus on the child's functioning in meaningful everyday activities. The ICF-CY could serve as a framework for the family and professionals to identify needs and to communicate rehabilitation goals.

Monitoring of body position and motion in children with severe cerebral palsy for 24 hours.

PubMed

Sato, Haruhiko; Iwasaki, Toshiyuki; Yokoyama, Misako; Inoue, Takenobu

2014-01-01

To investigate differences in position and body movements between children with severe cerebral palsy (CP) and children with typical development (TD) during the daytime and while asleep at night. Fifteen children with severe quadriplegic CP living at home (GMFCS level V, 7 males, 8 females; mean age 8 years 3 months; range 3-20 years) and 15 children with TD (6 males, 9 females; mean age 8 years 7 months; range 1-16 years) participated. Body position and movements were recorded for 24 h by a body position monitor and a physical activity monitor, respectively. The amount of time spent in one position and the durations of inactive periods during the daytime and during night-time sleep were computed and analyzed for group differences. In children with CP, the mean longest time spent in one position was longer than that in children with TD during night-time sleep (5.6 ± 3.5 h versus 1.6 ± 1.2 h). In contrast, no significant differences were found between the groups during the daytime (1.9 ± 1.1 h versus 1.6 ± 0.7 h). The mean longest time the body remained inactive was longer in the children with CP during both daytime and nighttime sleep (0.6 ± 0.3 h versus 0.3 ± 0.3 h for daytime, 1.4 ± 0.8 h versus 0.7 ± 0.3 h for nighttime). Children with severe CP living at home showed prolonged immobilized posture during night-time sleep when their caregivers would be likely to also be asleep. This may suggest that these children should receive postural care assistance at night.

Improved parent-reported mobility and achievement of individual goals on activity and participation level after functional power-training in young children with cerebral palsy: a double-baseline controlled trial.

PubMed

van Vulpen, Liesbeth F; de Groot, Sonja; Rameckers, Eugene A; Becher, Jules G; Dallmeijer, Annet J

2018-03-07

In children with cerebral palsy (CP), strength training programs to improve walking capacity and participation in activities of daily living are commonly used in clinical practice, despite lacking evidence of its effectiveness. It has been suggested that strength training with high movement velocity could be more effective than traditional resistance training to improve functional abilities such as walking. In a recently published study, we have demonstrated the positive effects of functional high-velocity resistance (power) training on muscle strength and walking capacity in young children with CP. Whether this type of training is also effective in achieving individual predefined goals in daily activities and self-reported mobility limitations, has not yet been described however. To evaluate the effect of functional power-training on parent-reported mobility and achievement of individual goals on activity and participation level in young children with CP. A double-baseline design was used to compare a 14-week period usual care with a 14-week period of functional power-training (3 times a week) and a follow-up period of 14-weeks. Twenty-two children with spastic CP (13 bilateral, GMFCS level I (N=10) and level II (N=12), mean age 7.5 years (SD 1.8, range 4-10 y)) and their parents participated. Outcome measures were goal attainment scaling (GAS) of individual daily activity related treatment goals, mobility performance as measured using the Functional Mobility Scale (FMS-5m, 50m and 500m), and the parent-reported Mobility Questionnaire (MobQues). After power-training, 86% of children achieved or exceeded their goal, compared with 14% in the usual care period (p<.001). The probability of improvement by one point or more on the FMS- 500 meter after functional power-training was 10 times higher, compared with the usual care period (Relative Risk=10.0 with 95%CI 1.4 - 71.3). No changes were found in the FMS-5m and FMS-50m categories. Improvement on the MobQues was significantly greater after power-training compared with usual care (7.9% (95% CI 2.7 - 13.0, p=.005)). The improvement in performance in the activities defined in the treatment goals continued during the follow-up period. The results indicated that functional power- training is an effective training to achieve personalized treatment goals for activities in daily life and parent-reported mobility performance in young children with cerebral palsy.

Gross motor function in children with spastic Cerebral Palsy and Cerebral Visual Impairment: A comparison between outcomes of the original and the Cerebral Visual Impairment adapted Gross Motor Function Measure-88 (GMFM-88-CVI).

PubMed

Salavati, M; Rameckers, E A A; Waninge, A; Krijnen, W P; Steenbergen, B; van der Schans, C P

2017-01-01

To investigate whether the adapted version of the Gross Motor Function Measure-88 (GMFM-88) for children with Cerebral Palsy (CP) and Cerebral Visual Impairment (CVI) results in higher scores. This is most likely to be a reflection of their gross motor function, however it may be the result of a better comprehension of the instruction of the adapted version. The scores of the original and adapted GMFM-88 were compared in the same group of children (n=21 boys and n=16 girls), mean (SD) age 113 (30) months with CP and CVI, within a time span of two weeks. A paediatric physical therapist familiar with the child assessed both tests in random order. The GMFCS level, mental development and age at testing were also collected. The Wilcoxon signed-rank test was used to compare two different measurements (the original and adapted GMFM-88) on a single sample, (the same child with CP and CVI; p<0.05). The comparison between scores on the original and adapted GMFM-88 in all children with CP and CVI showed a positive difference in percentage score on at least one of the five dimensions and positive percentage scores for the two versions differed on all five dimensions for fourteen children. For six children a difference was seen in four dimensions and in 10 children difference was present in three dimensions (GMFM dimension A, B& C or C, D & E) (p<0.001). The adapted GMFM-88 provides a better estimate of gross motor function per se in children with CP and CVI that is not adversely impacted bytheir visual problems. On the basis of these findings, we recommend using the adapted GMFM-88 to measure gross motor functioning in children with CP and CVI. Copyright © 2016 Elsevier Ltd. All rights reserved.

Influence of Botulinum Toxin Therapy on Postural Control and Lower Limb Intersegmental Coordination in Children with Spastic Cerebral Palsy

PubMed Central

Degelaen, Marc; de Borre, Ludo; Kerckhofs, Eric; de Meirleir, Linda; Buyl, Ronald; Cheron, Guy; Dan, Bernard

2013-01-01

Botulinum toxin injections may significantly improve lower limb kinematics in gait of children with spastic forms of cerebral palsy. Here we aimed to analyze the effect of lower limb botulinum toxin injections on trunk postural control and lower limb intralimb (intersegmental) coordination in children with spastic diplegia or spastic hemiplegia (GMFCS I or II). We recorded tridimensional trunk kinematics and thigh, shank and foot elevation angles in fourteen 3–12 year-old children with spastic diplegia and 14 with spastic hemiplegia while walking either barefoot or with ankle-foot orthoses (AFO) before and after botulinum toxin infiltration according to a management protocol. We found significantly greater trunk excursions in the transverse plane (barefoot condition) and in the frontal plane (AFO condition). Intralimb coordination showed significant differences only in the barefoot condition, suggesting that reducing the degrees of freedom may limit the emergence of selective coordination. Minimal relative phase analysis showed differences between the groups (diplegia and hemiplegia) but there were no significant alterations unless the children wore AFO. We conclude that botulinum toxin injection in lower limb spastic muscles leads to changes in motor planning, including through interference with trunk stability, but a combination of therapies (orthoses and physical therapy) is needed in order to learn new motor strategies. PMID:23344454

Prevalance of Obesity in Children with Cerebral Palsy

PubMed Central

Bansal, Ankita; Diwan, Jasmin; Vyas, Neeta

2014-01-01

Introduction: Obesity are epidemic among children and adolescents. There is worldwide tendency of increasing prevalence of obesity in children. Cerebral palsy (CP) is leading cause of childhood disability.studies have proposed mechanism of children with disability leading towards obesity and related health risks. So this study is aimed at determining whether such trend of obesity exists in children with CP in terms of BMI and WHR. Study Design: Cross -sectional study. Materials and Methods: Participants: 40 children diagnosed as CP age 2-18 years, GMFCS I-IV. Procedure: BMI; kg/m2 was calculated from height and weight. WHR was calculated by measuring waist circumference and hip circumference. BMI percentiles were reported according to sex-specific age group standards for growth set by the WHO growth charts. Results: Out of total CP subjects 40% were found to be underweight, 45%, 7.5% and 7.5% were found to be normal, overweight and obese respectively according to BMI. Whereas 20%, 20% 60% were found to be at high risk, moderate risk and high risk of obesity respectively according to WHR. Conclusion: In our patient population, analysis of BMI and WHR suggests that children with CP have a high rate of overweight and are at risk of overweight, particularly of central obesity. PMID:25302187

Variability of total step activity in children with cerebral palsy: influence of definition of a day on participant retention within the study.

PubMed

Wilson, Nichola C; Mudge, Suzie; Stott, N Susan

2016-08-20

Activity monitoring is important to establish accurate daily physical activity levels in children with cerebral palsy (CP). However, few studies address issues around inclusion or exclusion of step count data; in particular, how a valid day should be defined and what impact different lengths of monitoring have on retention of participant data within a study. This study assessed how different 'valid day' definitions influenced inclusion of participant data in final analyses and the subsequent variability of the data. Sixty-nine children with CP were fitted with a StepWatch™ Activity Monitor and instructed to wear it for a week. Data analysis used two broad definitions of a day, based on either number of steps in a 24 h monitoring period or the number of hours of recorded activity in a 24 h monitoring period. Eight children either did not use the monitor, or used it for only 1 day. The remaining 61 children provided 2 valid days of monitoring defined as >100 recorded steps per 24 h period and 55 (90 %) completed 2 valid days of monitoring with ≥10 h recorded activity per 24 h period. Performance variability in daily step count was lower across 2 days of monitoring when a valid day was defined as ≥10 h recorded activity per 24 h period (ICC = 0.765) and, higher when the definition >100 recorded steps per 24 h period (ICC = 0.62). Only 46 participants (75 %) completed 5 days of monitoring with >100 recorded steps per 24 h period and only 23 (38 %) achieved 5 days of monitoring with ≥10 h recorded activity per 24 h period. Datasets of participants who functioned at GMFCS level II were differentially excluded when the criteria for inclusion in final analysis was 5 valid days of ≥10 h recorded activity per 24 h period, leaving datasets available for only 8 of 32 participant datasets retained in the study. We conclude that changes in definition of a valid day have significant impacts on both inclusion of participant data in final analysis and measured variability of total step count.

Effects of the Integration of Dynamic Weight Shifting Training Into Treadmill Training on Walking Function of Children with Cerebral Palsy: A Randomized Controlled Study.

PubMed

Wu, Ming; Kim, Janis; Arora, Pooja; Gaebler-Spira, Deborah J; Zhang, Yunhui

2017-11-01

The aim of the study was to determine whether applying an assistance force to the pelvis and legs during treadmill training can improve walking function in children with cerebral palsy. Twenty-three children with cerebral palsy were randomly assigned to the robotic or treadmill only group. For participants who were assigned to the robotic group, a controlled force was applied to the pelvis and legs during treadmill walking. For participants who were assigned to the treadmill only group, manual assistance was provided as needed. Each participant trained 3 times/wk for 6 wks. Outcome measures included walking speed, 6-min walking distance, and clinical assessment of motor function, which were evaluated before, after training, and 8 wks after the end of training, and were compared between two groups. Significant increases in walking speed and 6-min walking distance were observed after robotic training (P = 0.03), but no significant change was observed after treadmill training only. A greater increase in 6-min walking distance was observed after robotic training than that after treadmill only training (P = 0.01). Applying a controlled force to the pelvis and legs, for facilitating weight-shift and leg swing, respectively, during treadmill training may improve walking speed and endurance in children with cerebral palsy. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) discuss the importance of physical activity at the participation level (sports programs) for children with cerebral palsy; (2) contrast the changes in walking ability and endurance for children in GMFCS level I, II and III following sports programs; and (3) identify the impact of higher frequency of sports program attendance over time on walking ability. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Use of the Measure of Processes of Care (MPOC-20) to evaluate health service delivery for children with cerebral palsy and their families in Jordan: validation of Arabic-translated version (AR-MPOC-20).

PubMed

Saleh, M; Almasri, N A

2014-09-01

Family-centred service (FCS) is widely accepted now as best practice in paediatric rehabilitation. The Measure of Processes of Care-20 items set (MPOC-20) is a valid and reliable self-report measure of parents' perceptions of the extent to which health services are family-centred. Arabic-translated and validated version of the MPOC-20 (AR-MPOC-20) is used to examine Jordanian families' perception of service providers' caregiving behaviours as they receive rehabilitation services for their children with cerebral palsy (CP). Parents of 114 children with CP who are receiving services at different settings in Jordan were interviewed using the AR-MPOC-20. Participating children aged 4.1 ± 4.4 years, 53.5% were males. Children varied across gross motor functional classification system (GMFCS). Parents were mostly mothers (76.3%), with at least high school education (71.9%). Factor analyses of the AR-MPOC-20 yielded a five-factor solution with items loaded differently from the original measure. All items correlated best and significantly with their own Arabic scale score (rs: 0.91-0.26, P < 0.01). Internal consistency values of AR-MPOC-20 scales were acceptable (Cronbach's α: 0.69-0.82). Scale 'Providing Written Information' has the lowest average score (1.9 ± 1.6), while scale 'Respectful & Coordinated Care' has the highest average score (5.2 ± 1.5). The AR-MPOC-20 is found to be a valid and reliable measure for use with Arabic-Jordanian families of children with CP. FCS is not yet well implemented in Jordan, with parents reporting more need for information about their children's health and available services. Service providers are encouraged to apply FCS in paediatric rehabilitation, and giving more attention to effective communication and information exchange with families. AR-MPOC-20 is recommended for use for program evaluation.

Australian Cerebral Palsy Child Study: protocol of a prospective population based study of motor and brain development of preschool aged children with cerebral palsy.

PubMed

Boyd, Roslyn N; Jordan, Rachel; Pareezer, Laura; Moodie, Anne; Finn, Christine; Luther, Belinda; Arnfield, Evyn; Pym, Aaron; Craven, Alex; Beall, Paula; Weir, Kelly; Kentish, Megan; Wynter, Meredith; Ware, Robert; Fahey, Michael; Rawicki, Barry; McKinlay, Lynne; Guzzetta, Andrea

2013-06-11

Cerebral palsy (CP) results from a static brain lesion during pregnancy or early life and remains the most common cause of physical disability in children (1 in 500). While the brain lesion is static, the physical manifestations and medical issues may progress resulting in altered motor patterns. To date, there are no prospective longitudinal studies of CP that follow a birth cohort to track early gross and fine motor development and use Magnetic Resonance Imaging (MRI) to determine the anatomical pattern and likely timing of the brain lesion. Existing studies do not consider treatment costs and outcomes. This study aims to determine the pathway(s) to motor outcome from diagnosis at 18 months corrected age (c.a.) to outcome at 5 years in relation to the nature of the brain lesion (using structural MRI). This prospective cohort study aims to recruit a total of 240 children diagnosed with CP born in Victoria (birth years 2004 and 2005) and Queensland (birth years 2006-2009). Children can enter the study at any time between 18 months to 5 years of age and will be assessed at 18, 24, 30, 36, 48 and 60 months c.a. Outcomes include gross motor function (GMFM-66 & GMFM-88), Gross Motor Function Classification System (GMFCS); musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function (Manual Ability Classification System), communication difficulties using Communication and Symbolic Behaviour Scales-Developmental Profile (CSBS-DP), participation using the Paediatric Evaluation of Disability Inventory (PEDI), parent reported quality of life and classification of medical and allied health resource use and determination of the aetiology of CP using clinical evaluation combined with MRI. The relationship between the pathways to motor outcome and the nature of the brain lesion will be analysed using multiple methods including non-linear modelling, multilevel mixed-effects models and generalised estimating equations. This protocol describes a large population-based study of early motor development and brain structure in a representative sample of preschool aged children with CP, using direct clinical assessment. The results of this study will be published in peer reviewed journals and presented at relevant international conferences. Australia and New Zealand Clinical Trials Register (ACTRN1261200169820).

Australian Cerebral Palsy Child Study: protocol of a prospective population based study of motor and brain development of preschool aged children with cerebral palsy

PubMed Central

2013-01-01

Background Cerebral palsy (CP) results from a static brain lesion during pregnancy or early life and remains the most common cause of physical disability in children (1 in 500). While the brain lesion is static, the physical manifestations and medical issues may progress resulting in altered motor patterns. To date, there are no prospective longitudinal studies of CP that follow a birth cohort to track early gross and fine motor development and use Magnetic Resonance Imaging (MRI) to determine the anatomical pattern and likely timing of the brain lesion. Existing studies do not consider treatment costs and outcomes. This study aims to determine the pathway(s) to motor outcome from diagnosis at 18 months corrected age (c.a.) to outcome at 5 years in relation to the nature of the brain lesion (using structural MRI). Methods This prospective cohort study aims to recruit a total of 240 children diagnosed with CP born in Victoria (birth years 2004 and 2005) and Queensland (birth years 2006–2009). Children can enter the study at any time between 18 months to 5 years of age and will be assessed at 18, 24, 30, 36, 48 and 60 months c.a. Outcomes include gross motor function (GMFM-66 & GMFM-88), Gross Motor Function Classification System (GMFCS); musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function (Manual Ability Classification System), communication difficulties using Communication and Symbolic Behaviour Scales-Developmental Profile (CSBS-DP), participation using the Paediatric Evaluation of Disability Inventory (PEDI), parent reported quality of life and classification of medical and allied health resource use and determination of the aetiology of CP using clinical evaluation combined with MRI. The relationship between the pathways to motor outcome and the nature of the brain lesion will be analysed using multiple methods including non-linear modelling, multilevel mixed-effects models and generalised estimating equations. Discussion This protocol describes a large population-based study of early motor development and brain structure in a representative sample of preschool aged children with CP, using direct clinical assessment. The results of this study will be published in peer reviewed journals and presented at relevant international conferences. Trial registration Australia and New Zealand Clinical Trials Register (ACTRN1261200169820) PMID:23758951

Physical strain of comfortable walking in children with mild cerebral palsy.

PubMed

Dallmeijer, Annet J; Brehm, Merel-Anne

2011-01-01

To evaluate the physical strain of comfortable walking in children with mild cerebral palsy (CP) in comparison to typically developing (TD) children. Physical strain was defined as the oxygen uptake during walking (VO(2walk)) expressed as a percentage of their maximal aerobic capacity (VO(2peak)). Eighteen children (aged 8-16 years) participated, including eight ambulant children (four girls, four boys) with mild spastic CP (three hemiplegia, five diplegia, GMFCS I: n = 7 and II: n = 1) and 10 TD children. VO(2walk) was measured during 5 min of walking on an indoor track at comfortable walking speed. VO(2peak) was measured in a shuttle run test. VO(2walk) was significantly higher in CP (19.7 (2.8) ml/kg/min) compared to TD (16.8 (3.6) ml/kg/min, p = 0.033), while walking speed did not differ significantly between groups. VO(2peak) was significantly lower in CP (37.2 (2.2) ml/kg/min) compared to TD (45.0 (5.3) ml/kg/min, p = 0.001). Consequently, the physical strain during walking was significantly higher in CP (52 (7.7) %) compared to TD (36 (8.4) %, p = 0.001). The higher physical strain during comfortable walking of children with mild CP compared to TD children may be related to reported problems with fatigue in this population, and suggest a need for physical aerobic training programmes.

Self-concept of children with cerebral palsy measured using the population-specific myTREEHOUSE Self-Concept Assessment.

PubMed

Cheong, Sau Kuan; Lang, Cathryne P; Johnston, Leanne M

2018-02-01

Self-concept is an individual's perception of him/herself. Research into the self-concept of children with cerebral palsy (CP) has been sparse due to the lack of a population-specific self-concept instrument. Using the new myTREEHOUSE Self-Concept Assessment, this study investigated the self-concept of children with CP in relation to age, gender, motor, communication and cognitive function. Children with CP aged 8-12 years (n = 50; 29 males; mean 10 years 2 months; GMFCS-E&R I = 36, II = 8, III = 5, IV = 1) completed myTREEHOUSE and a standardised intelligence measure. Most children reported positive self-concept from all three myTREEHOUSE Performance Perspectives and over half (60%) fell within the Low range for the Personal Concern Score. Self-concept was not associated with age, gender, motor function, or communication function. However, for cognitive function, associations were observed for Social Skills (Below Average > Average cognitive function; Cohen's d = 1.07) and Learning Skills (Above Average > Average cognitive function; Cohen's d = 0.95) domains when rated from a Personal Performance Perspective. As the first study of the self-concept of children with CP using a CP-specific assessment, this study offers important insights into what children with CP think about themselves. Generally, the self-concept of children with CP was sound. Future research on environmental facilitators and barriers to robust self-concept development is recommended. Copyright © 2017 Elsevier Ltd. All rights reserved.

Effects of antagonistic and synergistic muscles' co-activation on mechanics of activated spastic semitendinosus in children with cerebral palsy.

PubMed

Ateş, Filiz; Temelli, Yener; Yucesoy, Can A

2018-02-01

Most activities involve co-activation of several muscles and epimuscular myofascial force transmission (EMFT) can affect their mechanics. This can be relevant for spastic muscles of cerebral palsy (CP) patients. Isometric spastic semitendinosus (ST) forces vs. knee angle (KA-F ST ) data were collected intra-operatively to test the following hypotheses: (i) Inter-antagonistic EMFT elevates F ST , (ii) changes the shape of KA-F ST characteristics, (iii) reduces the muscle's joint range of force exertion (Range-F ST ) and (iv) combined inter-antagonistic and synergistic EMFT further changes those effects. 11 limbs of 6 patients with CP (mean (SD) = 7.7 (4.7) years; GMFCS levels = II-IV) were tested in 3 conditions from 120° to full extension: ST activated (I) exclusively, (II) simultaneously with an antagonist, and (III) with added activation of synergists. Condition II increased F ST (e.g., peak force = 87.6 N (30.5 N)) significantly (by 33.6%), but condition III caused no further change. No condition changed the muscle's wide Range-F ST (100.7° (15.9°)) significantly. Therefore, only the first hypothesis was confirmed. Co-activating its antagonist elevates forces of activated spastic ST substantially, but does not change its joint range of force exertion. Added activation of its synergists causes no further effects. Therefore, EMFT effects in CP can be relevant and need to be tested in other knee flexors. Copyright © 2017 Elsevier B.V. All rights reserved.

Feasibility of bioelectrical impedance analysis in persons with severe intellectual and visual disabilities.

PubMed

Havinga-Top, A M; Waninge, A; van der Schans, C P; Jager-Wittenaar, H

2015-12-01

Body composition measurements provide important information about physical fitness and nutritional status. People with severe intellectual and visual disabilities (SIVD) have an increased risk for altered body composition. Bioelectrical impedance analysis (BIA) has been evidenced as a reliable and non-invasive method to asses body composition in healthy persons and various patient populations; however, currently, there is no feasible method available to determine body composition in people with SIVD. In this study, therefore, we aimed to assess the feasibility of BIA measurements in persons with SIVD. In 33 participants with SIVD and Gross Motor Functioning Classification System (GMFCS) Scale I, II, III, or IV, two BIA measurements were sequentially performed employing Resistance and Reactance in Ohm and fat-free mass (FFM) in kg as outcome variables, utilizing the Bodystat(®) QuadScan 4000. Feasibility was considered sufficient if ≥ 80% of the first measurement was performed successfully. Agreement between two repeated measurements was determined by using the paired t-test and Intraclass Correlation Coefficient (ICC; two way random, absolute agreement). Bland-Altman analyses were utilized to determine limits of agreement (LOAs) and systematic error. Agreement was considered acceptable if LOAs were <10% of the mean of the first measurement. The first BIA measurements were completed successfully in 88% of the participants. The paired t-test demonstrated no significant differences in Resistance, Reactance, and FFM between BIA Measurements 1 and 2 (P=0.140, 0.091, and 0.866). ICC was 0.965 (95% CI: 0.922-0.984) for Resistance; 0.858 (95% CI: 0.705-0.934) for Reactance; and 0.992 (95% CI: 0.982-0.996) for FFM. LOAs expressed as a percentage of the mean of Measurement 1 were 6.1% for Resistance, 17.6% for Reactance, and 3.8% for FFM. The results of this study suggest that BIA measurements seem to be feasible in persons with SIVD. Although these results require confirmation in a more extensive sample of persons with SIVD, the findings of this study are an important first step in the assessment of applicability of BIA measurements for non-invasive monitoring of physical fitness and nutritional status of persons with SIVD. Copyright © 2015 Elsevier Ltd. All rights reserved.

Relationship between brain lesion characteristics and communication in preschool children with cerebral palsy.

PubMed

Coleman, Andrea; Fiori, Simona; Weir, Kelly A; Ware, Robert S; Boyd, Roslyn N

2016-11-01

MRI shows promise as a prognostic tool for clinical findings such as gross motor function in children with cerebral palsy(CP), however the relationship with communication skills requires exploration. To examine the relationship between the type and severity of brain lesion on MRI and communication skills in children with CP. 131 children with CP (73 males(56%)), mean corrected age(SD) 28(5) months, Gross Motor Functional Classification System distribution: I=57(44%), II=14(11%), III=19(14%), IV=17(13%), V=24(18%). Children were assessed on the Communication and Symbolic Behavioral Scales Developmental Profile (CSBS-DP) Infant-Toddler Checklist. Structural MRI was analysed with reference to type and semi-quantitative assessment of the severity of brain lesion. Children were classified for motor type, distribution and GMFCS. The relationships between type/severity of brain lesion and communication ability were analysed using multivariable tobit regression. Children with periventricular white matter lesions had better speech than children with cortical/deep grey matter lesions (β=-2.6, 95%CI=-5.0, -0.2, p=0.04). Brain lesion severity on the semi-quantitative scale was related to overall communication skills (β=-0.9, 95%CI=-1.4, -0.5, p<0.001). Motor impairment better accounted for impairment in overall communication skills than brain lesion severity. Structural MRI has potential prognostic value for communication impairment in children with CP. WHAT THIS PAPER ADDS?: This is the first paper to explore important aspects of communication in relation to the type and severity of brain lesion on MRI in a representative cohort of preschool-aged children with CP. We found a relationship between the type of brain lesion and communication skills, children who had cortical and deep grey matter lesions had overall communication skills>1 SD below children with periventricular white matter lesions. Children with more severe brain lesions on MRI had poorer overall communication skills. Children with CP born at term had poorer communication than those born prematurely and were more likely to have cortical and deep grey matter lesions. Gross motor function better accounted for overall communication skills than the type of brain lesion or brain lesion severity. Copyright © 2016. Published by Elsevier Ltd.

Does early communication mediate the relationship between motor ability and social function in children with cerebral palsy?

PubMed

Lipscombe, Belinda; Boyd, Roslyn N; Coleman, Andrea; Fahey, Michael; Rawicki, Barry; Whittingham, Koa

2016-01-01

Children diagnosed with neurodevelopmental conditions such as cerebral palsy (CP) are at risk of experiencing restrictions in social activities negatively impacting their subsequent social functioning. Research has identified motor and communication ability as being unique determinants of social function capabilities in children with CP, to date, no research has investigated whether communication is a mediator of the relationship between motor ability and social functioning. To investigate whether early communication ability at 24 months corrected age (ca.) mediates the relationship between early motor ability at 24 months ca. and later social development at 60 months ca. in a cohort of children diagnosed with cerebral palsy (CP). A cohort of 71 children (43 male) diagnosed with CP (GMFCS I=24, 33.8%, II=9, 12.7%, III=12, 16.9%, IV=10, 14.1%, V=16, 22.5%) were assessed at 24 and 60 months ca. Assessments included the Gross Motor Function Measure (GMFM), the Communication and Symbolic Behaviour Scales-Developmental Profile (CSBS-DP) Infant-Toddler Checklist and the Paediatric Evaluation of Disability Inventory (PEDI). A mediation model was examined using bootstrapping. Early communication skills mediated the relationship between early motor abilities and later social functioning, b=0.24 (95% CI=0.08-0.43 and the mediation model was significant, F (2, 68)=32.77, p<0.001, R(2)=0.49. Early communication ability partially mediates the relationship between early motor ability and later social function in children with CP. This demonstrates the important role of early communication in ongoing social development. Early identification of communication delay and enriched language exposure is crucial in this population. Copyright © 2016 Elsevier Ltd. All rights reserved.

Predictors for anterior pelvic tilt following surgical correction of flexed knee gait including patellar tendon shortening in children with cerebral palsy.

PubMed

Böhm, Harald; Hösl, Matthias; Döderlein, Leonhard

2017-05-01

Patellar tendon shortening procedure within single event multilevel surgeries was shown to improve crouch gait in Cerebral Palsy (CP) patients. However, one of the drawbacks associated to the correction of flexed knee gait may be increased pelvic anterior tilt with compensatory lumbar lordosis. Which CP patients are at risk for excessive anterior pelvic tilt following correction of flexed knee gait including patellar tendon shortening? 32 patients with CP between 8 and 18 years GMFCS I&II were included. They received patellar tendon shortenings within multilevel surgery. Patients with concomitant knee flexor lengthening were excluded. Gait analysis and clinical testing was performed pre- and 24.1 (SD=1.9) months postoperatively. Patients were subdivided into more/less than 5° increase in anterior pelvic tilt. Preoperative measures indicating m. rectus and m. psoas shortness, knee flexor over-length, hip extensor and abdominal muscle weakness and equinus gait were compared between groups. Stepwise multilinear regression of the response value increase in pelvic tilt during stance phase was performed from parameters that were significantly different between groups. 34% of patients showed more than 5° increased pelvic anterior tilt postoperatively. Best predictors for anterior pelvic tilt from preoperative measures were increased m. rectus tone and reduced hip extension during walking that explained together 39% of the variance in increase of anterior pelvic tilt. Every third patient showed considerable increased pelvic tilt following surgery of flexed knee gait. In particular patients with preoperative higher muscle tone in m. rectus and lower hip extension during walking were at risk and both features need to be addressed in the therapy. Copyright © 2017 Elsevier B.V. All rights reserved.

Treadmill training with an incline reduces ankle joint stiffness and improves active range of movement during gait in adults with cerebral palsy.

PubMed

Lorentzen, Jakob; Kirk, Henrik; Fernandez-Lago, Helena; Frisk, Rasmus; Scharff Nielsen, Nanna; Jorsal, Martin; Nielsen, Jens Bo

2017-05-01

We investigated if 30 min of daily treadmill training with an incline for 6 weeks would reduce ankle joint stiffness and improve active range of movement in adults with cerebral palsy (CP). The study was designed as a randomized controlled clinical trial including 32 adults with CP (GMFCS 1-3) aged 38.1 SD 12 years. The training group (n = 16) performed uphill treadmill training at home daily for 30 min for 6 weeks in addition to their usual activities. Passive and reflex mediated stiffness and range of motion (ROM) of the ankle joint, kinematic and functional measures of gait were obtained before and after the intervention/control period. Intervention subjects trained 31.4 SD 10.1 days for 29.0 SD 2.3 min (total) 15.2 h. Passive ankle joint stiffness was reduced (F = 5.1; p = 0.031), maximal gait speed increased (F = 42.8, p < 0.001), amplitude of toe lift prior to heel strike increased (F = 5.3, p < 0.03) and ankle angle at heel strike was decreased (F = 12.5; p < 0.001) significant in the training group as compared to controls. Daily treadmill training with an incline for 6 weeks reduces ankle joint stiffness and increases active ROM during gait in adults with CP. Intensive gait training may thus be beneficial in preventing and reducing contractures and help to maintain functional gait ability in adults with CP. Implications for rehabilitation Uphill gait training is an effective way to reduce ankle joint stiffness in adult with contractures. 6 weeks of daily uphill gait training improves functional gait parameters such as gait speed and dorsal flexion during gait in adults with cerebral palsy.

Real-time feedback to improve gait in children with cerebral palsy.

PubMed

van Gelder, Linda; Booth, Adam T C; van de Port, Ingrid; Buizer, Annemieke I; Harlaar, Jaap; van der Krogt, Marjolein M

2017-02-01

Real-time feedback may be useful for enhancing information gained from clinical gait analysis of children with cerebral palsy (CP). It may also be effective in functional gait training, however, it is not known if children with CP can adapt gait in response to real-time feedback of kinematic parameters. Sixteen children with cerebral palsy (age 6-16; GMFCS I-III), walking with a flexed-knee gait pattern, walked on an instrumented treadmill with virtual reality in three conditions: regular walking without feedback (NF), feedback on hip angle (FH) and feedback on knee angle (FK). Clinically relevant gait parameters were calculated and the gait profile score (GPS) was used as a measure of overall gait changes between conditions. All children, except one, were able to improve hip and/or knee extension during gait in response to feedback, with nine achieving a clinically relevant improvement. Peak hip extension improved significantly by 5.1±5.9° (NF: 8.9±12.8°, FH: 3.8±10.4°, p=0.01). Peak knee extension improved significantly by 7.7±7.1° (NF: 22.2±12.0°, FK: 14.5±12.7°, p<0.01). GPS did not change between conditions due to increased deviations in other gait parameters. Responders to feedback were shown to have worse initial gait as measured by GPS (p=0.005) and functional selectivity score (p=0.049). In conclusion, ambulatory children with CP show adaptability in gait and are able to respond to real-time feedback, resulting in significant and clinically relevant improvements in peak hip and knee extension. These findings show the potential of real-time feedback as a tool for functional gait training and advanced gait analysis in CP. Copyright © 2016 Elsevier B.V. All rights reserved.

Effects of gross motor function and manual function levels on performance-based ADL motor skills of children with spastic cerebral palsy.

PubMed

Park, Myoung-Ok

2017-02-01

[Purpose] The purpose of this study was to determine effects of Gross Motor Function Classification System and Manual Ability Classification System levels on performance-based motor skills of children with spastic cerebral palsy. [Subjects and Methods] Twenty-three children with cerebral palsy were included. The Assessment of Motor and Process Skills was used to evaluate performance-based motor skills in daily life. Gross motor function was assessed using Gross Motor Function Classification Systems, and manual function was measured using the Manual Ability Classification System. [Results] Motor skills in daily activities were significantly different on Gross Motor Function Classification System level and Manual Ability Classification System level. According to the results of multiple regression analysis, children categorized as Gross Motor Function Classification System level III scored lower in terms of performance based motor skills than Gross Motor Function Classification System level I children. Also, when analyzed with respect to Manual Ability Classification System level, level II was lower than level I, and level III was lower than level II in terms of performance based motor skills. [Conclusion] The results of this study indicate that performance-based motor skills differ among children categorized based on Gross Motor Function Classification System and Manual Ability Classification System levels of cerebral palsy.

Study on application of adaptive fuzzy control and neural network in the automatic leveling system

NASA Astrophysics Data System (ADS)

Xu, Xiping; Zhao, Zizhao; Lan, Weiyong; Sha, Lei; Qian, Cheng

2015-04-01

This paper discusses the adaptive fuzzy control and neural network BP algorithm in large flat automatic leveling control system application. The purpose is to develop a measurement system with a flat quick leveling, Make the installation on the leveling system of measurement with tablet, to be able to achieve a level in precision measurement work quickly, improve the efficiency of the precision measurement. This paper focuses on the automatic leveling system analysis based on fuzzy controller, Use of the method of combining fuzzy controller and BP neural network, using BP algorithm improve the experience rules .Construct an adaptive fuzzy control system. Meanwhile the learning rate of the BP algorithm has also been run-rate adjusted to accelerate convergence. The simulation results show that the proposed control method can effectively improve the leveling precision of automatic leveling system and shorten the time of leveling.

Design of automatic leveling and centering system of theodolite

NASA Astrophysics Data System (ADS)

Liu, Chun-tong; He, Zhen-Xin; Huang, Xian-xiang; Zhan, Ying

2012-09-01

To realize the theodolite automation and improve the azimuth Angle measurement instrument, the theodolite automatic leveling and centering system with the function of leveling error compensation is designed, which includes the system solution, key components selection, the mechanical structure of leveling and centering, and system software solution. The redesigned leveling feet are driven by the DC servo motor; and the electronic control center device is installed. Using high precision of tilt sensors as horizontal skew detection sensors ensures the effectiveness of the leveling error compensation. Aiming round mark center is located using digital image processing through surface array CCD; and leveling measurement precision can reach the pixel level, which makes the theodolite accurate centering possible. Finally, experiments are conducted using the automatic leveling and centering system of the theodolite. The results show the leveling and centering system can realize automatic operation with high centering accuracy of 0.04mm.The measurement precision of the orientation angle after leveling error compensation is improved, compared with that of in the traditional method. Automatic leveling and centering system of theodolite can satisfy the requirements of the measuring precision and its automation.

Air Force Recoverable Central Leveling System (D)28): Retail Handbook

DTIC Science & Technology

1988-09-01

historical stuff.. .Just how its done and how is it affecting me today* (4). *It’s not an "asset push* system, its a * levels push’ system.’ *The system...consists primarily of a ’pull* system. For this same reason they lack under- standing why Tertain recoverables are under a ’ levels push’ type of system . 2...levels in the order the D028 system calculates as the highest marginal gain. Each recorded user will receive a * levels push’ of at least one, and all D028

Optimal Design of Integrated Systems Health Management (ISHM) Systems for improving safety in NASA's Exploration Vehicles: A Two-Level Multidisciplinary Design Approach

NASA Technical Reports Server (NTRS)

Tumer, Irem; Mehr, Ali Farhang

2005-01-01

In this paper, a two-level multidisciplinary design approach is described to optimize the effectiveness of ISHM s. At the top level, the overall safety of the mission consists of system-level variables, parameters, objectives, and constraints that are shared throughout the system and by all subsystems. Each subsystem level will then comprise of these shared values in addition to subsystem-specific variables, parameters, objectives and constraints. A hierarchical structure will be established to pass up or down shared values between the two levels with system-level and subsystem-level optimization routines.

Potentiometric surface and water-level difference maps of selected confined aquifers in Southern Maryland and Maryland’s Eastern Shore, 1975-2015

USGS Publications Warehouse

Curtin, Stephen E.; Staley, Andrew W.; Andreasen, David C.

2016-01-01

Key Results This report presents potentiometric-surface maps of the Aquia and Magothy aquifers and the Upper Patapsco, Lower Patapsco, and Patuxent aquifer systems using water levels measured during September 2015. Water-level difference maps are also presented for these aquifers. The water-level differences in the Aquia aquifer are shown using groundwater-level data from 1982 and 2015, while the water-level differences are shown for the Magothy aquifer using data from 1975 and 2015. Water-level difference maps for both the Upper Patapsco and Lower Patapsco aquifer systems are shown using data from 1990 and 2015. The water-level differences in the Patuxent aquifer system are shown using groundwater-level data from 2007 and 2015. The potentiometric surface maps show water levels ranging from 53 feet above sea level to 164 feet below sea level in the Aquia aquifer, from 86 feet above sea level to 106 feet below sea level in the Magothy aquifer, from 115 feet above sea level to 115 feet below sea level in the Upper Patapsco aquifer system, from 106 feet above sea level to 194 feet below sea level in the Lower Patapsco aquifer system, and from 165 feet above sea level to 171 feet below sea level in the Patuxent aquifer system. Water levels have declined by as much as 116 feet in the Aquia aquifer since 1982, 99 feet in the Magothy aquifer since 1975, 66 and 83 feet in the Upper Patapsco and Lower Patapsco aquifer systems, respectively, since 1990, and 80 feet in the Patuxent aquifer system since 2007.

Emergy evaluation of contrasting dairy systems at multiple levels.

PubMed

Vigne, Mathieu; Peyraud, Jean-Louis; Lecomte, Philippe; Corson, Michael S; Wilfart, Aurélie

2013-11-15

Emergy accounting (EmA) was applied to a range of dairy systems, from low-input smallholder systems in South Mali (SM), to intermediate-input systems in two regions of France, Poitou-Charentes (PC) and Bretagne (BR), to high-input systems on Reunion Island (RI). These systems were studied at three different levels: whole-farm (dairy system and cropping system), dairy-system (dairy herd and forage land), and herd (animals only). Dairy farms in SM used the lowest total emergy at all levels and was the highest user of renewable resources. Despite the low quality of resources consumed (crop residues and natural pasture), efficiency of their use was similar to that of industrialised inputs by intensive systems in RI, PC and BR. In addition, among the systems studied, SM dairy farms lay closest to environmental sustainability, contradicting the usual image of high environmental impact of cattle production in developing countries. EmA also revealed characteristics of the three intensive systems. Systems from RI and PC had lower resource transformation efficiency and higher environmental impacts than those from BR, due mainly to feeding strategies that differed due to differing socio-climatic constraints. Application of EmA at multiple levels revealed the importance of a multi-level analysis. While the whole-farm level assesses the overall contribution of the system to its environment, the dairy-system level is suitable for comparison of multi-product systems. In contrast, the herd level focuses on herd management and bypasses debates about definition of system boundaries by excluding land management. Combining all levels highlights the contribution of livestock to the global agricultural system and identifies inefficiencies and influences of system components on the environment. Copyright © 2013 Elsevier Ltd. All rights reserved.

An architecture for object-oriented intelligent control of power systems in space

NASA Technical Reports Server (NTRS)

Holmquist, Sven G.; Jayaram, Prakash; Jansen, Ben H.

1993-01-01

A control system for autonomous distribution and control of electrical power during space missions is being developed. This system should free the astronauts from localizing faults and reconfiguring loads if problems with the power distribution and generation components occur. The control system uses an object-oriented simulation model of the power system and first principle knowledge to detect, identify, and isolate faults. Each power system component is represented as a separate object with knowledge of its normal behavior. The reasoning process takes place at three different levels of abstraction: the Physical Component Model (PCM) level, the Electrical Equivalent Model (EEM) level, and the Functional System Model (FSM) level, with the PCM the lowest level of abstraction and the FSM the highest. At the EEM level the power system components are reasoned about as their electrical equivalents, e.g, a resistive load is thought of as a resistor. However, at the PCM level detailed knowledge about the component's specific characteristics is taken into account. The FSM level models the system at the subsystem level, a level appropriate for reconfiguration and scheduling. The control system operates in two modes, a reactive and a proactive mode, simultaneously. In the reactive mode the control system receives measurement data from the power system and compares these values with values determined through simulation to detect the existence of a fault. The nature of the fault is then identified through a model-based reasoning process using mainly the EEM. Compound component models are constructed at the EEM level and used in the fault identification process. In the proactive mode the reasoning takes place at the PCM level. Individual components determine their future health status using a physical model and measured historical data. In case changes in the health status seem imminent the component warns the control system about its impending failure. The fault isolation process uses the FSM level for its reasoning base.

Automated Liquid-Level Control of a Nutrient Reservoir for a Hydroponic System

NASA Technical Reports Server (NTRS)

Smith, Boris; Asumadu, Johnson A.; Dogan, Numan S.

1997-01-01

A microprocessor-based system for control of the liquid level of a nutrient reservoir for a plant hydroponic growing system has been developed. The system uses an ultrasonic transducer to sense the liquid level or height. A National Instruments' Multifunction Analog and Digital Input/Output PC Kit includes NI-DAQ DOS/Windows driver software for an IBM 486 personal computer. A Labview Full Development system for Windows is the graphical programming system being used. The system allows liquid level control to within 0.1 cm for all levels tried between 8 and 36 cm in the hydroponic system application. The detailed algorithms have been developed and a fully automated microprocessor based nutrient replenishment system has been described for this hydroponic system.

Squeezed light from multi-level closed-cycling atomic systems

NASA Technical Reports Server (NTRS)

Xiao, Min; Zhu, Yi-Fu

1994-01-01

Amplitude squeezing is calculated for multi-level closed-cycling atomic systems. These systems can last without atomic population inversion in any atomic bases. Maximum squeezing is obtained for the parameters in the region of lasing without inversion. A practical four-level system and an ideal three-level system are presented. The latter system is analyzed in some detail and the mechanism of generating amplitude squeezing is discussed.

Design for testability and diagnosis at the system-level

NASA Technical Reports Server (NTRS)

Simpson, William R.; Sheppard, John W.

1993-01-01

The growing complexity of full-scale systems has surpassed the capabilities of most simulation software to provide detailed models or gate-level failure analyses. The process of system-level diagnosis approaches the fault-isolation problem in a manner that differs significantly from the traditional and exhaustive failure mode search. System-level diagnosis is based on a functional representation of the system. For example, one can exercise one portion of a radar algorithm (the Fast Fourier Transform (FFT) function) by injecting several standard input patterns and comparing the results to standardized output results. An anomalous output would point to one of several items (including the FFT circuit) without specifying the gate or failure mode. For system-level repair, identifying an anomalous chip is sufficient. We describe here an information theoretic and dependency modeling approach that discards much of the detailed physical knowledge about the system and analyzes its information flow and functional interrelationships. The approach relies on group and flow associations and, as such, is hierarchical. Its hierarchical nature allows the approach to be applicable to any level of complexity and to any repair level. This approach has been incorporated in a product called STAMP (System Testability and Maintenance Program) which was developed and refined through more than 10 years of field-level applications to complex system diagnosis. The results have been outstanding, even spectacular in some cases. In this paper we describe system-level testability, system-level diagnoses, and the STAMP analysis approach, as well as a few STAMP applications.

Validating the Use of pPerformance Risk Indices for System-Level Risk and Maturity Assessments

NASA Astrophysics Data System (ADS)

Holloman, Sherrica S.

With pressure on the U.S. Defense Acquisition System (DAS) to reduce cost overruns and schedule delays, system engineers' performance is only as good as their tools. Recent literature details a need for 1) objective, analytical risk quantification methodologies over traditional subjective qualitative methods -- such as, expert judgment, and 2) mathematically rigorous system-level maturity assessments. The Mahafza, Componation, and Tippett (2005) Technology Performance Risk Index (TPRI) ties the assessment of technical performance to the quantification of risk of unmet performance; however, it is structured for component- level data as input. This study's aim is to establish a modified TPRI with systems-level data as model input, and then validate the modified index with actual system-level data from the Department of Defense's (DoD) Major Defense Acquisition Programs (MDAPs). This work's contribution is the establishment and validation of the System-level Performance Risk Index (SPRI). With the introduction of the SPRI, system-level metrics are better aligned, allowing for better assessment, tradeoff and balance of time, performance and cost constraints. This will allow system engineers and program managers to ultimately make better-informed system-level technical decisions throughout the development phase.

An evaluator-blinded randomized controlled trial evaluating therapy effects and prognostic factors for a general and an individually defined physical therapy program in ambulant children with bilateral spastic cerebral palsy.

PubMed

Franki, I; Desloovere, K; De Cat, J; Tijhuis, W; Molenaers, G; Feys, H; Vanderstraeten, G; Van Den Broeck, C

2015-12-01

Cerebral palsy (CP) is characterized by a heterogeneous nature with a variety of problems. Therefore, individualized physical therapy might be more appropriate to address the needs for these children. The first aim was to compare the effectiveness of an individually-defined therapy program (IT) and a general therapy program (GT) on gait and gross motor function in children with CP. The second aim was to evaluate interaction-effects, time-effects, treatment with botulinum toxin A, age, gross Motor Function Classification Scale (GMFCS), treatment frequency and quality as factors influencing outcome. An evaluator-blinded, randomized controlled trial. Outpatient rehabilitation unit. Forty ambulant children with spastic bilateral CP (mean age 6 years 1 month). All children were randomly assigned to receive either IT or GT over a 10 week period. Nineteen of these children were enrolled into a second and/or third program, resulting in 60 interventions. Primary outcome was assessed with the Goal Attainment Scale (GAS) for gross motor function goals and z-scores for goals based on specific 3D gait parameters. Secondary outcome included the Gross Motor Function Measure-88 (GMFM-88) scores, time and distance gait parameters, Gait Profile Score, Movement Analysis Profiles and time needed to complete Timed-Up-and-Go and Five-Times-Sit-To-Stand tests. There were higher, but non-significant GAS and z-score changes following the IT program compared to the GT program (GAS: 46.2 for the IT versus 42.2 for the GT group, P=0.332, ES 0.15; z-score: 0.135 for the IT compared to 0.072 for the GT group, P=0.669, ES 0.05). Significant time-effects could be found on the GAS (P<0.001) and the GMFM-88 total score (P<0.001). Age was identified as a predictor for GAS and GMFM-88 improvement (P=0.023 and P=0.044). No significant differences could be registered between the effects of the IT and the GT. The favorable outcome after the IT program was only a trend and needs to be confirmed on larger groups and with programs of longer duration. Both programs had a positive impact on the children's motor functioning. It is useful to involve older children more actively in the process of goal setting.

Parallel Architectures and Parallel Algorithms for Integrated Vision Systems. Ph.D. Thesis

NASA Technical Reports Server (NTRS)

Choudhary, Alok Nidhi

1989-01-01

Computer vision is regarded as one of the most complex and computationally intensive problems. An integrated vision system (IVS) is a system that uses vision algorithms from all levels of processing to perform for a high level application (e.g., object recognition). An IVS normally involves algorithms from low level, intermediate level, and high level vision. Designing parallel architectures for vision systems is of tremendous interest to researchers. Several issues are addressed in parallel architectures and parallel algorithms for integrated vision systems.

Choosing the Right Systems Integration

NASA Astrophysics Data System (ADS)

Péči, Matúš; Važan, Pavel

2014-12-01

The paper examines systems integration and its main levels at higher levels of control. At present, the systems integration is one of the main aspects participating in the consolidation processes and financial flows of a company. Systems Integration is a complicated emotionconsuming process and it is often a problem to choose the right approach and level of integration. The research focused on four levels of integration, while each of them is characterized by specific conditions. At each level, there is a summary of recommendations and practical experience. The paper also discusses systems integration between the information and MES levels. The main part includes user-level integration where we describe an example of such integration. Finally, we list recommendations and also possible predictions of the systems integration as one of the important factors in the future.

46 CFR 154.1305 - Liquid level gauging system: Standards.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Equipment Instrumentation § 154.1305 Liquid level gauging system: Standards. (a) Each cargo tank must have at least one liquid level gauging system that is operable: (1) At pressures up to, and including, the... 46 Shipping 5 2011-10-01 2011-10-01 false Liquid level gauging system: Standards. 154.1305 Section...

46 CFR 154.1305 - Liquid level gauging system: Standards.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Equipment Instrumentation § 154.1305 Liquid level gauging system: Standards. (a) Each cargo tank must have at least one liquid level gauging system that is operable: (1) At pressures up to, and including, the... 46 Shipping 5 2013-10-01 2013-10-01 false Liquid level gauging system: Standards. 154.1305 Section...

46 CFR 154.1305 - Liquid level gauging system: Standards.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Equipment Instrumentation § 154.1305 Liquid level gauging system: Standards. (a) Each cargo tank must have at least one liquid level gauging system that is operable: (1) At pressures up to, and including, the... 46 Shipping 5 2012-10-01 2012-10-01 false Liquid level gauging system: Standards. 154.1305 Section...

46 CFR 154.1305 - Liquid level gauging system: Standards.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Equipment Instrumentation § 154.1305 Liquid level gauging system: Standards. (a) Each cargo tank must have at least one liquid level gauging system that is operable: (1) At pressures up to, and including, the... 46 Shipping 5 2014-10-01 2014-10-01 false Liquid level gauging system: Standards. 154.1305 Section...

46 CFR 154.1305 - Liquid level gauging system: Standards.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Equipment Instrumentation § 154.1305 Liquid level gauging system: Standards. (a) Each cargo tank must have at least one liquid level gauging system that is operable: (1) At pressures up to, and including, the... 46 Shipping 5 2010-10-01 2010-10-01 false Liquid level gauging system: Standards. 154.1305 Section...

A system-level mathematical model for evaluation of power train performance of load-leveled electric-vehicles

NASA Technical Reports Server (NTRS)

Purohit, G. P.; Leising, C. J.

1984-01-01

The power train performance of load leveled electric vehicles can be compared with that of nonload leveled systems by use of a simple mathematical model. This method of measurement involves a number of parameters including the degree of load leveling and regeneration, the flywheel mechanical to electrical energy fraction, and efficiencies of the motor, generator, flywheel, and transmission. Basic efficiency terms are defined and representative comparisons of a variety of systems are presented. Results of the study indicate that mechanical transfer of energy into and out of the flywheel is more advantageous than electrical transfer. An optimum degree of load leveling may be achieved in terms of the driving cycle, battery characteristics, mode of mechanization, and the efficiency of the components. For state of the art mechanically coupled flyheel systems, load leveling losses can be held to a reasonable 10%; electrically coupled systems can have losses that are up to six times larger. Propulsion system efficiencies for mechanically coupled flywheel systems are predicted to be approximately the 60% achieved on conventional nonload leveled systems.

An Investigation into Soft Error Detection Efficiency at Operating System Level

PubMed Central

Taheri, Hassan

2014-01-01

Electronic equipment operating in harsh environments such as space is subjected to a range of threats. The most important of these is radiation that gives rise to permanent and transient errors on microelectronic components. The occurrence rate of transient errors is significantly more than permanent errors. The transient errors, or soft errors, emerge in two formats: control flow errors (CFEs) and data errors. Valuable research results have already appeared in literature at hardware and software levels for their alleviation. However, there is the basic assumption behind these works that the operating system is reliable and the focus is on other system levels. In this paper, we investigate the effects of soft errors on the operating system components and compare their vulnerability with that of application level components. Results show that soft errors in operating system components affect both operating system and application level components. Therefore, by providing endurance to operating system level components against soft errors, both operating system and application level components gain tolerance. PMID:24574894

An investigation into soft error detection efficiency at operating system level.

PubMed

Asghari, Seyyed Amir; Kaynak, Okyay; Taheri, Hassan

2014-01-01

Electronic equipment operating in harsh environments such as space is subjected to a range of threats. The most important of these is radiation that gives rise to permanent and transient errors on microelectronic components. The occurrence rate of transient errors is significantly more than permanent errors. The transient errors, or soft errors, emerge in two formats: control flow errors (CFEs) and data errors. Valuable research results have already appeared in literature at hardware and software levels for their alleviation. However, there is the basic assumption behind these works that the operating system is reliable and the focus is on other system levels. In this paper, we investigate the effects of soft errors on the operating system components and compare their vulnerability with that of application level components. Results show that soft errors in operating system components affect both operating system and application level components. Therefore, by providing endurance to operating system level components against soft errors, both operating system and application level components gain tolerance.

Measurement with verification of stationary signals and noise in extremely quiet environments: Measuring below the noise floor

PubMed Central

Ellingson, Roger M.; Gallun, Frederick J.; Bock, Guillaume

2015-01-01

It can be problematic to measure stationary acoustic sound pressure level in any environment when the target level approaches or lies below the minimum measureable sound pressure level of the measurement system itself. This minimum measureable level, referred to as the inherent measurement system noise floor, is generally established by noise emission characteristics of measurement system components such as microphones, preamplifiers, and other system circuitry. In this paper, methods are presented and shown accurate measuring stationary levels within 20 dB above and below this system noise floor. Methodology includes (1) measuring inherent measurement system noise, (2) subtractive energy based, inherent noise adjustment of levels affected by system noise floor, and (3) verifying accuracy of inherent noise adjustment technique. While generalizable to other purposes, the techniques presented here were specifically developed to quantify ambient noise levels in very quiet rooms used to evaluate free-field human hearing thresholds. Results obtained applying the methods to objectively measure and verify the ambient noise level in an extremely quiet room, using various measurement system noise floors and analysis bandwidths, are presented and discussed. The verified results demonstrate the adjustment method can accurately extend measurement range to 20 dB below the measurement system noise floor, and how measurement system frequency bandwidth can affect accuracy of reported noise levels. PMID:25786932

Functioning information in the learning health system.

PubMed

Stucki, Gerold; Bickenbach, Jerome

2017-02-01

In this methodological note on applying the ICF in rehabilitation, we introduce functioning information as fundamental for the "learning health system" and the continuous improvement of the health system's response to people's functioning needs by means of the provision of rehabilitation. A learning health system for rehabilitation operates at the micro-level of the individual patient, meso-level of operational management, and the macro-level of policy that guides rehabilitation programming. All three levels rely on the capacity of the informational system of the health system for standardized documentation and coding of functioning information, and the development of national rehabilitation quality management systems. This methodological note describes how functioning information is used for the continuous improvement of functioning outcomes in a learning health system across these three levels.

Optical switching property of electromagnetically induced transparency in a Λ system

NASA Astrophysics Data System (ADS)

Zhang, Lianshui; Wang, Jian; Feng, Xiaomin; Yang, Lijun; Li, Xiaoli; Zhao, Min

2008-12-01

In this paper we study the coherent transient property of a Λ-three-level system (Ωd = 0) and a quasi- Λ -four-level system (Ωd>0). Optical switching of the probe field can be achieved by applying a pulsed coupling field or rf field. In Λ -shaped three-level system, when the coupling field was switched on, there is a almost total transparency of the probe field and the time required for the absorption changing from 90% to 10% of the maximum absorption is 2.9Γ0 (Γ0 is spontaneous emission lifetime). When the coupling field was switched off, there is an initial increase of the probe field absorption and then gradually evolves to the maximum of absorption of the two-level absorption, the time required for the absorption of the system changing from 10% to 90% is 4.2Γ0. In four-level system, where rf driving field is used as switching field, to achieve the same depth of the optical switching, the time of the optical switching is 2.5Γ0 and 6.1Γ0, respectively. The results show that with the same depth of the optical switching, the switch-on time of the four-level system is shorter than that of the three-level system, while the switch-off time of the four-level system is longer. The depth of the optical switching of the four-level system was much larger than that of the three-level system, where the depth of the optical switching of the latter is merely 14.8% of that of the former. The speed of optical switching of the two systems can be increased by the increase of Rabi frequency of coupling field or rf field.

Integration of Systems with Varying Levels of Autonomy (Integration de Systemes a Niveau d’Autonomie Variable)

DTIC Science & Technology

2008-09-01

SCI-144 Integration of Systems with Varying Levels of Autonomy (Intégration de systèmes à niveau d’autonomie variable) This Report was...prepared by Task Group SCI-144 on “ System -Level Integration of Control plus Automation” and has been sponsored by the Systems Concepts and Integration... Systems with Varying Levels of Autonomy (Intégration de systèmes à niveau d’autonomie variable) This Report was prepared by Task Group SCI-144 on

Integration of Systems with Varying Levels of Autonomy (Integration de systemes a niveau d’autonomie variable)

DTIC Science & Technology

2008-09-01

SCI-144 Integration of Systems with Varying Levels of Autonomy (Intégration de systèmes à niveau d’autonomie variable) This Report was...prepared by Task Group SCI-144 on “ System -Level Integration of Control plus Automation” and has been sponsored by the Systems Concepts and Integration... Systems with Varying Levels of Autonomy (Intégration de systèmes à niveau d’autonomie variable) This Report was prepared by Task Group SCI-144 on

46 CFR 154.1330 - Liquid level alarm system: Independent tank type C.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 5 2012-10-01 2012-10-01 false Liquid level alarm system: Independent tank type C. 154..., Construction and Equipment Instrumentation § 154.1330 Liquid level alarm system: Independent tank type C. Independent tanks type C need not have the high liquid level alarm system under § 154.1325 if: (a) The tank...

46 CFR 154.1330 - Liquid level alarm system: Independent tank type C.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 5 2011-10-01 2011-10-01 false Liquid level alarm system: Independent tank type C. 154..., Construction and Equipment Instrumentation § 154.1330 Liquid level alarm system: Independent tank type C. Independent tanks type C need not have the high liquid level alarm system under § 154.1325 if: (a) The tank...

46 CFR 154.1330 - Liquid level alarm system: Independent tank type C.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 5 2013-10-01 2013-10-01 false Liquid level alarm system: Independent tank type C. 154..., Construction and Equipment Instrumentation § 154.1330 Liquid level alarm system: Independent tank type C. Independent tanks type C need not have the high liquid level alarm system under § 154.1325 if: (a) The tank...

46 CFR 154.1330 - Liquid level alarm system: Independent tank type C.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 5 2010-10-01 2010-10-01 false Liquid level alarm system: Independent tank type C. 154..., Construction and Equipment Instrumentation § 154.1330 Liquid level alarm system: Independent tank type C. Independent tanks type C need not have the high liquid level alarm system under § 154.1325 if: (a) The tank...

46 CFR 154.1330 - Liquid level alarm system: Independent tank type C.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 5 2014-10-01 2014-10-01 false Liquid level alarm system: Independent tank type C. 154..., Construction and Equipment Instrumentation § 154.1330 Liquid level alarm system: Independent tank type C. Independent tanks type C need not have the high liquid level alarm system under § 154.1325 if: (a) The tank...

46 CFR 154.1300 - Liquid level gauging system: General.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 5 2013-10-01 2013-10-01 false Liquid level gauging system: General. 154.1300 Section... Equipment Instrumentation § 154.1300 Liquid level gauging system: General. (a) If Table 4 lists a closed gauge for a cargo, the liquid level gauging system under § 154.1305 must be closed gauges that do not...

46 CFR 154.1300 - Liquid level gauging system: General.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 5 2010-10-01 2010-10-01 false Liquid level gauging system: General. 154.1300 Section... Equipment Instrumentation § 154.1300 Liquid level gauging system: General. (a) If Table 4 lists a closed gauge for a cargo, the liquid level gauging system under § 154.1305 must be closed gauges that do not...

46 CFR 154.1300 - Liquid level gauging system: General.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 5 2012-10-01 2012-10-01 false Liquid level gauging system: General. 154.1300 Section... Equipment Instrumentation § 154.1300 Liquid level gauging system: General. (a) If Table 4 lists a closed gauge for a cargo, the liquid level gauging system under § 154.1305 must be closed gauges that do not...

46 CFR 154.1300 - Liquid level gauging system: General.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 5 2011-10-01 2011-10-01 false Liquid level gauging system: General. 154.1300 Section... Equipment Instrumentation § 154.1300 Liquid level gauging system: General. (a) If Table 4 lists a closed gauge for a cargo, the liquid level gauging system under § 154.1305 must be closed gauges that do not...

46 CFR 154.1300 - Liquid level gauging system: General.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 5 2014-10-01 2014-10-01 false Liquid level gauging system: General. 154.1300 Section... Equipment Instrumentation § 154.1300 Liquid level gauging system: General. (a) If Table 4 lists a closed gauge for a cargo, the liquid level gauging system under § 154.1305 must be closed gauges that do not...

Adding Concrete Syntax to a Prolog-Based Program Synthesis System

NASA Technical Reports Server (NTRS)

Fischer, Bernd; Visser, Eelco

2004-01-01

Program generation and transformation systems work on two language levels, the object-level (i e., the language of the manipulated programs), and the meta-level (i.e., the implementation language of the system itself). The meta-level representations of object-level program fragments are usually built in an essentially syntax-free fashion using the operations provided by the meta-language. However, syntax matters and a large conceptual distance between the two languages makes it difficult to maintain and extend such systems. Here we describe how an existing Prolog-based system can gradually be retrofitted with concrete object-level syntax, thus shrinking this distance.

System and method for inventorying multiple remote objects

DOEpatents

Carrender, Curtis L.; Gilbert, Ronald W.

2007-10-23

A system and method of inventorying multiple objects utilizing a multi-level or a chained radio frequency identification system. The system includes a master tag and a plurality of upper level tags and lower level tags associated with respective objects. The upper and lower level tags communicate with each other and the master tag so that reading of the master tag reveals the presence and absence of upper and lower level tags. In the chained RF system, the upper and lower level tags communicate locally with each other in a manner so that more remote tags that are out of range of some of the upper and lower level tags have their information relayed through adjacent tags to the master tag and thence to a controller.

System and method for inventorying multiple remote objects

DOEpatents

Carrender, Curtis L [Morgan Hill, CA; Gilbert, Ronald W [Morgan Hill, CA

2009-12-29

A system and method of inventorying multiple objects utilizing a multi-level or a chained radio frequency identification system. The system includes a master tag and a plurality of upper level tags and lower level tags associated with respective objects. The upper and lower level tags communicate with each other and the master tag so that reading of the master tag reveals the presence and absence of upper and lower level tags. In the chained RF system, the upper and lower level tags communicate locally with each other in a manner so that more remote tags that are out of range of some of the upper and lower level tags have their information relayed through adjacent tags to the master tag and thence to a controller.

Theoretical foundations of spatially-variant mathematical morphology part ii: gray-level images.

PubMed

Bouaynaya, Nidhal; Schonfeld, Dan

2008-05-01

In this paper, we develop a spatially-variant (SV) mathematical morphology theory for gray-level signals and images in the Euclidean space. The proposed theory preserves the geometrical concept of the structuring function, which provides the foundation of classical morphology and is essential in signal and image processing applications. We define the basic SV gray-level morphological operators (i.e., SV gray-level erosion, dilation, opening, and closing) and investigate their properties. We demonstrate the ubiquity of SV gray-level morphological systems by deriving a kernel representation for a large class of systems, called V-systems, in terms of the basic SV graylevel morphological operators. A V-system is defined to be a gray-level operator, which is invariant under gray-level (vertical) translations. Particular attention is focused on the class of SV flat gray-level operators. The kernel representation for increasing V-systems is a generalization of Maragos' kernel representation for increasing and translation-invariant function-processing systems. A representation of V-systems in terms of their kernel elements is established for increasing and upper-semi-continuous V-systems. This representation unifies a large class of spatially-variant linear and non-linear systems under the same mathematical framework. Finally, simulation results show the potential power of the general theory of gray-level spatially-variant mathematical morphology in several image analysis and computer vision applications.

Real-time Geographic Information System (GIS) for Monitoring the Area of Potential Water Level Using Rule Based System

NASA Astrophysics Data System (ADS)

Anugrah, Wirdah; Suryono; Suseno, Jatmiko Endro

2018-02-01

Management of water resources based on Geographic Information System can provide substantial benefits to water availability settings. Monitoring the potential water level is needed in the development sector, agriculture, energy and others. In this research is developed water resource information system using real-time Geographic Information System concept for monitoring the potential water level of web based area by applying rule based system method. GIS consists of hardware, software, and database. Based on the web-based GIS architecture, this study uses a set of computer that are connected to the network, run on the Apache web server and PHP programming language using MySQL database. The Ultrasound Wireless Sensor System is used as a water level data input. It also includes time and geographic location information. This GIS maps the five sensor locations. GIS is processed through a rule based system to determine the level of potential water level of the area. Water level monitoring information result can be displayed on thematic maps by overlaying more than one layer, and also generating information in the form of tables from the database, as well as graphs are based on the timing of events and the water level values.

Problem of two-level hierarchical minimax program control the final state of regional social and economic system with incomplete information

NASA Astrophysics Data System (ADS)

Shorikov, A. F.

2016-12-01

In this article we consider a discrete-time dynamical system consisting of a set a controllable objects (region and forming it municipalities). The dynamics each of these is described by the corresponding linear or nonlinear discrete-time recurrent vector relations and its control system consist from two levels: basic level (control level I) that is dominating level and auxiliary level (control level II) that is subordinate level. Both levels have different criterions of functioning and united by information and control connections which defined in advance. In this article we study the problem of optimization of guaranteed result for program control by the final state of regional social and economic system in the presence of risks vectors. For this problem we propose a mathematical model in the form of two-level hierarchical minimax program control problem of the final states of this system with incomplete information and the general scheme for its solving.

Optimal maintenance policy incorporating system level and unit level for mechanical systems

NASA Astrophysics Data System (ADS)

Duan, Chaoqun; Deng, Chao; Wang, Bingran

2018-04-01

The study works on a multi-level maintenance policy combining system level and unit level under soft and hard failure modes. The system experiences system-level preventive maintenance (SLPM) when the conditional reliability of entire system exceeds SLPM threshold, and also undergoes a two-level maintenance for each single unit, which is initiated when a single unit exceeds its preventive maintenance (PM) threshold, and the other is performed simultaneously the moment when any unit is going for maintenance. The units experience both periodic inspections and aperiodic inspections provided by failures of hard-type units. To model the practical situations, two types of economic dependence have been taken into account, which are set-up cost dependence and maintenance expertise dependence due to the same technology and tool/equipment can be utilised. The optimisation problem is formulated and solved in a semi-Markov decision process framework. The objective is to find the optimal system-level threshold and unit-level thresholds by minimising the long-run expected average cost per unit time. A formula for the mean residual life is derived for the proposed multi-level maintenance policy. The method is illustrated by a real case study of feed subsystem from a boring machine, and a comparison with other policies demonstrates the effectiveness of our approach.

Robustness of Flexible Systems With Component-Level Uncertainties

NASA Technical Reports Server (NTRS)

Maghami, Peiman G.

2000-01-01

Robustness of flexible systems in the presence of model uncertainties at the component level is considered. Specifically, an approach for formulating robustness of flexible systems in the presence of frequency and damping uncertainties at the component level is presented. The synthesis of the components is based on a modifications of a controls-based algorithm for component mode synthesis. The formulation deals first with robustness of synthesized flexible systems. It is then extended to deal with global (non-synthesized ) dynamic models with component-level uncertainties by projecting uncertainties from component levels to system level. A numerical example involving a two-dimensional simulated docking problem is worked out to demonstrate the feasibility of the proposed approach.

The ATLAS Level-1 Topological Trigger performance in Run 2

NASA Astrophysics Data System (ADS)

Riu, Imma; ATLAS Collaboration

2017-10-01

The Level-1 trigger is the first event rate reducing step in the ATLAS detector trigger system, with an output rate of up to 100 kHz and decision latency smaller than 2.5 μs. During the LHC shutdown after Run 1, the Level-1 trigger system was upgraded at hardware, firmware and software levels. In particular, a new electronics sub-system was introduced in the real-time data processing path: the Level-1 Topological trigger system. It consists of a single electronics shelf equipped with two Level-1 Topological processor blades. They receive real-time information from the Level-1 calorimeter and muon triggers, which is processed to measure angles between trigger objects, invariant masses or other kinematic variables. Complementary to other requirements, these measurements are taken into account in the final Level-1 trigger decision. The system was installed and commissioning started in 2015 and continued during 2016. As part of the commissioning, the decisions from individual algorithms were simulated and compared with the hardware response. An overview of the Level-1 Topological trigger system design, commissioning process and impact on several event selections are illustrated.

More than meets the eye: Using cognitive work analysis to identify design requirements for future rail level crossing systems.

PubMed

Salmon, Paul M; Lenné, Michael G; Read, Gemma J M; Mulvihill, Christine M; Cornelissen, Miranda; Walker, Guy H; Young, Kristie L; Stevens, Nicholas; Stanton, Neville A

2016-03-01

An increasing intensity of operations means that the longstanding safety issue of rail level crossings is likely to become worse in the transport systems of the future. It has been suggested that the failure to prevent collisions may be, in part, due to a lack of systems thinking during design, crash analysis, and countermeasure development. This paper presents a systems analysis of current active rail level crossing systems in Victoria, Australia that was undertaken to identify design requirements to improve safety in future rail level crossing environments. Cognitive work analysis was used to analyse rail level crossing systems using data derived from a range of activities. Overall the analysis identified a range of instances where modification or redesign in line with systems thinking could potentially improve behaviour and safety. A notable finding is that there are opportunities for redesign outside of the physical rail level crossing infrastructure, including improved data systems, in-vehicle warnings and modifications to design processes, standards and guidelines. The implications for future rail level crossing systems are discussed. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Effects of Water Sprinklers on the Performance of Low Level AFFF Aircraft Hangar Fire Suppression Systems

DTIC Science & Technology

2000-05-22

AFFF fire suppression system. The combined overhead water-only sprinkler and low level AFFF system is being considered as a new protection scheme for...performance of a low level system during AFFF discharge (4.0 Lpm/sq m (0.1 gpm/sq ft)). Based on the results of these tests, the design criteria for...Navy hangar protection may be revised to incorporate AFFF application from only the low level system, combined with overhead closed-head guide response water sprinklers.

NASA System-Level Design, Analysis and Simulation Tools Research on NextGen

NASA Technical Reports Server (NTRS)

Bardina, Jorge

2011-01-01

A review of the research accomplished in 2009 in the System-Level Design, Analysis and Simulation Tools (SLDAST) of the NASA's Airspace Systems Program is presented. This research thrust focuses on the integrated system-level assessment of component level innovations, concepts and technologies of the Next Generation Air Traffic System (NextGen) under research in the ASP program to enable the development of revolutionary improvements and modernization of the National Airspace System. The review includes the accomplishments on baseline research and the advancements on design studies and system-level assessment, including the cluster analysis as an annualization standard of the air traffic in the U.S. National Airspace, and the ACES-Air MIDAS integration for human-in-the-loop analyzes within the NAS air traffic simulation.

Lightning testing at the subsystem level

NASA Technical Reports Server (NTRS)

Luteran, Frank

1991-01-01

Testing at the subsystem or black box level for lightning hardness is required if system hardness is to be assured at the system level. The often applied philosophy of lighting testing only at the system level leads to extensive end of the line design changes which result in excessive costs and time delays. In order to perform testing at the subsystem level two important factors must be defined to make the testing simulation meaningful. The first factor is the definition of the test stimulus appropriate to the subsystem level. Application of system level stimulations to the subsystem level usually leads to significant overdesign of the subsystem which is not necessary and may impair normal subsystem performance. The second factor is the availability of test equipment needed to provide the subsystem level lightning stimulation. Equipment for testing at this level should be portable or at least movable to enable efficient testing in a design laboratory environment. Large fixed test installations for system level tests are not readily available for use by the design engineers at the subsystem level and usually require special operating skills. The two factors, stimulation level and test equipment availability, must be evaluated together in order to produce a practical, workable test standard. The neglect or subordination of either factor will guarantee failure in generating the standard. It is not unusual to hear that test standards or specifications are waived because a specified stimulation level cannot be accomplished by in-house or independent test facilities. Determination of subsystem lightning simulation level requires a knowledge and evaluation of field coupling modes, peak and median levels of voltages and currents, bandwidths, and repetition rates. Practical limitations on test systems may require tradeoffs in lightning stimulation parameters in order to build practical test equipment. Peak power levels that can be generated at specified bandwidths with standard electrical components must be considered in the design and costing of the test system. Stimulation tests equipment and test methods are closely related and must be considered a test system for lightning simulation. A non-perfect specification that can be reliably and repeatedly applied at the subsystem test level is more desirable than a perfect specification that cannot be applied at all.

Maturity Assessment of Space Plug-and-Play Architecture

DTIC Science & Technology

2013-03-01

SSM SPA Service Module SRL System Readiness Level TAT Time-at-Tone TRA Technology Readiness Assessment TRL Technology Readiness Level USB Universal...maturity assessment—the Technology Readiness Level (TRL) process, the Integration Readiness Level (IRL) process, and the System Readiness Level ( SRL ...is an important hallmark of the SPA concept, and makes possible the composability and scalability of system designs that employ it. 14 4. SPA

A Distributed Approach to System-Level Prognostics

NASA Technical Reports Server (NTRS)

Daigle, Matthew J.; Bregon, Anibal; Roychoudhury, Indranil

2012-01-01

Prognostics, which deals with predicting remaining useful life of components, subsystems, and systems, is a key technology for systems health management that leads to improved safety and reliability with reduced costs. The prognostics problem is often approached from a component-centric view. However, in most cases, it is not specifically component lifetimes that are important, but, rather, the lifetimes of the systems in which these components reside. The system-level prognostics problem can be quite difficult due to the increased scale and scope of the prognostics problem and the relative Jack of scalability and efficiency of typical prognostics approaches. In order to address these is ues, we develop a distributed solution to the system-level prognostics problem, based on the concept of structural model decomposition. The system model is decomposed into independent submodels. Independent local prognostics subproblems are then formed based on these local submodels, resul ting in a scalable, efficient, and flexible distributed approach to the system-level prognostics problem. We provide a formulation of the system-level prognostics problem and demonstrate the approach on a four-wheeled rover simulation testbed. The results show that the system-level prognostics problem can be accurately and efficiently solved in a distributed fashion.

Liquid and Gaseous Waste Operations Department annual operating report CY 1996

DOE Office of Scientific and Technical Information (OSTI.GOV)

Maddox, J.J.; Scott, C.B.

1997-03-01

This annual report summarizes operating activities dealing with the process waste system, the liquid low-level waste system, and the gaseous waste system. It also describes upgrade activities dealing with the process and liquid low-level waste systems, the cathodic protection system, a stack ventilation system, and configuration control. Maintenance activities are described dealing with nonradiological wastewater treatment plant, process waste treatment plant and collection system, liquid low-level waste system, and gaseous waste system. Miscellaneous activities include training, audits/reviews/tours, and environmental restoration support.

A survey of core and support activities of communicable disease surveillance systems at operating-level CDCs in China.

PubMed

Xiong, Weiyi; Lv, Jun; Li, Liming

2010-11-17

In recent years, problems like insufficient coordination, low efficiency, and heavy working load in national communicable disease surveillance systems in China have been pointed out by many researchers. To strengthen the national communicable disease surveillance systems becomes an immediate concern. Since the World Health Organization has recommended that a structured approach to strengthen national communicable disease surveillance must include an evaluation to existing systems which usually begins with a systematic description, we conducted the first survey for communicable disease surveillance systems in China, in order to understand the situation of core and support surveillance activities at province-level and county-level centers for disease control and prevention (CDCs). A nationwide survey was conducted by mail between May and October 2006 to investigate the implementation of core and support activities of the Notifiable Disease Reporting System (NDRS) and disease-specific surveillance systems in all of the 31 province-level and selected 14 county-level CDCs in Mainland China The comments on the performance of communicable disease surveillance systems were also collected from the directors of CDCs in this survey. The core activities of NDRS such as confirmation, reporting and analysis and some support activities such as supervision and staff training were found sufficient in both province-level and county-level surveyed CDCs, but other support activities including information feedback, equipment and financial support need to be strengthened in most of the investigated CDCs. A total of 47 communicable diseases or syndromes were under surveillance at province level, and 20 diseases or syndromes at county level. The activities among different disease-specific surveillance systems varied widely. Acute flaccid paralysis (AFP), measles and tuberculosis (TB) surveillance systems got relatively high recognition both at province level and county level. China has already established a national communicable disease surveillance framework that combines NDRS and disease-specific surveillance systems. The core and support activities of NDRS were found sufficient, while the implementation of those activities varied among different disease-specific surveillance systems.

System-level strategies for conserving rare or little-known species

Treesearch

Bruce G. Marcot; Carolyn Hull Sieg

2007-01-01

In this chapter we review the literature on system-level strategies for conserving rare or little-known (RLK) species, continuing from the species-level approaches addressed in the previous chapter. We define system-level approaches as those that result in conservation actions focused on providing for community or ecosystem composition, structure, or function.

On-line diagnosis of sequential systems

NASA Technical Reports Server (NTRS)

Sundstrom, R. J.

1973-01-01

A model for on-line diagnosis was investigated for discrete-time systems, and resettable sequential systems. Generalized notions of a realization are discussed along with fault tolerance and errors. Further investigation into the theory of on-line diagnosis is recommended for three levels: binary state-assigned level, logical circuit level, and the subsystem-network level.

The model of the optical-electronic control system of vehicles location at level crossing

NASA Astrophysics Data System (ADS)

Verezhinskaia, Ekaterina A.; Gorbachev, Aleksei A.; Maruev, Ivan A.; Shavrygina, Margarita A.

2016-04-01

Level crossing - one of the most dangerous sections of the road network, where railway line crosses motor road at the same level. The collision of trains with vehicles at a level crossing is a serious type of road traffic accidents. The purpose of this research is to develop complex optical electronic control system of vehicles location in the dangerous zone of level crossing. The system consists of registration blocks (including photodetector, lens, infrared emitting diode), determinant devices and camera installed within the boundaries of level crossing. The system performs detection of objects (vehicles) by analysing the time of the object movement opposite to the registration block and level of the reflected signal from the object. The paper presents theoretical description and experimental research of main principles of the system operation. Experimental research of the system model with selected optical-electronic components have confirmed the possibility of metal objects detection at the required distance (0.5 - 2 m) with different values of background illuminance.

Is health workforce planning recognising the dynamic interplay between health literacy at an individual, organisation and system level?

PubMed

Naccarella, Lucio; Wraight, Brenda; Gorman, Des

2016-02-01

The growing demands on the health system to adapt to constant change has led to investment in health workforce planning agencies and approaches. Health workforce planning approaches focusing on identifying, predicting and modelling workforce supply and demand are criticised as being simplistic and not contributing to system-level resiliency. Alternative evidence- and needs-based health workforce planning approaches are being suggested. However, to contribute to system-level resiliency, workforce planning approaches need to also adopt system-based approaches. The increased complexity and fragmentation of the healthcare system, especially for patients with complex and chronic conditions, has also led to a focus on health literacy not simply as an individual trait, but also as a dynamic product of the interaction between individual (patients, workforce)-, organisational- and system-level health literacy. Although it is absolutely essential that patients have a level of health literacy that enables them to navigate and make decisions, so too the health workforce, organisations and indeed the system also needs to be health literate. Herein we explore whether health workforce planning is recognising the dynamic interplay between health literacy at an individual, organisation and system level, and the potential for strengthening resiliency across all those levels.

Description of the SSF PMAD DC testbed control system data acquisition function

NASA Technical Reports Server (NTRS)

Baez, Anastacio N.; Mackin, Michael; Wright, Theodore

1992-01-01

The NASA LeRC in Cleveland, Ohio has completed the development and integration of a Power Management and Distribution (PMAD) DC Testbed. This testbed is a reduced scale representation of the end to end, sources to loads, Space Station Freedom Electrical Power System (SSF EPS). This unique facility is being used to demonstrate DC power generation and distribution, power management and control, and system operation techniques considered to be prime candidates for the Space Station Freedom. A key capability of the testbed is its ability to be configured to address system level issues in support of critical SSF program design milestones. Electrical power system control and operation issues like source control, source regulation, system fault protection, end-to-end system stability, health monitoring, resource allocation, and resource management are being evaluated in the testbed. The SSF EPS control functional allocation between on-board computers and ground based systems is evolving. Initially, ground based systems will perform the bulk of power system control and operation. The EPS control system is required to continuously monitor and determine the current state of the power system. The DC Testbed Control System consists of standard controllers arranged in a hierarchical and distributed architecture. These controllers provide all the monitoring and control functions for the DC Testbed Electrical Power System. Higher level controllers include the Power Management Controller, Load Management Controller, Operator Interface System, and a network of computer systems that perform some of the SSF Ground based Control Center Operation. The lower level controllers include Main Bus Switch Controllers and Photovoltaic Controllers. Power system status information is periodically provided to the higher level controllers to perform system control and operation. The data acquisition function of the control system is distributed among the various levels of the hierarchy. Data requirements are dictated by the control system algorithms being implemented at each level. A functional description of the various levels of the testbed control system architecture, the data acquisition function, and the status of its implementationis presented.

Metrics for the NASA Airspace Systems Program

NASA Technical Reports Server (NTRS)

Smith, Jeremy C.; Neitzke, Kurt W.

2009-01-01

This document defines an initial set of metrics for use by the NASA Airspace Systems Program (ASP). ASP consists of the NextGen-Airspace Project and the NextGen-Airportal Project. The work in each project is organized along multiple, discipline-level Research Focus Areas (RFAs). Each RFA is developing future concept elements in support of the Next Generation Air Transportation System (NextGen), as defined by the Joint Planning and Development Office (JPDO). In addition, a single, system-level RFA is responsible for integrating concept elements across RFAs in both projects and for assessing system-wide benefits. The primary purpose of this document is to define a common set of metrics for measuring National Airspace System (NAS) performance before and after the introduction of ASP-developed concepts for NextGen as the system handles increasing traffic. The metrics are directly traceable to NextGen goals and objectives as defined by the JPDO and hence will be used to measure the progress of ASP research toward reaching those goals. The scope of this document is focused on defining a common set of metrics for measuring NAS capacity, efficiency, robustness, and safety at the system-level and at the RFA-level. Use of common metrics will focus ASP research toward achieving system-level performance goals and objectives and enable the discipline-level RFAs to evaluate the impact of their concepts at the system level.

Information Quality Evaluation of C2 Systems at Architecture Level

DTIC Science & Technology

2014-06-01

based on architecture models of C2 systems, which can help to identify key factors impacting information quality and improve the system capability at the stage of architecture design of C2 system....capability evaluation of C2 systems at architecture level becomes necessary and important for improving the system capability at the stage of architecture ... design . This paper proposes a method for information quality evaluation of C2 system at architecture level. First, the information quality model is

Sounding the warning bells: the need for a systems approach to understanding behaviour at rail level crossings.

PubMed

Read, Gemma J M; Salmon, Paul M; Lenné, Michael G

2013-09-01

Collisions at rail level crossings are an international safety concern and have been the subject of considerable research effort. Modern human factors practice advocates a systems approach to investigating safety issues in complex systems. This paper describes the results of a structured review of the level crossing literature to determine the extent to which a systems approach has been applied. The measures used to determine if previous research was underpinned by a systems approach were: the type of analysis method utilised, the number of component relationships considered, the number of user groups considered, the number of system levels considered and the type of model described in the research. None of research reviewed was found to be consistent with a systems approach. It is recommended that further research utilise a systems approach to the study of the level crossing system to enable the identification of effective design improvements. Copyright © 2013 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Magnetic-field-induced mixed-level Kondo effect in two-level systems

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wong, Arturo; Ngo, Anh T.; Ulloa, Sergio E.

2016-10-17

We consider a two-orbital impurity system with intra-and interlevel Coulomb repulsion that is coupled to a single conduction channel. This situation can generically occur in multilevel quantum dots or in systems of coupled quantum dots. For finite energy spacing between spin-degenerate orbitals, an in-plane magnetic field drives the system from a local-singlet ground state to a "mixed-level" Kondo regime, where the Zeeman-split levels are degenerate for opposite-spin states. We use the numerical renormalization group approach to fully characterize this mixed-level Kondo state and discuss its properties in terms of the applied Zeeman field, temperature, and system parameters. Under suitable conditions,more » the total spectral function is shown to develop a Fermi-level resonance, so that the linear conductance of the system peaks at a finite Zeeman field while it decreases as a function of temperature. These features, as well as the local moment and entropy contribution of the impurity system, are commensurate with Kondo physics, which can be studied in suitably tuned quantum dot systems.« less

46 CFR 153.409 - High level alarms.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 5 2010-10-01 2010-10-01 false High level alarms. 153.409 Section 153.409 Shipping... Systems § 153.409 High level alarms. When Table 1 refers to this section or requires a cargo to have a closed gauging system, the cargo's containment system must have a high level alarm: (a) That gives an...

49 CFR 325.37 - Location and operation of sound level measurement system; highway operations.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Location and operation of sound level measurement...; Highway Operations § 325.37 Location and operation of sound level measurement system; highway operations. (a) The microphone of a sound level measurement system that conforms to the rules in § 325.23 of this...

TEMPEST in a gallimaufry: applying multilevel systems theory to person-in-context research.

PubMed

Peck, Stephen C

2007-12-01

Terminological ambiguity and inattention to personal and contextual multilevel systems undermine personality, self, and identity theories. Hierarchical and heterarchical systems theories are used to describe contents and processes existing within and across three interrelated multilevel systems: levels of organization, representation, and integration. Materially nested levels of organization are used to distinguish persons from contexts and personal from social identity. Functionally nested levels of representation are used to distinguish personal identity from the sense of identity and symbolic (belief) from iconic (schema) systems. Levels of integration are hypothesized to unfold separately but interdependently across levels of representation. Multilevel system configurations clarify alternative conceptualizations of traits and contextualized identity. Methodological implications for measurement and analysis (e.g., integrating variable- and pattern-centered methods) are briefly described.

Ontological Problem-Solving Framework for Assigning Sensor Systems and Algorithms to High-Level Missions

PubMed Central

Qualls, Joseph; Russomanno, David J.

2011-01-01

The lack of knowledge models to represent sensor systems, algorithms, and missions makes opportunistically discovering a synthesis of systems and algorithms that can satisfy high-level mission specifications impractical. A novel ontological problem-solving framework has been designed that leverages knowledge models describing sensors, algorithms, and high-level missions to facilitate automated inference of assigning systems to subtasks that may satisfy a given mission specification. To demonstrate the efficacy of the ontological problem-solving architecture, a family of persistence surveillance sensor systems and algorithms has been instantiated in a prototype environment to demonstrate the assignment of systems to subtasks of high-level missions. PMID:22164081

Formal Verification at System Level

NASA Astrophysics Data System (ADS)

Mazzini, S.; Puri, S.; Mari, F.; Melatti, I.; Tronci, E.

2009-05-01

System Level Analysis calls for a language comprehensible to experts with different background and yet precise enough to support meaningful analyses. SysML is emerging as an effective balance between such conflicting goals. In this paper we outline some the results obtained as for SysML based system level functional formal verification by an ESA/ESTEC study, with a collaboration among INTECS and La Sapienza University of Roma. The study focuses on SysML based system level functional requirements techniques.

Ground-Based Icing Condition Remote Sensing System Definition

NASA Technical Reports Server (NTRS)

Reehorst, Andrew L.; Koenig, George G.

2001-01-01

This report documents the NASA Glenn Research Center activities to assess and down select remote sensing technologies for the purpose of developing a system capable of measuring icing condition hazards aloft. The information generated by such a remote sensing system is intended for use by the entire aviation community, including flight crews. air traffic controllers. airline dispatchers, and aviation weather forecasters. The remote sensing system must be capable of remotely measuring temperature and liquid water content (LWC), and indicating the presence of super-cooled large droplets (SLD). Technologies examined include Profiling Microwave Radiometer, Dual-Band Radar, Multi-Band Radar, Ka-Band Radar. Polarized Ka-Band Radar, and Multiple Field of View (MFOV) Lidar. The assessment of these systems took place primarily during the Mt. Washington Icing Sensors Project (MWISP) in April 1999 and the Alliance Icing Research Study (AIRS) from November 1999 to February 2000. A discussion of the various sensing technologies is included. The result of the assessment is that no one sensing technology can satisfy all of the stated project goals. Therefore a proposed system includes radiometry and Ka-band radar. A multilevel approach is proposed to allow the future selection of the fielded system based upon required capability and available funding. The most basic level system would be the least capable and least expensive. The next level would increase capability and cost, and the highest level would be the most capable and most expensive to field. The Level 1 system would consist of a Profiling Microwave Radiometer. The Level 2 system would add a Ka-Band Radar. The Level 3 system would add polarization to the Ka-Band Radar. All levels of the system would utilize hardware that is already under development by the U.S. Government. However, to meet the needs of the aviation community, all levels of the system will require further development. In addition to the proposed system, it is also recommended that NASA continue to foster the development of Multi-Band Radar and airborne microwave radiometer technologies.

To Three or not to Three: Improving Human Computation Game Onboarding with a Three-Star System.

PubMed

Gaston, Jacqueline; Cooper, Seth

2017-01-01

While many popular casual games use three-star systems, which give players up to three stars based on their performance in a level, this technique has seen limited application in human computation games (HCGs). This gives rise to the question of what impact, if any, a three-star system will have on the behavior of players in HCGs. In this work, we examined the impact of a three-star system implemented in the protein folding HCG Foldit . We compared the basic game's introductory levels with two versions using a three-star system, where players were rewarded with more stars for completing levels in fewer moves. In one version, players could continue playing levels for as many moves as they liked, and in the other, players were forced to reset the level if they used more moves than required to achieve at least one star on the level. We observed that the three-star system encouraged players to use fewer moves, take more time per move, and replay completed levels more often. We did not observe an impact on retention. This indicates that three-star systems may be useful for re-enforcing concepts introduced by HCG levels, or as a flexible means to encourage desired behaviors.

A survey of major east coast snowstorms, 1960-1983. Part 2. Summary of surface and upperlevel characteristics

NASA Technical Reports Server (NTRS)

Kocin, P. J.; Uccellini, L. W.

1985-01-01

Surface and upper-level characteristics of selected meteorological fields are summarized. Two major types of sea level development are described and applied to the cases at hand, with a few storm systems showing characteristics of both types. Aspects such as rapid sea level deepening, coastal frontogenesis, cold air damming, low level jet formation, the development of an S-shaped isotherm pattern, diffluence downwind of a negatively tilted upper level trough axis, upper level confluence and an increase of geopotential heights at the base of the upper level trough characterized the pre-cyclogenetic and cyclogenetic periods of many of the storm systems. Large variability was also observed, especially with regard to the spatial dimensions of the surface and upper level systems, as well as variations in trough/ridge amplification and the evolution of upper level jet streak systems. The influence of transverse circulations associated with a confluent jet streak entrance region and the diffluent exit region of a jet streak/trough system on the production of snowfall is also discussed.

Human Factors Integration Requirements for Armoured Fightmg Vehicles. Part 2: A Review of the Human Systems Integration Material Available for Armour Systems SORs and a Plan for Future HSI and R&D

DTIC Science & Technology

2000-01-01

Material for Amour System SORs Humaruystems Incorporated • Clothing and Equipment level Estimated contracting cost- $15K 2. Construct and distribute...for Amour System SORs Huma~stems Incorporated • vehicle level • Troop leader level • Squadron OC level 1. Tasks to identifY the human error...During the period 1994 to 1999 a number of activities conducted by the Defence Research and Development Branch (DRDB) focused on the level ofHSI

Primary culture system of adrenocortical cells from dogs to evaluate direct effects of chemicals on steroidogenesis.

PubMed

Morishita, K; Okumura, H; Ito, N; Takahashi, N

2001-08-28

The present study was conducted to confirm the usefulness of a primary culture system of adrenocortical cells from dogs for detecting the direct effects of the chemicals on adrenal cortex. Corticosteroid levels in the culture supernatant were measured using high-performance liquid chromatography (HPLC) following 24-h incubation with the chemicals. Ketoconazole, miconazole, metyrapone, aminoglutethimide, and 1-(o-chlorophenyl)-1-(p-chlorophenyl)-2,2-dichloroethane (o,p-DDD), which were known to inhibit cortisol production were evaluated in this system. Both viable cells and corticosteroid levels were decreased by o,p-DDD treatment. Other chemicals showed various inhibition patterns of corticosteroid levels as follows without affecting cell viability. Ketoconazole decreased total corticosteroids level by mainly due to the decreases in cortisol and 11-deoxycortisol levels. Miconazole decreased cortisol and 11-deoxycortisol levels, however, slightly increased corticosterone level. Metyrapone decreased cortisol and corticosterone levels as 11-deoxycortisol and 11-deoxycorticosterone levels were increased. Aminoglutethimide decreased total corticosteroids level by mainly decreasing cortisol, corticosterone and 11-deoxycortisol levels. These results suggested that determination of the pattern of corticosteroid levels by HPLC in this system well reflected the mode of their action on steroidogenesis. Thus, we conclude this simple system was useful to determine the direct effects of chemicals on steroidogenesis in the adrenal cortex.

A Next Generation Digital Counting System For Low-Level Tritium Studies (Project Report)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bowman, P.

2016-10-03

Since the early seventies, SRNL has pioneered low-level tritium analysis using various nuclear counting technologies and techniques. Since 1999, SRNL has successfully performed routine low-level tritium analyses with counting systems based on digital signal processor (DSP) modules developed in the late 1990s. Each of these counting systems are complex, unique to SRNL, and fully dedicated to performing routine tritium analyses of low-level environmental samples. It is time to modernize these systems due to a variety of issues including (1) age, (2) lack of direct replacement electronics modules and (3) advances in digital signal processing and computer technology. There has beenmore » considerable development in many areas associated with the enterprise of performing low-level tritium analyses. The objective of this LDRD project was to design, build, and demonstrate a Next Generation Tritium Counting System (NGTCS), while not disrupting the routine low-level tritium analyses underway in the facility on the legacy counting systems. The work involved (1) developing a test bed for building and testing new counting system hardware that does not interfere with our routine analyses, (2) testing a new counting system based on a modern state of the art DSP module, and (3) evolving the low-level tritium counter design to reflect the state of the science.« less

Robustness of self-organised systems to changes in behaviour: an example from real and simulated self-organised snail aggregations.

PubMed

Stafford, Richard; Williams, Gray A; Davies, Mark S

2011-01-01

Group or population level self-organised systems comprise many individuals displaying group-level emergent properties. Current theory indicates that individual-level behaviours have an effect on the final group-level behaviour; that is, self-organised systems are sensitive to small changes in individual behaviour. Here we examine a self-organised behaviour in relation to environmentally-driven individual-level changes in behaviour, using both natural systems and computer simulations. We demonstrate that aggregations of intertidal snails slightly decrease in size when, owing to hotter and more desiccating conditions, individuals forage for shorter periods--a seemingly non-adaptive behaviour for the snails since aggregation reduces desiccation stress. This decrease, however, only occurs in simple experimental systems (and simulations of these systems). When studied in their natural and more complex environment, and simulations of such an environment, using the same reduced foraging time, no difference in aggregation behaviour was found between hot and cool days. These results give an indication of how robust self-organised systems are to changes in individual-level behaviour. The complexity of the natural environment and the interactions of individuals with this environment, therefore, can result in self-organised systems being more resilient to individual-level changes than previously assumed.

Lessons Learned from Application of System and Software Level RAMS Analysis to a Space Control System

NASA Astrophysics Data System (ADS)

Silva, N.; Esper, A.

2012-01-01

The work presented in this article represents the results of applying RAMS analysis to a critical space control system, both at system and software levels. The system level RAMS analysis allowed the assignment of criticalities to the high level components, which was further refined by a tailored software level RAMS analysis. The importance of the software level RAMS analysis in the identification of new failure modes and its impact on the system level RAMS analysis is discussed. Recommendations of changes in the software architecture have also been proposed in order to reduce the criticality of the SW components to an acceptable minimum. The dependability analysis was performed in accordance to ECSS-Q-ST-80, which had to be tailored and complemented in some aspects. This tailoring will also be detailed in the article and lessons learned from the application of this tailoring will be shared, stating the importance to space systems safety evaluations. The paper presents the applied techniques, the relevant results obtained, the effort required for performing the tasks and the planned strategy for ROI estimation, as well as the soft skills required and acquired during these activities.

Atorvastatin therapy reduces interferon-regulated chemokine CXCL9 plasma levels in patients with systemic lupus erythematosus.

PubMed

Ferreira, G A; Teixeira, A L; Sato, E I

2010-07-01

A recent study showed transcriptional levels of interferon-inducible chemokines in peripheral blood cells were associated with disease activity and organ damage in systemic lupus erythematosus, and may be useful in monitoring disease activity and prognosis. Our objective was to evaluate the capacity of atorvastatin to reduce plasma levels of interferon-regulated chemokines (CCL2, CCL3 and CXCL9) and to study the correlation between these chemokines and disease activity in patients with systemic lupus erythematosus. Eighty-eight female patients with systemic lupus erythematosus were divided into two groups: 64 receiving 20 mg/day of atorvastatin (intervention group) and 24 without atorvastatin (control group). All patients were followed for 8 weeks. At baseline and after 8 weeks laboratory tests were performed for all patients. Plasma levels of chemokines were measured by ELISA using commercial kits (DuoSet, R&D Systems, Minneapolis, USA). In a univariate analysis we found correlation between CCL2, CCL3 and CXCL9 plasma levels and SLEDAI score. In the intervention group we observed a significant decrease in CXCL9 plasma levels comparing baseline and levels at the end of the study (p = 0.04); however, no differences were observed regarding CCL2 or CCL3 plasma levels in this study. No significant difference was observed in the plasma levels of these chemokines in the control group. We conclude that treatment with atorvastatin was associated with a significant decrease in the plasma levels of CXCL9 in patients with systemic lupus erythematosus. As the plasma levels of CXCL9 correlated with the SLEDAI score, we ask whether reducing levels of this chemokine could help to control systemic lupus erythematosus activity.

Systems Operation Studies for Automated Guideway Transit Systems : Availability Model Functional Specification

DOT National Transportation Integrated Search

1981-01-01

The System Availability Model (SAM) is a system-level model which provides measures of vehicle and passenger availability. The SAM will be used to evaluate the system-level influence of availability concepts employed in AGT systems. This functional s...

49 CFR 325.57 - Location and operation of sound level measurement systems; stationary test.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 5 2012-10-01 2012-10-01 false Location and operation of sound level measurement...; Stationary Test § 325.57 Location and operation of sound level measurement systems; stationary test. (a) The microphone of a sound level measurement system that conforms to the rules in § 325.23 shall be located at a...

49 CFR 325.57 - Location and operation of sound level measurement systems; stationary test.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 5 2013-10-01 2013-10-01 false Location and operation of sound level measurement...; Stationary Test § 325.57 Location and operation of sound level measurement systems; stationary test. (a) The microphone of a sound level measurement system that conforms to the rules in § 325.23 shall be located at a...

49 CFR 325.57 - Location and operation of sound level measurement systems; stationary test.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Location and operation of sound level measurement...; Stationary Test § 325.57 Location and operation of sound level measurement systems; stationary test. (a) The microphone of a sound level measurement system that conforms to the rules in § 325.23 shall be located at a...

Simulation of fiber optic liquid level sensor demodulation system

NASA Astrophysics Data System (ADS)

Yi, Cong-qin; Luo, Yun; Zhang, Zheng-ping

Measuring liquid level with high accuracy is an urgent requirement. This paper mainly focus on the demodulation system of fiber-optic liquid level sensor based on Fabry-Perot cavity, design and simulate the demodulation system by the single-chip simulation software.

Evaluation of Uniform Cost Accounting System to Fully Capture Depot Level Repair Costs.

DTIC Science & Technology

1985-12-01

RD-RI65 522 EVALUATION OF UNIFORM COST ACCOUNTING SYSTEM TO FULLY i/I CAPTURE DEPOT LEVEL REPAIR COSTS (U) NAVAL POSTGRADUATE SCHOOL MONTEREY CA D R...8217.LECTE B ,- THESIS EVALUATION OF UNIFORM COST ACCOUNTING SYSTEM 0TO FULLY CAPTURE DEPOT LEVEL REPAIR COSTS Jby __jDavid Richmond O’Brien lj,,, December...Include Security Classification) EVALUATION OF UNIFORM COST ACCOUNTING SYSTEM TO FULLY CAPTURE DEPOT LEVEL REPAIR COSTS 12 PERSONAL AUTHOR(S) O’Brien- David

Cadherin-11 Regulation of Fibrosis through Modulation of Epithelial-to-Mesenchymal Transition: Implications for Pulmonary Fibrosis in Scleroderma

DTIC Science & Technology

2015-10-01

first tested on a sera from healthy patients (n=20), systemic lupus erythematosus patients (n=29) and systemic sclerosis patients (n=20). Patients...with lupus and systemic sclerosis both had an increase in circulating soluble cadherin-11 levels that was statistically significant over levels seen...level. These data suggest that cadherin-11 levels are increased in patients with systemic sclerosis and lupus . These data use a small set of samples

Cadherin-11 Regulation of Fibrosis through Modulation of Epithelial-to-Mesenchymal Transition: Implications for Pulmonary Fibrosis in Scleroderma

DTIC Science & Technology

2016-05-01

first tested on a sera from healthy patients (n=20), systemic lupus erythematosus patients (n=29) and systemic sclerosis patients (n=20). Patients...with lupus and systemic sclerosis both had an increase in circulating soluble cadherin-11 levels that was statistically significant over levels seen...level. These data suggest that cadherin-11 levels are increased in patients with systemic sclerosis and lupus . These data use a small set of samples

Single Microwave-Photon Detector using an Artificial Lambda-type Three-Level System

DTIC Science & Technology

2016-01-11

Single microwave-photon detector using an artificial Λ-type three- level system Kunihiro Inomata,1∗†, Zhirong Lin,1†, Kazuki Koshino,2, William D...three- level system Kunihiro Inomata,1∗† Zhirong Lin,1† Kazuki Koshino,2 William D. Oliver,3,4 Jaw-Shen Tsai,1 Tsuyoshi Yamamoto,5 Yasunobu Nakamura...single-microwave-photon detector based on the deterministic switching in an artificial Λ-type three- level system implemented using the dressed states of a

Reliability model generator

NASA Technical Reports Server (NTRS)

Cohen, Gerald C. (Inventor); McMann, Catherine M. (Inventor)

1991-01-01

An improved method and system for automatically generating reliability models for use with a reliability evaluation tool is described. The reliability model generator of the present invention includes means for storing a plurality of low level reliability models which represent the reliability characteristics for low level system components. In addition, the present invention includes means for defining the interconnection of the low level reliability models via a system architecture description. In accordance with the principles of the present invention, a reliability model for the entire system is automatically generated by aggregating the low level reliability models based on the system architecture description.

Testing Orions Fairing Separation System

NASA Technical Reports Server (NTRS)

Martinez, Henry; Cloutier, Chris; Lemmon, Heber; Rakes, Daniel; Oldham, Joe; Schlagel, Keith

2014-01-01

Traditional fairing systems are designed to fully encapsulate and protect their payload from the harsh ascent environment including acoustic vibrations, aerodynamic forces and heating. The Orion fairing separation system performs this function and more by also sharing approximately half of the vehicle structural load during ascent. This load-share condition through launch and during jettison allows for a substantial increase in mass to orbit. A series of component-level development tests were completed to evaluate and characterize each component within Orion's unique fairing separation system. Two full-scale separation tests were performed to verify system-level functionality and provide verification data. This paper summarizes the fairing spring, Pyramidal Separation Mechanism and forward seal system component-level development tests, system-level separation tests, and lessons learned.

Multi-level manual and autonomous control superposition for intelligent telerobot

NASA Technical Reports Server (NTRS)

Hirai, Shigeoki; Sato, T.

1989-01-01

Space telerobots are recognized to require cooperation with human operators in various ways. Multi-level manual and autonomous control superposition in telerobot task execution is described. The object model, the structured master-slave manipulation system, and the motion understanding system are proposed to realize the concept. The object model offers interfaces for task level and object level human intervention. The structured master-slave manipulation system offers interfaces for motion level human intervention. The motion understanding system maintains the consistency of the knowledge through all the levels which supports the robot autonomy while accepting the human intervention. The superposing execution of the teleoperational task at multi-levels realizes intuitive and robust task execution for wide variety of objects and in changeful environment. The performance of several examples of operating chemical apparatuses is shown.

Assume-Guarantee Verification of Source Code with Design-Level Assumptions

NASA Technical Reports Server (NTRS)

Giannakopoulou, Dimitra; Pasareanu, Corina S.; Cobleigh, Jamieson M.

2004-01-01

Model checking is an automated technique that can be used to determine whether a system satisfies certain required properties. To address the 'state explosion' problem associated with this technique, we propose to integrate assume-guarantee verification at different phases of system development. During design, developers build abstract behavioral models of the system components and use them to establish key properties of the system. To increase the scalability of model checking at this level, we have developed techniques that automatically decompose the verification task by generating component assumptions for the properties to hold. The design-level artifacts are subsequently used to guide the implementation of the system, but also to enable more efficient reasoning at the source code-level. In particular we propose to use design-level assumptions to similarly decompose the verification of the actual system implementation. We demonstrate our approach on a significant NASA application, where design-level models were used to identify; and correct a safety property violation, and design-level assumptions allowed us to check successfully that the property was presented by the implementation.

Human factors evaluation of level 2 and level 3 automated driving concepts : concepts of operation.

DOT National Transportation Integrated Search

2014-07-01

The Concepts of Operation document evaluates the functional framework of operations for Level 2 and Level 3 automated vehicle systems. This is done by defining the varying levels of automation, the operator vehicle interactions, and system components...

Method of calibrating a fluid-level measurement system

NASA Technical Reports Server (NTRS)

Woodard, Stanley E. (Inventor); Taylor, Bryant D. (Inventor)

2010-01-01

A method of calibrating a fluid-level measurement system is provided. A first response of the system is recorded when the system's sensor(s) is (are) not in contact with a fluid of interest. A second response of the system is recorded when the system's sensor(s) is (are) fully immersed in the fluid of interest. Using the first and second responses, a plurality of expected responses of the system's sensor(s) is (are) generated for a corresponding plurality of levels of immersion of the sensor(s) in the fluid of interest.

A study of electron transfer using a three-level system coupled to an ohmic bath

NASA Technical Reports Server (NTRS)

Takasu, Masako; Chandler, David

1993-01-01

Electron transfer is studied using a multi-level system coupled to a bosonic bath. Two body correlation functions are obtained using both exact enumeration of spin paths and Monte Carlo simulation. It was found that the phase boundary for the coherent-incoherent transition lies at a smaller friction in the asymmetric two-level model than in the symmetric two-level model. A similar coherent-incoherent transition is observed for three-level system.

A closed-loop automatic control system for high-intensity acoustic test systems.

NASA Technical Reports Server (NTRS)

Slusser, R. A.

1973-01-01

Description of an automatic control system for high-intensity acoustic tests in reverberation chambers. Working in 14 one-third-octave bands from 50 to 1000 Hz, the desired sound pressure levels are set into the memory in the control system before the test. The control system then increases the sound pressure level in the reverberation chamber gradually in each of the one-third-octave bands until the level set in the memory is reached. This level is then maintained for the duration of the test. Additional features of the system are overtest protection, the capability of 'holding' the spectrum at any time, and the presence of a total test timer.

Systems Epidemiology: What’s in a Name?

PubMed Central

Dammann, O.; Gray, P.; Gressens, P.; Wolkenhauer, O.; Leviton, A.

2014-01-01

Systems biology is an interdisciplinary effort to integrate molecular, cellular, tissue, organ, and organism levels of function into computational models that facilitate the identification of general principles. Systems medicine adds a disease focus. Systems epidemiology adds yet another level consisting of antecedents that might contribute to the disease process in populations. In etiologic and prevention research, systems-type thinking about multiple levels of causation will allow epidemiologists to identify contributors to disease at multiple levels as well as their interactions. In public health, systems epidemiology will contribute to the improvement of syndromic surveillance methods. We encourage the creation of computational simulation models that integrate information about disease etiology, pathogenetic data, and the expertise of investigators from different disciplines. PMID:25598870

Optimal Quasi-steady Plasma Thruster system characteristics.

NASA Technical Reports Server (NTRS)

Ludwig, D. E.; Kelly, A. J.

1972-01-01

The overall characteristics of a generalized Quasi-steady Plasma Thruster (QPT) system consisting of thruster head, power conditioning network, propellant supply subsystem are studied. Energy balance equations for the system are coupled with component mass relationships in order to determine overall system mass and performance. Power supply power levels varying from 100 to 10,000 watts with thruster power levels ranging from 300 kw to 30 Mw employing argon as the propellant are considered. The manner in which overall system mass, average thrust, and burn time vary as a function power supply power level, quasi-steady power level, and pulse time are studied. Results indicate the existence of optimum pulse times when system mass is employed as an optimization criterion.

The information protection level assessment system implementation

NASA Astrophysics Data System (ADS)

Trapeznikov, E. V.

2018-04-01

Currently, the threat of various attacks increases significantly as automated systems become more widespread. On the basis of the conducted analysis the information protection level assessment system establishing objective was identified. The paper presents the information protection level assessment software implementation in the information system by applying the programming language C #. In conclusions the software features are identified and experimental results are represented.

Collaborative Systems Thinking: A Response to the Problems Faced by Systems Engineering's 'Middle Tier'

NASA Technical Reports Server (NTRS)

Phfarr, Barbara B.; So, Maria M.; Lamb, Caroline Twomey; Rhodes, Donna H.

2009-01-01

Experienced systems engineers are adept at more than implementing systems engineering processes: they utilize systems thinking to solve complex engineering problems. Within the space industry demographics and economic pressures are reducing the number of experienced systems engineers that will be available in the future. Collaborative systems thinking within systems engineering teams is proposed as a way to integrate systems engineers of various experience levels to handle complex systems engineering challenges. This paper uses the GOES-R Program Systems Engineering team to illustrate the enablers and barriers to team level systems thinking and to identify ways in which performance could be improved. Ways NASA could expand its engineering training to promote team-level systems thinking are proposed.

AIRS pulse tube cooler system-level and in-space performance comparison

NASA Technical Reports Server (NTRS)

Ross, R. G.

2002-01-01

This paper presents the derivation of the test and analysis techniques as well as the measured system-level performance of the flight AIRS coolers during instrument-level, spacecraft-level, and in-space operation.

Alpha-synuclein levels in patients with multiple system atrophy: a meta-analysis.

PubMed

Yang, Fei; Li, Wan-Jun; Huang, Xu-Sheng

2018-05-01

This study evaluates the relationship between multiple system atrophy and α-synuclein levels in the cerebrospinal fluid, plasma and neural tissue. Literature search for relevant research articles was undertaken in electronic databases and study selection was based on a priori eligibility criteria. Random-effects meta-analyses of standardized mean differences in α-synuclein levels between multiple system atrophy patients and normal controls were conducted to obtain the overall and subgroup effect sizes. Meta-regression analyses were performed to evaluate the effect of age, gender and disease severity on standardized mean differences. Data were obtained from 11 studies involving 378 multiple system atrophy patients and 637 healthy controls (age: multiple system atrophy patients 64.14 [95% confidence interval 62.05, 66.23] years; controls 64.16 [60.06, 68.25] years; disease duration: 44.41 [26.44, 62.38] months). Cerebrospinal fluid α-synuclein levels were significantly lower in multiple system atrophy patients than in controls but in plasma and neural tissue, α-synuclein levels were significantly higher in multiple system atrophy patients (standardized mean difference: -0.99 [-1.65, -0.32]; p = 0.001). Percentage of male multiple system atrophy patients was significantly positively associated with the standardized mean differences of cerebrospinal fluid α-synuclein levels (p = 0.029) whereas the percentage of healthy males was not associated with the standardized mean differences of cerebrospinal fluid α-synuclein levels (p = 0.920). In multiple system atrophy patients, α-synuclein levels were significantly lower in the cerebrospinal fluid and were positively associated with the male gender.

Systems Biology-an interdisciplinary approach.

PubMed

Friboulet, Alain; Thomas, Daniel

2005-06-15

System-level approaches in biology are not new but foundations of "Systems Biology" are achieved only now at the beginning of the 21st century [Kitano, H., 2001. Foundations of Systems Biology. MIT Press, Cambridge, MA]. The renewed interest for a system-level approach is linked to the progress in collecting experimental data and to the limits of the "reductionist" approach. System-level understanding of native biological and pathological systems is needed to provide potential therapeutic targets. Examples of interdisciplinary approach in Systems Biology are described in U.S., Japan and Europe. Robustness in biology, metabolic engineering and idiotypic networks are discussed in the framework of Systems Biology.

Problem of two-level hierarchical minimax program control the final state of regional social and economic system in the presence of risks

DOE Office of Scientific and Technical Information (OSTI.GOV)

Shorikov, A. F., E-mail: afshorikov@mail.ru

This article discusses a discrete-time dynamical system consisting of a set a controllable objects (region and forming it municipalities). The dynamics each of these is described by the corresponding vector nonlinear discrete-time recurrent vector equations and its control system consist from two levels: basic (control level I) that is dominating and subordinate level (control level II). Both levels have different criterions of functioning and united a priori by determined informational and control connections defined in advance. In this paper we study the problem of optimization of guaranteed result for program control by the final state of regional social and economicmore » system in the presence of risks. For this problem we proposed in this work an economical and mathematical model of two-level hierarchical minimax program control the final state of regional social and economic system in the presence of risks and the general scheme for its solving.« less

An introduction to autonomous control systems

NASA Technical Reports Server (NTRS)

Antsaklis, Panos J.; Passino, Kevin M.; Wang, S. J.

1991-01-01

The functions, characteristics, and benefits of autonomous control are outlined. An autonomous control functional architecture for future space vehicles that incorporates the concepts and characteristics described is presented. The controller is hierarchical, with an execution level (the lowest level), coordination level (middle level), and management and organization level (highest level). The general characteristics of the overall architecture, including those of the three levels, are explained, and an example to illustrate their functions is given. Mathematical models for autonomous systems, including 'logical' discrete event system models, are discussed. An approach to the quantitative, systematic modeling, analysis, and design of autonomous controllers is also discussed. It is a hybrid approach since it uses conventional analysis techniques based on difference and differential equations and new techniques for the analysis of the systems described with a symbolic formalism such as finite automata. Some recent results from the areas of planning and expert systems, machine learning, artificial neural networks, and the area restructurable controls are briefly outlined.

Designing Better Scaffolding in Teaching Complex Systems with Graphical Simulations

NASA Astrophysics Data System (ADS)

Li, Na

Complex systems are an important topic in science education today, but they are usually difficult for secondary-level students to learn. Although graphic simulations have many advantages in teaching complex systems, scaffolding is a critical factor for effective learning. This dissertation study was conducted around two complementary research questions on scaffolding: (1) How can we chunk and sequence learning activities in teaching complex systems? (2) How can we help students make connections among system levels across learning activities (level bridging)? With a sample of 123 seventh-graders, this study employed a 3x2 experimental design that factored sequencing methods (independent variable 1; three levels) with level-bridging scaffolding (independent variable 2; two levels) and compared the effectiveness of each combination. The study measured two dependent variables: (1) knowledge integration (i.e., integrating and connecting content-specific normative concepts and providing coherent scientific explanations); (2) understanding of the deep causal structure (i.e., being able to grasp and transfer the causal knowledge of a complex system). The study used a computer-based simulation environment as the research platform to teach the ideal gas law as a system. The ideal gas law is an emergent chemical system that has three levels: (1) experiential macro level (EM) (e.g., an aerosol can explodes when it is thrown into the fire); (2) abstract macro level (AM) (i.e., the relationships among temperature, pressure and volume); (3) micro level (Mi) (i.e., molecular activity). The sequencing methods of these levels were manipulated by changing the order in which they were delivered with three possibilities: (1) EM-AM-Mi; (2) Mi-AM-EM; (3) AM-Mi-EM. The level-bridging scaffolding variable was manipulated on two aspects: (1) inserting inter-level questions among learning activities; (2) two simulations dynamically linked in the final learning activity. Addressing the first research question, the Experiential macro-Abstract macro-Micro (EM-AM-Mi) sequencing method, following the "concrete to abstract" principle, produced better knowledge integration while the Micro-Abstract macro-Experiential macro (Mi-AM-EM) sequencing method, congruent with the causal direction of the emergent system, produced better understanding of the deep causal structure only when level-bridging scaffolding was provided. The Abstract macro-Micro-Experiential macro (AM-Mi-EM) sequencing method produced worse performance in general, because it did not follow the "concrete to abstract" principle, nor did it align with the causal structure of the emergent system. As to the second research question, the results showed that level-bridging scaffolding was important for both knowledge integration and understanding of the causal structure in learning the ideal gas law system.

Minimax terminal approach problem in two-level hierarchical nonlinear discrete-time dynamical system

DOE Office of Scientific and Technical Information (OSTI.GOV)

Shorikov, A. F., E-mail: afshorikov@mail.ru

We consider a discrete–time dynamical system consisting of three controllable objects. The motions of all objects are given by the corresponding vector nonlinear or linear discrete–time recurrent vector relations, and control system for its has two levels: basic (first or I level) that is dominating and subordinate level (second or II level) and both have different criterions of functioning and united a priori by determined informational and control connections defined in advance. For the dynamical system in question, we propose a mathematical formalization in the form of solving a multistep problem of two-level hierarchical minimax program control over the terminalmore » approach process with incomplete information and give a general scheme for its solving.« less

Component model reduction via the projection and assembly method

NASA Technical Reports Server (NTRS)

Bernard, Douglas E.

1989-01-01

The problem of acquiring a simple but sufficiently accurate model of a dynamic system is made more difficult when the dynamic system of interest is a multibody system comprised of several components. A low order system model may be created by reducing the order of the component models and making use of various available multibody dynamics programs to assemble them into a system model. The difficulty is in choosing the reduced order component models to meet system level requirements. The projection and assembly method, proposed originally by Eke, solves this difficulty by forming the full order system model, performing model reduction at the the system level using system level requirements, and then projecting the desired modes onto the components for component level model reduction. The projection and assembly method is analyzed to show the conditions under which the desired modes are captured exactly; to the numerical precision of the algorithm.

System-Level Shared Governance Structures and Processes in Healthcare Systems With Magnet®-Designated Hospitals: A Descriptive Study.

PubMed

Underwood, Carlisa M; Hayne, Arlene N

The purpose was to identify and describe structures and processes of best practices for system-level shared governance in healthcare systems. Currently, more than 64.6% of US community hospitals are part of a system. System chief nurse executives (SCNEs) are challenged to establish leadership structures and processes that effectively and efficiently disseminate best practices for patients and staff across complex organizations, geographically dispersed locations, and populations. Eleven US healthcare SCNEs from the American Nurses Credentialing Center's repository of Magnet®-designated facilities participated in a 35-multiquestion interview based on Kanter's Theory of Organizational Empowerment. Most SCNEs reported the presence of more than 50% of the empowerment structures and processes in system-level shared governance. Despite the difficulties and complexities of growing health systems, SCNEs have replicated empowerment characteristics of hospital shared governance structures and processes at the system level.

Micro-electro-optical devices in a five-level polysilicon surface-micromachining technology

NASA Astrophysics Data System (ADS)

Smith, James H.; Rodgers, M. Steven; Sniegowski, Jeffry J.; Miller, Samuel L.; Hetherington, Dale L.; McWhorter, Paul J.; Warren, Mial E.

1998-09-01

We recently reported on the development of a 5-level polysilicon surface micromachine fabrication process consisting of four levels of mechanical poly plus an electrical interconnect layer and its application to complex mechanical systems. This paper describes the application of this technology to create micro-optical systems-on-a-chip. These are demonstration systems, which show that give levels of polysilicon provide greater performance, reliability, and significantly increased functionality. This new technology makes it possible to realize levels of system complexity that have so far only existed on paper, while simultaneously adding to the robustness of many of the individual subassemblies.

Rates, levels, and determinants of electronic health record system adoption: a study of hospitals in Riyadh, Saudi Arabia.

PubMed

Aldosari, Bakheet

2014-05-01

Outside a small number of OECD countries, little information exists regarding the rates, levels, and determinants of hospital electronic health record (EHR) system adoption. This study examines EHR system adoption in Riyadh, Saudi Arabia. Respondents from 22 hospitals were surveyed regarding the implementation, maintenance, and improvement phases of EHR system adoption. Thirty-seven items were graded on a three-point scale of preparedness/completion. Measured determinants included hospital size, level of care, ownership, and EHR system development team composition. Eleven of the hospitals had implemented fully functioning EHR systems, eight had systems in progress, and three had not adopted a system. Sixteen different systems were being used across the 19 adopting hospitals. Differential adoption levels were positively related to hospital size and negatively to the level of care (secondary versus tertiary). Hospital ownership (nonprofit versus private) and development team composition showed mixed effects depending on the particular adoption phase being considered. Adoption rates compare favourably with those reported from other countries and other districts in Saudi Arabia, but wide variations exist among hospitals in the levels of adoption of individual items. General weaknesses in the implementation phase concern the legacy of paper data systems, including document scanning and data conversion; in the maintenance phase concern updating/maintaining software; and in the improvement phase concern the communication and exchange of health information. This study is the first to investigate the level and determinants of EHR system adoption for public, other nonprofit, and private hospitals in Saudi Arabia. Wide interhospital variations in adoption bear implications for policy-making and funding intervention. Identified areas of weakness require action to increase the degree of adoption and usefulness of EHR systems. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Modeling of BN Lifetime Prediction of a System Based on Integrated Multi-Level Information

PubMed Central

Wang, Xiaohong; Wang, Lizhi

2017-01-01

Predicting system lifetime is important to ensure safe and reliable operation of products, which requires integrated modeling based on multi-level, multi-sensor information. However, lifetime characteristics of equipment in a system are different and failure mechanisms are inter-coupled, which leads to complex logical correlations and the lack of a uniform lifetime measure. Based on a Bayesian network (BN), a lifetime prediction method for systems that combine multi-level sensor information is proposed. The method considers the correlation between accidental failures and degradation failure mechanisms, and achieves system modeling and lifetime prediction under complex logic correlations. This method is applied in the lifetime prediction of a multi-level solar-powered unmanned system, and the predicted results can provide guidance for the improvement of system reliability and for the maintenance and protection of the system. PMID:28926930

Modeling of BN Lifetime Prediction of a System Based on Integrated Multi-Level Information.

PubMed

Wang, Jingbin; Wang, Xiaohong; Wang, Lizhi

2017-09-15

Predicting system lifetime is important to ensure safe and reliable operation of products, which requires integrated modeling based on multi-level, multi-sensor information. However, lifetime characteristics of equipment in a system are different and failure mechanisms are inter-coupled, which leads to complex logical correlations and the lack of a uniform lifetime measure. Based on a Bayesian network (BN), a lifetime prediction method for systems that combine multi-level sensor information is proposed. The method considers the correlation between accidental failures and degradation failure mechanisms, and achieves system modeling and lifetime prediction under complex logic correlations. This method is applied in the lifetime prediction of a multi-level solar-powered unmanned system, and the predicted results can provide guidance for the improvement of system reliability and for the maintenance and protection of the system.

Silicon compilation: From the circuit to the system

NASA Astrophysics Data System (ADS)

Obrien, Keven

The methodology used for the compilation of silicon from a behavioral level to a system level is presented. The aim was to link the heretofore unrelated areas of high level synthesis and system level design. This link will play an important role in the development of future design automation tools as it will allow hardware/software co-designs to be synthesized. A design methodology that alllows, through the use of an intermediate representation, SOLAR, a System level Design Language (SDL), to be combined with a Hardware Description Language (VHDL) is presented. Two main steps are required in order to transform this specification into a synthesizable one. Firstly, a system level synthesis step including partitioning and communication synthesis is required in order to split the model into a set of interconnected subsystems, each of which will be processed by a high level synthesis tool. For this latter step AMICAL is used and this allows powerful scheduling techniques to be used, that accept very abstract descriptions of control flow dominated circuits as input, and interconnected RTL blocks that may feed existing logic-level synthesis tools to be generated.

Uniform task level definitions for robotic system performance comparisons

NASA Technical Reports Server (NTRS)

Price, Charles; Tesar, Delbert

1989-01-01

A series of ten task levels of increasing difficulty was compiled for use in comparative performance evaluations of available and future robotics technology. Each level has a breakdown of ten additional levels of difficulty to provide a layering of 100 levels. It is assumed that each level of task performance must be achieved by the system before it can be appropriately considered for the next level.

The Lack of Collaboration between Companies and Schools in the German Dual Apprenticeship System: Historical Background and Recent Data

ERIC Educational Resources Information Center

Gessler, Michael

2017-01-01

On the macro level (federal level) and exo level (state or regional level), the German Dual Apprenticeship System shows a high degree of institutionalised collaboration. However, the companies and vocational schools on the meso level (institutional level and level of the actors), in contrast, are just loosely coupled with a dominant partner (i.e.,…

Evaluation of Multi-Level Support Structure Requirements for New Weapon Systems.

DTIC Science & Technology

1987-09-01

transformer 1 total consumed manhours on this level 19.45 hrs average manhrs within 4 weeks on this level : .38 hrs average rounded number of mainten; personal ...major unit data to provide conclusions about the logistics behavior of failing weapon systems. The modeling of system behavior with CAESAR has severa-l...characteristic data and major unit data to provide conclusions about the logistics behavior of failing weapon systems. The modelling of system behavior

Capturing system level activities and impacts of mental health consumer-run organizations.

PubMed

Janzen, Rich; Nelson, Geoffrey; Hausfather, Nadia; Ochocka, Joanna

2007-06-01

Since the 1970s mental health consumer-run organizations have come to offer not only mutual support, but they have also adopted agendas for broader social change. Despite an awareness of the need for system level efforts that create supportive environments for their members, there has been limited research demonstrating how their system level activities can be documented or their impacts evaluated. The purpose of this paper is to feature a method of evaluating systems change activities and impacts. The paper is based on a longitudinal study evaluating four mental health consumer-run organizations in Ontario, Canada. The study tracked system level activities and impacts using both qualitative and quantitative methodologies. The article begins by describing the development and implementation of these methods. Next it offers a critical analysis of the methods used. It concludes by reflecting on three lessons learned about capturing system level activities and impacts of mental health consumer-run organizations.

49 CFR 325.25 - Calibration of measurement systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Standard Institute Standard Methods for Measurements of Sound Pressure Levels (ANSI S1.13-1971) for field... sound level measurement system must be calibrated and appropriately adjusted at one or more frequencies... 5-15 minutes thereafter, until it has been determined that the sound level measurement system has...

49 CFR 325.25 - Calibration of measurement systems.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Standard Institute Standard Methods for Measurements of Sound Pressure Levels (ANSI S1.13-1971) for field... sound level measurement system must be calibrated and appropriately adjusted at one or more frequencies... 5-15 minutes thereafter, until it has been determined that the sound level measurement system has...

Level System Use in Special Education: Classroom Intervention with Prima Facie Appeal.

ERIC Educational Resources Information Center

Smith, Stephen W.; Farrell, Daniel T.

1993-01-01

This article chronicles the development of level systems designed for students with significant behavior problems, to foster student improvement through self-management and positive reinforcement. The article examines assumptions underlying level systems' concepts and components and offers recommendations to guide future research into the design…

Statistics from the Operation of the Low-Level Wind Shear Alert System (LLWAS) during the Joint Airport Weather Studies (JAWS) Project.

DTIC Science & Technology

1984-12-01

AD-RI59 367 STATISTICS FROM THE OPERATION OF THE LOW-LEVEL WIND I/i SHEAR ALERT SYSTEM (L..(U) NATIONAL CENTER FOR ATOMSPHERIC RESEARCH BOULDER CO...NATIONAL BUREAU OF STANDARDS-1963A % % Oh b DOT/FAAIPM-84132 Statistics from the Operation of the Program Engineering Low-Level Wind Shear Alert System and...The Operation of The Low-Level Wind December 1984 Shear Alert System (LLWAS) During The JAWS Project: 6. Performing Organization Code An Interim Report

Advanced Health Management of a Brushless Direct Current Motor/Controller

NASA Technical Reports Server (NTRS)

Pickett, R. D.

2003-01-01

This effort demonstrates that health management can be taken to the component level for electromechanical systems. The same techniques can be applied to take any health management system to the component level, based on the practicality of the implementation for that particular system. This effort allows various logic schemes to be implemented for the identification and management of failures. By taking health management to the component level, integrated vehicle health management systems can be enhanced by protecting box-level avionics from being shut down in order to isolate a failed computer.

A methodology for the environmental assessment of advanced coal extraction systems

NASA Technical Reports Server (NTRS)

Sullivan, P. J.; Hutchinson, C. F.; Makihara, J.; Evensizer, J.

1980-01-01

Procedures developed to identify and assess potential environment impacts of advanced mining technology as it moves from a generic concept to a more systems definition are described. Two levels of assessment are defined in terms of the design stage of the technology being evaluated. The first level of analysis is appropriate to a conceptual design. At this level it is assumed that each mining process has known and potential environmental impacts that are generic to each mining activity. By using this assumption, potential environmental impacts can be identified for new mining systems. When two or more systems have been assessed, they can be evaluated comparing potential environmental impacts. At the preliminary stage of design, a systems performance can be assessed again with more precision. At this level of systems definition, potential environmental impacts can be analyzed and their significane determined in a manner to facilitate comparisons between systems. At each level of analysis, suggestions calculated to help the designer mitigate potentially harmful impacts are provided.

Autonomous navigation system. [gyroscopic pendulum for air navigation

NASA Technical Reports Server (NTRS)

Merhav, S. J. (Inventor)

1981-01-01

An inertial navigation system utilizing a servo-controlled two degree of freedom pendulum to obtain specific force components in the locally level coordinate system is described. The pendulum includes a leveling gyroscope and an azimuth gyroscope supported on a two gimbal system. The specific force components in the locally level coordinate system are converted to components in the geographical coordinate system by means of a single Euler transformation. The standard navigation equations are solved to determine longitudinal and lateral velocities. Finally, vehicle position is determined by a further integration.

The Management of Defense System and Equipment Training: A Guide for the Naval Education and Training Command

DTIC Science & Technology

1977-07-01

SYSTEM EVOLUTION 4- LEVEL 1 LEVEL 2 LEVEL 3 ,_J LEVEL 4 PERSONNEL ENTRY FACTORS (SKILL, KNOWLEDGE, EXPERIENCE ) HIGH HIGH AND ABOVE...system) and their associated program characteristics (cost, schedules, and operational parameters) based on a combination of analyses, experiments , and...Naval Operations Appropriations (blue doll ars) Appropriation Abbreviation Sponsor Research, Development, Test and Evaluation, Navy RDT&EN ASN (R&D

Automation in the Space Station module power management and distribution Breadboard

NASA Technical Reports Server (NTRS)

Walls, Bryan; Lollar, Louis F.

1990-01-01

The Space Station Module Power Management and Distribution (SSM/PMAD) Breadboard, located at NASA's Marshall Space Flight Center (MSFC) in Huntsville, Alabama, models the power distribution within a Space Station Freedom Habitation or Laboratory module. Originally designed for 20 kHz ac power, the system is now being converted to high voltage dc power with power levels on a par with those expected for a space station module. In addition to the power distribution hardware, the system includes computer control through a hierarchy of processes. The lowest level process consists of fast, simple (from a computing standpoint) switchgear, capable of quickly safing the system. The next level consists of local load center processors called Lowest Level Processors (LLP's). These LLP's execute load scheduling, perform redundant switching, and shed loads which use more than scheduled power. The level above the LLP's contains a Communication and Algorithmic Controller (CAC) which coordinates communications with the highest level. Finally, at this highest level, three cooperating Artificial Intelligence (AI) systems manage load prioritization, load scheduling, load shedding, and fault recovery and management. The system provides an excellent venue for developing and examining advanced automation techniques. The current system and the plans for its future are examined.

Simultaneous multiplexing and encoding of multiple images based on a double random phase encryption system

NASA Astrophysics Data System (ADS)

Alfalou, Ayman; Mansour, Ali

2009-09-01

Nowadays, protecting information is a major issue in any transmission system, as showed by an increasing number of research papers related to this topic. Optical encoding methods, such as a Double Random Phase encryption system i.e. DRP, are widely used and cited in the literature. DRP systems have very simple principle and they are easily applicable to most images (B&W, gray levels or color). Moreover, some applications require an enhanced encoding level based on multiencryption scheme and including biometric keys (as digital fingerprints). The enhancement should be done without increasing transmitted or stored information. In order to achieve that goal, a new approach for simultaneous multiplexing & encoding of several target images is developed in this manuscript. By introducing two additional security levels, our approach enhances the security level of a classic "DRP" system. Our first security level consists in using several independent image-keys (randomly and structurally) along with a new multiplexing algorithm. At this level, several target images (multiencryption) are used. This part can reduce needed information (encoding information). At the second level a standard DRP system is included. Finally, our approach can detect if any vandalism attempt has been done on transmitted encrypted images.

Elevated systemic galectin-1 levels characterize HELLP syndrome.

PubMed

Schnabel, Annegret; Blois, Sandra M; Meint, Peter; Freitag, Nancy; Ernst, Wolfgang; Barrientos, Gabriela; Conrad, Melanie L; Rose, Matthias; Seelbach-Göbel, Birgit

2016-04-01

Galectin-1 (gal-1), a member of a family of conserved β-galactoside-binding proteins, has been shown to exert a key role during gestation. Though gal-1 is expressed at higher levels in the placenta from HELLP patients, it is still poorly understood whether systemic gal-1 levels also differ in HELLP patients. In the present study, we evaluated the systemic expression of gal-1, together with the angiogenic factors, placental growth factor (PlGF) and soluble fms-like tyrosine kinase 1 (sFlt-1) in conjunction with HELLP syndrome severity. Systemic levels of gal-1 and sFlt-1 were elevated in patients with both early- and late-onset HELLP syndrome as compared to healthy controls. In contrast, peripheral PlGF levels were decreased in early- and late-onset HELLP. A positive correlation between systemic gal-1 levels and sFlt-1/PlGF ratios was found in early onset HELLP patients. Our results show that HELLP syndrome is associated with increased circulating levels of gal-1; integrating systemic gal-1 measurements into the diagnostic analyses of pregnant women may provide more effective prediction of HELLP syndrome development. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Cellular Decomposition Based Hybrid-Hierarchical Control Systems with Applications to Flight Management Systems

NASA Technical Reports Server (NTRS)

Caines, P. E.

1999-01-01

The work in this research project has been focused on the construction of a hierarchical hybrid control theory which is applicable to flight management systems. The motivation and underlying philosophical position for this work has been that the scale, inherent complexity and the large number of agents (aircraft) involved in an air traffic system imply that a hierarchical modelling and control methodology is required for its management and real time control. In the current work the complex discrete or continuous state space of a system with a small number of agents is aggregated in such a way that discrete (finite state machine or supervisory automaton) controlled dynamics are abstracted from the system's behaviour. High level control may then be either directly applied at this abstracted level, or, if this is in itself of significant complexity, further layers of abstractions may be created to produce a system with an acceptable degree of complexity at each level. By the nature of this construction, high level commands are necessarily realizable at lower levels in the system.

Lane-Level Vehicle Positioning : Integrating Diverse Systems for Precision and Reliability

DOT National Transportation Integrated Search

2013-05-13

Integrated global positioning system/inertial navigation system (GPS/INS) technology, the backbone of vehicle positioning systems, cannot provide the precision and reliability needed for vehicle-based, lane-level positioning in all driving environmen...

Diagnostics in the Extendable Integrated Support Environment (EISE)

NASA Technical Reports Server (NTRS)

Brink, James R.; Storey, Paul

1988-01-01

Extendable Integrated Support Environment (EISE) is a real-time computer network consisting of commercially available hardware and software components to support systems level integration, modifications, and enhancement to weapons systems. The EISE approach offers substantial potential savings by eliminating unique support environments in favor of sharing common modules for the support of operational weapon systems. An expert system is being developed that will help support diagnosing faults in this network. This is a multi-level, multi-expert diagnostic system that uses experiential knowledge relating symptoms to faults and also reasons from structural and functional models of the underlying physical model when experiential reasoning is inadequate. The individual expert systems are orchestrated by a supervisory reasoning controller, a meta-level reasoner which plans the sequence of reasoning steps to solve the given specific problem. The overall system, termed the Diagnostic Executive, accesses systems level performance checks and error reports, and issues remote test procedures to formulate and confirm fault hypotheses.

System of experts for intelligent data management (SEIDAM)

NASA Technical Reports Server (NTRS)

Goodenough, David G.; Iisaka, Joji; Fung, KO

1993-01-01

A proposal to conduct research and development on a system of expert systems for intelligent data management (SEIDAM) is being developed. CCRS has much expertise in developing systems for integrating geographic information with space and aircraft remote sensing data and in managing large archives of remotely sensed data. SEIDAM will be composed of expert systems grouped in three levels. At the lowest level, the expert systems will manage and integrate data from diverse sources, taking account of symbolic representation differences and varying accuracies. Existing software can be controlled by these expert systems, without rewriting existing software into an Artificial Intelligence (AI) language. At the second level, SEIDAM will take the interpreted data (symbolic and numerical) and combine these with data models. at the top level, SEIDAM will respond to user goals for predictive outcomes given existing data. The SEIDAM Project will address the research areas of expert systems, data management, storage and retrieval, and user access and interfaces.

System of Experts for Intelligent Data Management (SEIDAM)

NASA Technical Reports Server (NTRS)

Goodenough, David G.; Iisaka, Joji; Fung, KO

1992-01-01

It is proposed to conduct research and development on a system of expert systems for intelligent data management (SEIDAM). CCRS has much expertise in developing systems for integrating geographic information with space and aircraft remote sensing data and in managing large archives of remotely sensed data. SEIDAM will be composed of expert systems grouped in three levels. At the lowest level, the expert systems will manage and integrate data from diverse sources, taking account of symbolic representation differences and varying accuracies. Existing software can be controlled by these expert systems, without rewriting existing software into an Artificial Intelligence (AI) language. At the second level, SEIDAM will take the interpreted data (symbolic and numerical) and combine these with data models. At the top level, SEIDAM will respond to user goals for predictive outcomes given existing data. The SEIDAM Project will address the research areas of expert systems, data management, storage and retrieval, and user access and interfaces.

User acceptance of intelligent avionics: A study of automatic-aided target recognition

NASA Technical Reports Server (NTRS)

Becker, Curtis A.; Hayes, Brian C.; Gorman, Patrick C.

1991-01-01

User acceptance of new support systems typically was evaluated after the systems were specified, designed, and built. The current study attempts to assess user acceptance of an Automatic-Aided Target Recognition (ATR) system using an emulation of such a proposed system. The detection accuracy and false alarm level of the ATR system were varied systematically, and subjects rated the tactical value of systems exhibiting different performance levels. Both detection accuracy and false alarm level affected the subjects' ratings. The data from two experiments suggest a cut-off point in ATR performance below which the subjects saw little tactical value in the system. An ATR system seems to have obvious tactical value only if it functions at a correct detection rate of 0.7 or better with a false alarm level of 0.167 false alarms per square degree or fewer.

Designing collective behavior in a termite-inspired robot construction team.

PubMed

Werfel, Justin; Petersen, Kirstin; Nagpal, Radhika

2014-02-14

Complex systems are characterized by many independent components whose low-level actions produce collective high-level results. Predicting high-level results given low-level rules is a key open challenge; the inverse problem, finding low-level rules that give specific outcomes, is in general still less understood. We present a multi-agent construction system inspired by mound-building termites, solving such an inverse problem. A user specifies a desired structure, and the system automatically generates low-level rules for independent climbing robots that guarantee production of that structure. Robots use only local sensing and coordinate their activity via the shared environment. We demonstrate the approach via a physical realization with three autonomous climbing robots limited to onboard sensing. This work advances the aim of engineering complex systems that achieve specific human-designed goals.

PyGirl: Generating Whole-System VMs from High-Level Prototypes Using PyPy

NASA Astrophysics Data System (ADS)

Bruni, Camillo; Verwaest, Toon

Virtual machines (VMs) emulating hardware devices are generally implemented in low-level languages for performance reasons. This results in unmaintainable systems that are difficult to understand. In this paper we report on our experience using the PyPy toolchain to improve the portability and reduce the complexity of whole-system VM implementations. As a case study we implement a VM prototype for a Nintendo Game Boy, called PyGirl, in which the high-level model is separated from low-level VM implementation issues. We shed light on the process of refactoring from a low-level VM implementation in Java to a high-level model in RPython. We show that our whole-system VM written with PyPy is significantly less complex than standard implementations, without substantial loss in performance.

Mathematical model comparing of the multi-level economics systems

NASA Astrophysics Data System (ADS)

Brykalov, S. M.; Kryanev, A. V.

2017-12-01

The mathematical model (scheme) of a multi-level comparison of the economic system, characterized by the system of indices, is worked out. In the mathematical model of the multi-level comparison of the economic systems, the indicators of peer review and forecasting of the economic system under consideration can be used. The model can take into account the uncertainty in the estimated values of the parameters or expert estimations. The model uses the multi-criteria approach based on the Pareto solutions.

A reusable rocket engine intelligen control

NASA Technical Reports Server (NTRS)

Merrill, Walter C.; Lorenzo, Carl F.

1988-01-01

An intelligent control system for reusable space propulsion systems for future launch vehicles is described. The system description includes a framework for the design. The framework consists of an execution level with high-speed control and diagnostics, and a coordination level which marries expert system concepts with traditional control. A comparison is made between air breathing and rocket engine control concepts to assess the relative levels of development and to determine the applicability of air breathing control concepts to future reusable rocket engine systems.

A reusable rocket engine intelligent control

NASA Technical Reports Server (NTRS)

Merrill, Walter C.; Lorenzo, Carl F.

1988-01-01

An intelligent control system for reusable space propulsion systems for future launch vehicles is described. The system description includes a framework for the design. The framework consists of an execution level with high-speed control and diagnostics, and a coordination level which marries expert system concepts with traditional control. A comparison is made between air breathing and rocket engine control concepts to assess the relative levels of development and to determine the applicability of air breathing control concepts ot future reusable rocket engine systems.

Distributed Access View Integrated Database (DAVID) system

NASA Technical Reports Server (NTRS)

Jacobs, Barry E.

1991-01-01

The Distributed Access View Integrated Database (DAVID) System, which was adopted by the Astrophysics Division for their Astrophysics Data System, is a solution to the system heterogeneity problem. The heterogeneous components of the Astrophysics problem is outlined. The Library and Library Consortium levels of the DAVID approach are described. The 'books' and 'kits' level is discussed. The Universal Object Typer Management System level is described. The relation of the DAVID project with the Small Business Innovative Research (SBIR) program is explained.

Smart Networked Elements in Support of ISHM

NASA Technical Reports Server (NTRS)

Oostdyk, Rebecca; Mata, Carlos; Perotti, Jose M.

2008-01-01

At the core of ISHM is the ability to extract information and knowledge from raw data. Conventional data acquisition systems sample and convert physical measurements to engineering units, which higher-level systems use to derive health and information about processes and systems. Although health management is essential at the top level, there are considerable advantages to implementing health-related functions at the sensor level. The distribution of processing to lower levels reduces bandwidth requirements, enhances data fusion, and improves the resolution for detection and isolation of failures in a system, subsystem, component, or process. The Smart Networked Element (SNE) has been developed to implement intelligent functions and algorithms at the sensor level in support of ISHM.

Comparative distribution of pilocarpine in ocular tissues of the rabbit during administration by eyedrop or by membrane-controlled delivery systems.

PubMed

Sendelbeck, L; Moore, D; Urquhart, J

1975-08-01

We compared the patterns of pilocarpine distribution in the rabbit eye during two regimens that were comparably efficacious in human clinical use: an administration of 2% pilocarpine nitrate eyedrops, every six hours, for four and eight days, and a continuous delivery of pilocarpine for as long as eight days, at 20 mug/hr, from a membrane-controlled delivery system in the inferior cul-de-sac. Pilocarpine labeled with radioactive carbon (14C) was used as a tracer. With administration of eyedrops, 14C levels in ocular tissues rose and fell within each six-hour interval between eyedrops, but with the delivery system, 14C levels remained constant over the two- to eight-day period. In each tissue, the 14C level within the first hour after the most recently administered eyedrop always exceeded the constant level maintained by the delivery system. Three to six hours after eyedrop administration, the 14C levels in cornea, iris, and sclera were approximately equal to those maintained by the delivery system. However, in lens, vitreous humor, and conjunctiva, the 14C levels were always two to five times higher with eyedrop administration than with the delivery system. Only aqueous humor showed a significantly lower 14C level with eyedrops than with the delivery system, occurring late in the interval between eyedrops. Compared to eyedrop administration, the membrane-controlled delivery system produced drug levels in ocular tissues that were constant rather than variable with time, and appreciably lower in tissues where the drug made no known contribution to the reduction of pressure.

A fault-tolerant intelligent robotic control system

NASA Technical Reports Server (NTRS)

Marzwell, Neville I.; Tso, Kam Sing

1993-01-01

This paper describes the concept, design, and features of a fault-tolerant intelligent robotic control system being developed for space and commercial applications that require high dependability. The comprehensive strategy integrates system level hardware/software fault tolerance with task level handling of uncertainties and unexpected events for robotic control. The underlying architecture for system level fault tolerance is the distributed recovery block which protects against application software, system software, hardware, and network failures. Task level fault tolerance provisions are implemented in a knowledge-based system which utilizes advanced automation techniques such as rule-based and model-based reasoning to monitor, diagnose, and recover from unexpected events. The two level design provides tolerance of two or more faults occurring serially at any level of command, control, sensing, or actuation. The potential benefits of such a fault tolerant robotic control system include: (1) a minimized potential for damage to humans, the work site, and the robot itself; (2) continuous operation with a minimum of uncommanded motion in the presence of failures; and (3) more reliable autonomous operation providing increased efficiency in the execution of robotic tasks and decreased demand on human operators for controlling and monitoring the robotic servicing routines.

Miniaturized Water Flow and Level Monitoring System for Flood Disaster Early Warning

NASA Astrophysics Data System (ADS)

Ifedapo Abdullahi, Salami; Hadi Habaebi, Mohamed; Surya Gunawan, Teddy; Rafiqul Islam, MD

2017-11-01

This study presents the performance of a prototype miniaturised water flow and water level monitoring sensor designed towards supporting flood disaster early warning systems. The design involved selection of sensors, coding to control the system mechanism, and automatic data logging and storage. During the design phase, the apparatus was constructed where all the components were assembled using locally sourced items. Subsequently, under controlled laboratory environment, the system was tested by running water through the inlet during which the flow rate and rising water levels are automatically recorded and stored in a database via Microsoft Excel using Coolterm software. The system is simulated such that the water level readings measured in centimeters is output in meters using a multiplicative of 10. A total number of 80 readings were analyzed to evaluate the performance of the system. The result shows that the system is sensitive to water level rise and yielded accurate measurement of water level. But, the flow rate fluctuates due to the manual water supply that produced inconsistent flow. It was also observed that the flow sensor has a duty cycle of 50% of operating time under normal condition which implies that the performance of the flow sensor is optimal.

Charge redistribution in QM:QM ONIOM model systems: a constrained density functional theory approach

NASA Astrophysics Data System (ADS)

Beckett, Daniel; Krukau, Aliaksandr; Raghavachari, Krishnan

2017-11-01

The ONIOM hybrid method has found considerable success in QM:QM studies designed to approximate a high level of theory at a significantly reduced cost. This cost reduction is achieved by treating only a small model system with the target level of theory and the rest of the system with a low, inexpensive, level of theory. However, the choice of an appropriate model system is a limiting factor in ONIOM calculations and effects such as charge redistribution across the model system boundary must be considered as a source of error. In an effort to increase the general applicability of the ONIOM model, a method to treat the charge redistribution effect is developed using constrained density functional theory (CDFT) to constrain the charge experienced by the model system in the full calculation to the link atoms in the truncated model system calculations. Two separate CDFT-ONIOM schemes are developed and tested on a set of 20 reactions with eight combinations of levels of theory. It is shown that a scheme using a scaled Lagrange multiplier term obtained from the low-level CDFT model calculation outperforms ONIOM at each combination of levels of theory from 32% to 70%.

A Chronic Disease Prevention and Management Corridor© to Supporting System-Level Transformations for Chronic Conditions.

PubMed

Sampalli, Tara; Christian, Erin; Edwards, Lynn; Ryer, Ashley

2015-01-01

Improving care for chronic conditions requires system-level transformations to ensure multiple levels of adoption and sustainability of the implemented improvements. These comprehensive solutions require transformations and supports at various levels, leadership and process changes at service/program level. Recognizing the importance of an organization-wide strategy to mitigate the growing issue of chronic disease prevention and management, a novel system-level approach has been developed in a district health authority in Nova Scotia, Canada. In this paper, the contextual factors and efforts that led to the conceptual framework of the Chronic Disease Prevention and Management (CDPM) "Corridor©" to management of chronic conditions are discussed. The CDPM Corridor© essentially constitutes a system-level redesign process; common elements, tools and resources; and a hub of supports for chronic disease prevention and management. The CDPM Corridor © will include a toolkit to guide the implementation of the proposed transformations.

Exactly soluble model of the time-resolved fluorescence return to thermal equilibrium in many-particle systems after excitation

NASA Astrophysics Data System (ADS)

Czachor, Andrzej

2016-02-01

In this paper we consider the assembly of weakly interacting identical particles, where the occupation of single-particle energy-levels at thermal equilibrium is governed by statistics. The analytic form of the inter-energy-level jump matrix is derived and analytic solution of the related eigen-problem is given. It allows one to demonstrate the nature of decline in time of the energy emission (fluorescence, recombination) of such many-level system after excitation in a relatively simple and unifying way - as a multi-exponential de-excitation. For the system of L energy levels the number of the de-excitation lifetimes is L-1. The lifetimes depend on the energy level spectrum as a whole. Two- and three-level systems are considered in detail. The impact of the energy level degeneracy on the lifetimes is discussed.

Understanding Whole Systems Change in Health Care: Insights into System Level Diffusion from Nursing Service Delivery Innovations--A Multiple Case Study

ERIC Educational Resources Information Center

Berta, Whitney; Virani, Tazim; Bajnok, Irmajean; Edwards, Nancy; Rowan, Margo

2014-01-01

Our study responds to calls for theory-driven approaches to studying innovation diffusion processes in health care. While most research on diffusion in health care is situated at the service delivery level, we study innovations and associated processes that have diffused to the system level, and refer to work on complex adaptive systems and whole…

[Coupling coordinated development of ecological-economic system in Loess Plateau].

PubMed

Zhang, Qing-Feng; Wu, Fa-Qi; Wang, Li; Wang, Jian

2011-06-01

Based on system theory, a coupling coordinated development model of ecological-economic system in Loess Plateau was established, and the evaluation criteria and basic types of the coordinated development of the ecological-economic system were proposed. The county-level coupling coordinated development of the ecological-economic system was also discussed, based on the local characteristics. The interactions between the ecological and economic systems in Loess Plateau could be divided into four stages, i.e., seriously disordered development stage, mild-disordered development stage, low-level coordinated development stage, and high level well-coordinated development stage. At each stage, there existed a cyclic process of profit and loss-antagonist-running-dominant-synchronous development. The coupling development degree of the ecological-economic system in Loess Plateau was overall at a lower level, being about 62.7% of the counties at serious disorder, 30.1% of the counties at mild disorder, and 7.1% of the counties at low but coordinated level. The coupling development degree based on the model established in this study could better reflect the current social-economic and ecological environment situations, especially the status of coordination. To fully understand the coupling of ecological-economic system and to adopt appropriate development mode would be of significance to promote the county-level coordinated development in Loess Plateau.

Digital Low Level RF Systems for Fermilab Main Ring and Tevatron

NASA Astrophysics Data System (ADS)

Chase, B.; Barnes, B.; Meisner, K.

1997-05-01

At Fermilab, a new Low Level RF system is successfully installed and operating in the Main Ring. Installation is proceeding for a Tevatron system. This upgrade replaces aging CAMAC/NIM components for an increase in accuracy, reliability, and flexibility. These VXI systems are based on a custom three channel direct digital synthesizer(DDS) module. Each synthesizer channel is capable of independent or ganged operation for both frequency and phase modulation. New frequency and phase values are computed at a 100kHz rate on the module's Analog Devices ADSP21062 (SHARC) digital signal processor. The DSP concurrently handles feedforward, feedback, and beam manipulations. Higher level state machines and the control system interface are handled at the crate level using the VxWorks operating system. This paper discusses the hardware, software and operational aspects of these LLRF systems.

Fuzzy control for a nonlinear mimo-liquid level problem

DOE Office of Scientific and Technical Information (OSTI.GOV)

Smith, R. E.; Mortensen, F. N.; Wantuck, P. J.

2001-01-01

Nonlinear systems are very common in the chemical process industries. Control of these systems, particularly multivariable systems, is extremely difficult. In many chemical plants, because of this difficulty, control is seldom optimal. Quite often, the best control is obtained in the manual mode using experienced operators. Liquid level control is probably one of the most common control problems in a chemical plant. Liquid level is important in heat exchanger control where heat and mass transfer rates can be controlled by the amount of liquid covering the tubes. Distillation columns, mixing tanks, and surge tanks are other examples where liquid levelmore » control is very important. The problem discussed in this paper is based on the simultaneous level control of three tanks connected in series. Each tank holds slightly less than 0.01 m{sup 3} of liquid. All three tanks are connected, Liquid is pumped into the first and the third tanks to maintain their levels. The third tank in the series drains to the system exit. The levels in the first and third tank control the level in the middle tank. The level in the middle tank affects the levels in the two end tanks. Many other chemical plant systems can be controlled in a manner similar to this three-tank system. For example, in any distillation column liquid level control problems can be represented as a total condenser with liquid level control, a reboiler with liquid level control, with the interactive column in between. The solution to the three-tank-problem can provide insight into many of the nonlinear control problems in the chemical process industries. The system was tested using the fuzzy logic controller and a proportional-integral (PI) controller, in both the setpoint tracking mode and disturbance rejection mode. The experimental results are discussed and comparisons between fuzzy controller and the standard PI controller are made.« less

76 FR 20992 - Guidance for Industry and Food and Drug Administration Staff; Class II Special Controls Guidance...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-04-14

...: Low Level Laser System for Aesthetic Use; Availability AGENCY: Food and Drug Administration, HHS... guidance entitled ``Class II Special Controls Guidance Document: Low Level Laser System for Aesthetic Use.'' This guidance document describes a means by which low level laser systems for aesthetic use may comply...

A Circle of Courage Level System in Day Treatment

ERIC Educational Resources Information Center

Harper, Elaine

2005-01-01

Educators continue to seek effective behavior management strategies and therapeutic techniques to help students with emotional disturbance and behavior disorders to manage their own behavior and to achieve academically. One strategy employed to overcome the challenges is the use of a level system in the classroom. Level systems are often used with…

46 CFR 154.1325 - Liquid level alarm system: All cargo tanks.

Code of Federal Regulations, 2010 CFR

2010-10-01

... percent liquid full and without causing the pressure in the loading lines to exceed the design pressure... 46 Shipping 5 2010-10-01 2010-10-01 false Liquid level alarm system: All cargo tanks. 154.1325... Equipment Instrumentation § 154.1325 Liquid level alarm system: All cargo tanks. Except as allowed under...

46 CFR 154.1325 - Liquid level alarm system: All cargo tanks.

Code of Federal Regulations, 2013 CFR

2013-10-01

... percent liquid full and without causing the pressure in the loading lines to exceed the design pressure... 46 Shipping 5 2013-10-01 2013-10-01 false Liquid level alarm system: All cargo tanks. 154.1325... Equipment Instrumentation § 154.1325 Liquid level alarm system: All cargo tanks. Except as allowed under...

46 CFR 154.1325 - Liquid level alarm system: All cargo tanks.

Code of Federal Regulations, 2012 CFR

2012-10-01

... percent liquid full and without causing the pressure in the loading lines to exceed the design pressure... 46 Shipping 5 2012-10-01 2012-10-01 false Liquid level alarm system: All cargo tanks. 154.1325... Equipment Instrumentation § 154.1325 Liquid level alarm system: All cargo tanks. Except as allowed under...

46 CFR 154.1325 - Liquid level alarm system: All cargo tanks.

Code of Federal Regulations, 2011 CFR

2011-10-01

... percent liquid full and without causing the pressure in the loading lines to exceed the design pressure... 46 Shipping 5 2011-10-01 2011-10-01 false Liquid level alarm system: All cargo tanks. 154.1325... Equipment Instrumentation § 154.1325 Liquid level alarm system: All cargo tanks. Except as allowed under...

46 CFR 154.1325 - Liquid level alarm system: All cargo tanks.

Code of Federal Regulations, 2014 CFR

2014-10-01

... percent liquid full and without causing the pressure in the loading lines to exceed the design pressure... 46 Shipping 5 2014-10-01 2014-10-01 false Liquid level alarm system: All cargo tanks. 154.1325... Equipment Instrumentation § 154.1325 Liquid level alarm system: All cargo tanks. Except as allowed under...

Noise in the Classroom: Understanding the Problem.

ERIC Educational Resources Information Center

Lilly, Jerry G.

2000-01-01

Presents guidelines for designing classroom HVAC systems that will be able to achieve lower background noise levels that conform to the NC-30 background noise rating level. Guidelines for both central and dedicated systems are offered revealing that the use of conventional HVAC system components can be used to achieve sound levels comparable to…

40 CFR 141.73 - Filtration.

Code of Federal Regulations, 2014 CFR

2014-07-01

... turbidity level of representative samples of a system's filtered water must be less than or equal to 0.5 NTU....74 (a)(1) and (c)(1). (2) The turbidity level of representative samples of a system's filtered water... filtration, the turbidity level of representative samples of a system's filtered water must be less than or...

Implementation of Local Wellness Policies in Schools: Role of School Systems, School Health Councils, and Health Disparities

ERIC Educational Resources Information Center

Hager, Erin R.; Rubio, Diana S.; Eidel, G. Stewart; Penniston, Erin S.; Lopes, Megan; Saksvig, Brit I.; Fox, Renee E.; Black, Maureen M.

2016-01-01

Background: Written local wellness policies (LWPs) are mandated in school systems to enhance opportunities for healthy eating/activity. LWP effectiveness relies on school-level implementation. We examined factors associated with school-level LWP implementation. Hypothesized associations included system support for school-level implementation and…

Harmony search algorithm: application to the redundancy optimization problem

NASA Astrophysics Data System (ADS)

Nahas, Nabil; Thien-My, Dao

2010-09-01

The redundancy optimization problem is a well known NP-hard problem which involves the selection of elements and redundancy levels to maximize system performance, given different system-level constraints. This article presents an efficient algorithm based on the harmony search algorithm (HSA) to solve this optimization problem. The HSA is a new nature-inspired algorithm which mimics the improvization process of music players. Two kinds of problems are considered in testing the proposed algorithm, with the first limited to the binary series-parallel system, where the problem consists of a selection of elements and redundancy levels used to maximize the system reliability given various system-level constraints; the second problem for its part concerns the multi-state series-parallel systems with performance levels ranging from perfect operation to complete failure, and in which identical redundant elements are included in order to achieve a desirable level of availability. Numerical results for test problems from previous research are reported and compared. The results of HSA showed that this algorithm could provide very good solutions when compared to those obtained through other approaches.

On Designing Lightweight Threads for Substrate Software

NASA Technical Reports Server (NTRS)

Haines, Matthew

1997-01-01

Existing user-level thread packages employ a 'black box' design approach, where the implementation of the threads is hidden from the user. While this approach is often sufficient for application-level programmers, it hides critical design decisions that system-level programmers must be able to change in order to provide efficient service for high-level systems. By applying the principles of Open Implementation Analysis and Design, we construct a new user-level threads package that supports common thread abstractions and a well-defined meta-interface for altering the behavior of these abstractions. As a result, system-level programmers will have the advantages of using high-level thread abstractions without having to sacrifice performance, flexibility or portability.

Study of multi-level atomic systems with the application of magnetic field

NASA Astrophysics Data System (ADS)

Hu, Jianping; Roy, Subhankar; Ummal Momeen, M.

2018-04-01

The complexity of multiple energy levels associated with each atomic system determines the various processes related to light- matter interactions. It is necessary to understand the influence of different levels in a given atomic system. In this work we focus on multi- level atomic schemes with the application of magnetic field. We analyze the different EIT windows which appears in the presence of moderately high magnetic field (∼ 10 G) strength.

Development and Application of an Integrated Approach toward NASA Airspace Systems Research

NASA Technical Reports Server (NTRS)

Barhydt, Richard; Fong, Robert K.; Abramson, Paul D.; Koenke, Ed

2008-01-01

The National Aeronautics and Space Administration's (NASA) Airspace Systems Program is contributing air traffic management research in support of the 2025 Next Generation Air Transportation System (NextGen). Contributions support research and development needs provided by the interagency Joint Planning and Development Office (JPDO). These needs generally call for integrated technical solutions that improve system-level performance and work effectively across multiple domains and planning time horizons. In response, the Airspace Systems Program is pursuing an integrated research approach and has adapted systems engineering best practices for application in a research environment. Systems engineering methods aim to enable researchers to methodically compare different technical approaches, consider system-level performance, and develop compatible solutions. Systems engineering activities are performed iteratively as the research matures. Products of this approach include a demand and needs analysis, system-level descriptions focusing on NASA research contributions, system assessment and design studies, and common systemlevel metrics, scenarios, and assumptions. Results from the first systems engineering iteration include a preliminary demand and needs analysis; a functional modeling tool; and initial system-level metrics, scenario characteristics, and assumptions. Demand and needs analysis results suggest that several advanced concepts can mitigate demand/capacity imbalances for NextGen, but fall short of enabling three-times current-day capacity at the nation s busiest airports and airspace. Current activities are focusing on standardizing metrics, scenarios, and assumptions, conducting system-level performance assessments of integrated research solutions, and exploring key system design interfaces.

Superradiant phase transitions with three-level systems

NASA Astrophysics Data System (ADS)

Baksic, Alexandre; Nataf, Pierre; Ciuti, Cristiano

2013-02-01

We determine the phase diagram of N identical three-level systems interacting with a single photonic mode in the thermodynamical limit (N→∞) by accounting for the so-called diamagnetic term and the inequalities imposed by the Thomas-Reich-Kuhn (TRK) oscillator strength sum rule. The key role of transitions between excited levels and the occurrence of first-order phase transitions is discussed. We show that, in contrast to two-level systems, in the three-level case the TRK inequalities do not always prevent a superradiant phase transition in the presence of a diamagnetic term.

Art of disaster preparedness in European union: a survey on the health systems.

PubMed

Djalali, Ahmadreza; Della Corte, Francesco; Foletti, Marco; Ragazzoni, Luca; Ripoll Gallardo, Alba; Lupescu, Olivera; Arculeo, Chris; von Arnim, Götz; Friedl, Tom; Ashkenazi, Michael; Fischer, Philipp; Hreckovski, Boris; Khorram-Manesh, Amir; Komadina, Radko; Lechner, Konstanze; Patru, Cristina; Burkle, Frederick M; Ingrassia, Pier Luigi

2014-12-17

Naturally occurring and man-made disasters have been increasing in the world, including Europe, over the past several decades. Health systems are a key part of any community disaster management system. The success of preparedness and prevention depends on the success of activities such as disaster planning, organization and training. The aim of this study is to evaluate health system preparedness for disasters in the 27 European Union member countries. A cross-sectional analysis study was completed between June-September 2012. The checklist used for this survey was a modified from the World Health Organization toolkit for assessing health-system capacity for crisis management. Three specialists from each of the 27 European Union countries were included in the survey. Responses to each survey question were scored and the range of preparedness level was defined as 0-100%, categorized in three levels as follows: Acceptable; Transitional; or Insufficient. Response rate was 79.1%. The average level of disaster management preparedness in the health systems of 27 European Union member states was 68% (Acceptable). The highest level of preparedness was seen in the United Kingdom, Luxemburg, and Lithuania. Considering the elements of disaster management system, the highest level of preparedness score was at health information elements (86%), and the lowest level was for hospitals, and educational elements (54%). This survey study suggests that preparedness level of European Union countries in 2012 is at an acceptable level but could be improved. Elements such as hospitals and education and training suffer from insufficient levels of preparedness. The European Union health systems need a collective strategic plan, as well as enough resources, to establish a comprehensive and standardized disaster management strategy plan. A competency based training curriculum for managers and first responders is basic to accomplishing this goal. Disaster medicine; Disaster preparedness; Disaster epidemiology; Health systems; European Union.

Art of Disaster Preparedness in European Union: a Survey on the Health Systems

PubMed Central

Djalali, Ahmadreza; Della Corte, Francesco; Foletti, Marco; Ragazzoni, Luca; Ripoll Gallardo, Alba; Lupescu, Olivera; Arculeo, Chris; von Arnim, Götz; Friedl, Tom; Ashkenazi, Michael; Fischer, Philipp; Hreckovski, Boris; Khorram-Manesh, Amir; Komadina, Radko; Lechner, Konstanze; Patru, Cristina; Burkle, Frederick M.; Ingrassia, Pier Luigi

2014-01-01

Introduction: Naturally occurring and man-made disasters have been increasing in the world, including Europe, over the past several decades. Health systems are a key part of any community disaster management system. The success of preparedness and prevention depends on the success of activities such as disaster planning, organization and training. The aim of this study is to evaluate health system preparedness for disasters in the 27 European Union member countries. Method: A cross-sectional analysis study was completed between June-September 2012. The checklist used for this survey was a modified from the World Health Organization toolkit for assessing health-system capacity for crisis management. Three specialists from each of the 27 European Union countries were included in the survey. Responses to each survey question were scored and the range of preparedness level was defined as 0-100%, categorized in three levels as follows: Acceptable; Transitional; or Insufficient. Results: Response rate was 79.1%. The average level of disaster management preparedness in the health systems of 27 European Union member states was 68% (Acceptable). The highest level of preparedness was seen in the United Kingdom, Luxemburg, and Lithuania. Considering the elements of disaster management system, the highest level of preparedness score was at health information elements (86%), and the lowest level was for hospitals, and educational elements (54%). Conclusion: This survey study suggests that preparedness level of European Union countries in 2012 is at an acceptable level but could be improved. Elements such as hospitals and education and training suffer from insufficient levels of preparedness. The European Union health systems need a collective strategic plan, as well as enough resources, to establish a comprehensive and standardized disaster management strategy plan. A competency based training curriculum for managers and first responders is basic to accomplishing this goal. Keywords: Disaster medicine; Disaster preparedness; Disaster epidemiology; Health systems; European Union PMID:25685628

Evaluation of the effects of botulinum toxin A injections when used to improve ease of care and comfort in children with cerebral palsy whom are non-ambulant: a double blind randomized controlled trial

PubMed Central

2012-01-01

Background Children with cerebral palsy (CP) whom are non-ambulant are at risk of reduced quality of life and poor health status. Severe spasticity leads to discomfort and pain. Carer burden for families is significant. This study aims to determine whether intramuscular injections of botulinum toxin A (BoNT-A) combined with a regime of standard therapy has a positive effect on care and comfort for children with CP whom are non-ambulant (GMFCS IV/V), compared with standard therapy alone (cycle I), and whether repeated injections with the same regime of adjunctive therapy results in greater benefits compared with a single injecting episode (cycle II). The regime of therapy will include serial casting, splinting and/or provision of orthoses, as indicated, combined with four sessions of goal directed occupational therapy or physiotherapy. Method/design This study is a double blind randomized controlled trial. Forty participants will be recruited. In cycle I, participants will be randomized to either a treatment group who will receive BoNT-A injections into selected upper and/or lower limb muscles, or a control group who will undergo sham injections. Both groups will receive occupational therapy and /or physiotherapy following injections. Groups will be assessed at baseline then compared at 4 and 16 weeks following injections or sham control. Parents, treating clinicians and assessors will be masked to group allocation. In cycle II, all participants will undergo intramuscular BoNT-A injections to selected upper and/or lower limb muscles, followed by therapy. The primary outcome measure will be change in parent ratings in identified areas of concern for their child’s care and comfort, using the Canadian Occupational Performance Measure (COPM). Secondary measures will include the Care and Comfort Hypertonicity Scale (ease of care), the Cerebral Palsy Quality of Life Questionnaire (CP QoL–Child) (quality of life), the Caregiver Priorities and Child Health Index of Life with Disabilities Questionnaire (CPCHILD©) (health status) and the Paediatric Pain Profile (PPP) (pain). Adverse events will be carefully monitored by a clinician masked to group allocation. Discussion This paper outlines the theoretical basis, study hypotheses and outcome measures for a trial of BoNT-A injections and therapy for children with non-ambulant CP. Trial registration Australia New Zealand Clinical Trials Registry:N12609000360213 PMID:22873758

The Two-Level System of Higher Education: Western Traditions and Russian Reality

ERIC Educational Resources Information Center

Druzhilov, S. A.

2011-01-01

The law on the two-level system of higher education has now gone into effect in Russia: the bachelor's degree will correspond to the first level of higher education, while the master's degree will correspond to the second level. These levels entail separate state educational standards and separate final certification. In the process of adopting…

The generic task toolset: High level languages for the construction of planning and problem solving systems

NASA Technical Reports Server (NTRS)

Chandrasekaran, B.; Josephson, J.; Herman, D.

1987-01-01

The current generation of languages for the construction of knowledge-based systems as being at too low a level of abstraction is criticized, and the need for higher level languages for building problem solving systems is advanced. A notion of generic information processing tasks in knowledge-based problem solving is introduced. A toolset which can be used to build expert systems in a way that enhances intelligibility and productivity in knowledge acquistion and system construction is described. The power of these ideas is illustrated by paying special attention to a high level language called DSPL. A description is given of how it was used in the construction of a system called MPA, which assists with planning in the domain of offensive counter air missions.

40 CFR 205.54-2 - Sound data acquisition system.

Code of Federal Regulations, 2010 CFR

2010-07-01

... meets the “fast” dynamic requirement of a precision sound level meter indicating meter system for the... 40 Protection of Environment 24 2010-07-01 2010-07-01 false Sound data acquisition system. 205.54... data acquisition system. (a) Systems employing tape recorders and graphic level recorders may be...

Electromagnetic interference in electrical systems of motor vehicles

NASA Astrophysics Data System (ADS)

Dziubiński, M.; Drozd, A.; Adamiec, M.; Siemionek, E.

2016-09-01

Electronic ignition system affects the electronic equipment of the vehicle by electric and magnetic fields. The measurement of radio electromagnetic interference originating from the ignition system affecting the audiovisual test bench was carried out with a variable speed of the ignition system. The paper presents measurements of radio electromagnetic interference in automobiles. In order to determine the level of electromagnetic interference, the audiovisual test bench was equipped with a set of meters for power consumption and assessment of the level of electromagnetic interference. Measurements of the electromagnetic interference level within the audiovisual system were performed on an experimental test bench consisting of the ignition system, starting system and charging system with an alternator and regulator.

Evaluation of Contamination Inspection and Analysis Methods through Modeling System Performance

NASA Technical Reports Server (NTRS)

Seasly, Elaine; Dever, Jason; Stuban, Steven M. F.

2016-01-01

Contamination is usually identified as a risk on the risk register for sensitive space systems hardware. Despite detailed, time-consuming, and costly contamination control efforts during assembly, integration, and test of space systems, contaminants are still found during visual inspections of hardware. Improved methods are needed to gather information during systems integration to catch potential contamination issues earlier and manage contamination risks better. This research explores evaluation of contamination inspection and analysis methods to determine optical system sensitivity to minimum detectable molecular contamination levels based on IEST-STD-CC1246E non-volatile residue (NVR) cleanliness levels. Potential future degradation of the system is modeled given chosen modules representative of optical elements in an optical system, minimum detectable molecular contamination levels for a chosen inspection and analysis method, and determining the effect of contamination on the system. By modeling system performance based on when molecular contamination is detected during systems integration and at what cleanliness level, the decision maker can perform trades amongst different inspection and analysis methods and determine if a planned method is adequate to meet system requirements and manage contamination risk.

Chaos based encryption system for encrypting electroencephalogram signals.

PubMed

Lin, Chin-Feng; Shih, Shun-Han; Zhu, Jin-De

2014-05-01

In the paper, we use the Microsoft Visual Studio Development Kit and C# programming language to implement a chaos-based electroencephalogram (EEG) encryption system involving three encryption levels. A chaos logic map, initial value, and bifurcation parameter for the map were used to generate Level I chaos-based EEG encryption bit streams. Two encryption-level parameters were added to these elements to generate Level II chaos-based EEG encryption bit streams. An additional chaotic map and chaotic address index assignment process was used to implement the Level III chaos-based EEG encryption system. Eight 16-channel EEG Vue signals were tested using the encryption system. The encryption was the most rapid and robust in the Level III system. The test yielded superior encryption results, and when the correct deciphering parameter was applied, the EEG signals were completely recovered. However, an input parameter error (e.g., a 0.00001 % initial point error) causes chaotic encryption bit streams, preventing the recovery of 16-channel EEG Vue signals.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

The Office of Civilian Radioactive Waste Management Systems Engineering Management Plan (OCRWM SEMP) specifies the technical management approach for the development of the waste management system, and specifies the approach for the development of each of the system elements -- the waste acceptance system, the transportation system, the Monitored Retrievable Storage (MRS) facility, and the mined geologic disposal system, which includes site characterization activity. The SEMP also delineates how systems engineering will be used by OCRWM to describe the system development process; it identifies responsibilities for its implementation, and specifies the minimum requirements for systems engineering. It also identifies themore » close interrelationship of system engineering and licensing processes. This SEMP, which is a combined OCRWM and M&O SEMP, is part of the top-level program documentation and is prepared in accordance with the direction provided in the Program Management System Manual (PMSM). The relationship of this document to other top level documents in the CRWMS document hierarchy is defined in the PMSM. A systems engineering management plan for each project, which specifies the actions to be taken in implementing systems engineering at the project level, shall be prepared by the respective project managers. [``Program`` refers to the CRWMS-wide activity and ``project`` refers to that level responsible for accomplishing the specific activities of that segment of the program.] The requirements for the project level SEMPs are addressed in Section 4.2.2.2. They represent the minimum set of requirements, and do not preclude the broadening of systems engineering activities to meet the specific needs of each project.« less

Information slows down hierarchy growth

NASA Astrophysics Data System (ADS)

Czaplicka, Agnieszka; Suchecki, Krzysztof; Miñano, Borja; Trias, Miquel; Hołyst, Janusz A.

2014-06-01

We consider models of growing multilevel systems wherein the growth process is driven by rules of tournament selection. A system can be conceived as an evolving tree with a new node being attached to a contestant node at the best hierarchy level (a level nearest to the tree root). The proposed evolution reflects limited information on system properties available to new nodes. It can also be expressed in terms of population dynamics. Two models are considered: a constant tournament (CT) model wherein the number of tournament participants is constant throughout system evolution, and a proportional tournament (PT) model where this number increases proportionally to the growing size of the system itself. The results of analytical calculations based on a rate equation fit well to numerical simulations for both models. In the CT model all hierarchy levels emerge, but the birth time of a consecutive hierarchy level increases exponentially or faster for each new level. The number of nodes at the first hierarchy level grows logarithmically in time, while the size of the last, "worst" hierarchy level oscillates quasi-log-periodically. In the PT model, the occupations of the first two hierarchy levels increase linearly, but worse hierarchy levels either do not emerge at all or appear only by chance in the early stage of system evolution to further stop growing at all. The results allow us to conclude that information available to each new node in tournament dynamics restrains the emergence of new hierarchy levels and that it is the absolute amount of information, not relative, which governs such behavior.

Information slows down hierarchy growth.

PubMed

Czaplicka, Agnieszka; Suchecki, Krzysztof; Miñano, Borja; Trias, Miquel; Hołyst, Janusz A

2014-06-01

We consider models of growing multilevel systems wherein the growth process is driven by rules of tournament selection. A system can be conceived as an evolving tree with a new node being attached to a contestant node at the best hierarchy level (a level nearest to the tree root). The proposed evolution reflects limited information on system properties available to new nodes. It can also be expressed in terms of population dynamics. Two models are considered: a constant tournament (CT) model wherein the number of tournament participants is constant throughout system evolution, and a proportional tournament (PT) model where this number increases proportionally to the growing size of the system itself. The results of analytical calculations based on a rate equation fit well to numerical simulations for both models. In the CT model all hierarchy levels emerge, but the birth time of a consecutive hierarchy level increases exponentially or faster for each new level. The number of nodes at the first hierarchy level grows logarithmically in time, while the size of the last, "worst" hierarchy level oscillates quasi-log-periodically. In the PT model, the occupations of the first two hierarchy levels increase linearly, but worse hierarchy levels either do not emerge at all or appear only by chance in the early stage of system evolution to further stop growing at all. The results allow us to conclude that information available to each new node in tournament dynamics restrains the emergence of new hierarchy levels and that it is the absolute amount of information, not relative, which governs such behavior.

Multi-level systems modeling and optimization for novel aircraft

NASA Astrophysics Data System (ADS)

Subramanian, Shreyas Vathul

This research combines the disciplines of system-of-systems (SoS) modeling, platform-based design, optimization and evolving design spaces to achieve a novel capability for designing solutions to key aeronautical mission challenges. A central innovation in this approach is the confluence of multi-level modeling (from sub-systems to the aircraft system to aeronautical system-of-systems) in a way that coordinates the appropriate problem formulations at each level and enables parametric search in design libraries for solutions that satisfy level-specific objectives. The work here addresses the topic of SoS optimization and discusses problem formulation, solution strategy, the need for new algorithms that address special features of this problem type, and also demonstrates these concepts using two example application problems - a surveillance UAV swarm problem, and the design of noise optimal aircraft and approach procedures. This topic is critical since most new capabilities in aeronautics will be provided not just by a single air vehicle, but by aeronautical Systems of Systems (SoS). At the same time, many new aircraft concepts are pressing the boundaries of cyber-physical complexity through the myriad of dynamic and adaptive sub-systems that are rising up the TRL (Technology Readiness Level) scale. This compositional approach is envisioned to be active at three levels: validated sub-systems are integrated to form conceptual aircraft, which are further connected with others to perform a challenging mission capability at the SoS level. While these multiple levels represent layers of physical abstraction, each discipline is associated with tools of varying fidelity forming strata of 'analysis abstraction'. Further, the design (composition) will be guided by a suitable hierarchical complexity metric formulated for the management of complexity in both the problem (as part of the generative procedure and selection of fidelity level) and the product (i.e., is the mission best achieved via a large collection of interacting simple systems, or a relatively few highly capable, complex air vehicles). The vastly unexplored area of optimization in evolving design spaces will be studied and incorporated into the SoS optimization framework. We envision a framework that resembles a multi-level, mult-fidelity, multi-disciplinary assemblage of optimization problems. The challenge is not simply one of scaling up to a new level (the SoS), but recognizing that the aircraft sub-systems and the integrated vehicle are now intensely cyber-physical, with hardware and software components interacting in complex ways that give rise to new and improved capabilities. The work presented here is a step closer to modeling the information flow that exists in realistic SoS optimization problems between sub-contractors, contractors and the SoS architect.

The Comprehensive AOCMF Classification: Skull Base and Cranial Vault Fractures – Level 2 and 3 Tutorial

PubMed Central

Ieva, Antonio Di; Audigé, Laurent; Kellman, Robert M.; Shumrick, Kevin A.; Ringl, Helmut; Prein, Joachim; Matula, Christian

2014-01-01

The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial classification system with increasing level of complexity and details. The highest level 1 system distinguish four major anatomical units, including the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). This tutorial presents the level 2 and more detailed level 3 systems for the skull base and cranial vault units. The level 2 system describes fracture location outlining the topographic boundaries of the anatomic regions, considering in particular the endocranial and exocranial skull base surfaces. The endocranial skull base is divided into nine regions; a central skull base adjoining a left and right side are divided into the anterior, middle, and posterior skull base. The exocranial skull base surface and cranial vault are divided in regions defined by the names of the bones involved: frontal, parietal, temporal, sphenoid, and occipital bones. The level 3 system allows assessing fracture morphology described by the presence of fracture fragmentation, displacement, and bone loss. A documentation of associated intracranial diagnostic features is proposed. This tutorial is organized in a sequence of sections dealing with the description of the classification system with illustrations of the topographical skull base and cranial vault regions along with rules for fracture location and coding, a series of case examples with clinical imaging and a general discussion on the design of this classification. PMID:25489394

33 CFR 154.812 - Facility requirements for vessel liquid overfill protection.

Code of Federal Regulations, 2011 CFR

2011-07-01

... intrinsically safe cargo tank level sensor system complying with 46 CFR 39.20-9(b) as its only means of overfill... shutdown signal from the cargo tank level sensor system that: (1) Closes the remotely operated cargo vapor...) Electrical continuity of the cargo tank level sensor system is lost; (2) Activates an alarm which is audible...

33 CFR 154.812 - Facility requirements for vessel liquid overfill protection.

Code of Federal Regulations, 2012 CFR

2012-07-01

... intrinsically safe cargo tank level sensor system complying with 46 CFR 39.20-9(b) as its only means of overfill... shutdown signal from the cargo tank level sensor system that: (1) Closes the remotely operated cargo vapor...) Electrical continuity of the cargo tank level sensor system is lost; (2) Activates an alarm which is audible...

33 CFR 154.812 - Facility requirements for vessel liquid overfill protection.

Code of Federal Regulations, 2013 CFR

2013-07-01

... intrinsically safe cargo tank level sensor system complying with 46 CFR 39.20-9(b) as its only means of overfill... shutdown signal from the cargo tank level sensor system that: (1) Closes the remotely operated cargo vapor...) Electrical continuity of the cargo tank level sensor system is lost; (2) Activates an alarm which is audible...

Environmental Education for Social-Ecological System Resilience: A Perspective from Activity Theory

ERIC Educational Resources Information Center

Krasny, Marianne E.; Roth, Wolff-Michael

2010-01-01

In this paper we attempt to integrate environmental education, with a focus on building capacity at the level of the individual, with frameworks for resilience, with a focus on adaptive capacity at the level of the social-ecological system. Whereas previous work has focused on enhancing system-level capacity through building adaptive capacity in…

A real-time single sperm tracking, laser trapping, and ratiometric fluorescent imaging system

NASA Astrophysics Data System (ADS)

Shi, Linda Z.; Botvinick, Elliot L.; Nascimento, Jaclyn; Chandsawangbhuwana, Charlie; Berns, Michael W.

2006-08-01

Sperm cells from a domestic dog were treated with oxacarbocyanine DiOC II(3), a ratiometrically-encoded membrane potential fluorescent probe in order to monitor the mitochondria stored in an individual sperm's midpiece. This dye normally emits a red fluorescence near 610 nm as well as a green fluorescence near 515 nm. The ratio of red to green fluorescence provides a substantially accurate and precise measurement of sperm midpiece membrane potential. A two-level computer system has been developed to quantify the motility and energetics of sperm using video rate tracking, automated laser trapping (done by the upper-level system) and fluorescent imaging (done by the lower-level system). The communication between these two systems is achieved by a networked gigabit TCP/IP cat5e crossover connection. This allows for the curvilinear velocity (VCL) and ratio of the red to green fluorescent images of individual sperm to be written to the hard drive at video rates. This two-level automatic system has increased experimental throughput over our previous single-level system (Mei et al., 2005) by an order of magnitude.

System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Dichter, Jeffrey R; Kanter, Robert K; Dries, David; Luyckx, Valerie; Lim, Matthew L; Wilgis, John; Anderson, Michael R; Sarani, Babak; Hupert, Nathaniel; Mutter, Ryan; Devereaux, Asha V; Christian, Michael D; Kissoon, Niranjan

2014-10-01

System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning. System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

System-Level Planning, Coordination, and Communication

PubMed Central

Kanter, Robert K.; Dries, David; Luyckx, Valerie; Lim, Matthew L.; Wilgis, John; Anderson, Michael R.; Sarani, Babak; Hupert, Nathaniel; Mutter, Ryan; Devereaux, Asha V.; Christian, Michael D.; Kissoon, Niranjan; Christian, Michael D.; Devereaux, Asha V.; Dichter, Jeffrey R.; Kissoon, Niranjan; Rubinson, Lewis; Amundson, Dennis; Anderson, Michael R.; Balk, Robert; Barfield, Wanda D.; Bartz, Martha; Benditt, Josh; Beninati, William; Berkowitz, Kenneth A.; Daugherty Biddison, Lee; Braner, Dana; Branson, Richard D; Burkle, Frederick M.; Cairns, Bruce A.; Carr, Brendan G.; Courtney, Brooke; DeDecker, Lisa D.; De Jong, Marla J.; Dominguez-Cherit, Guillermo; Dries, David; Einav, Sharon; Erstad, Brian L.; Etienne, Mill; Fagbuyi, Daniel B.; Fang, Ray; Feldman, Henry; Garzon, Hernando; Geiling, James; Gomersall, Charles D.; Grissom, Colin K.; Hanfling, Dan; Hick, John L.; Hodge, James G.; Hupert, Nathaniel; Ingbar, David; Kanter, Robert K.; King, Mary A.; Kuhnley, Robert N.; Lawler, James; Leung, Sharon; Levy, Deborah A.; Lim, Matthew L.; Livinski, Alicia; Luyckx, Valerie; Marcozzi, David; Medina, Justine; Miramontes, David A.; Mutter, Ryan; Niven, Alexander S.; Penn, Matthew S.; Pepe, Paul E.; Powell, Tia; Prezant, David; Reed, Mary Jane; Rich, Preston; Rodriquez, Dario; Roxland, Beth E.; Sarani, Babak; Shah, Umair A.; Skippen, Peter; Sprung, Charles L.; Subbarao, Italo; Talmor, Daniel; Toner, Eric S.; Tosh, Pritish K.; Upperman, Jeffrey S.; Uyeki, Timothy M.; Weireter, Leonard J.; West, T. Eoin; Wilgis, John; Ornelas, Joe; McBride, Deborah; Reid, David; Baez, Amado; Baldisseri, Marie; Blumenstock, James S.; Cooper, Art; Ellender, Tim; Helminiak, Clare; Jimenez, Edgar; Krug, Steve; Lamana, Joe; Masur, Henry; Mathivha, L. Rudo; Osterholm, Michael T.; Reynolds, H. Neal; Sandrock, Christian; Sprecher, Armand; Tillyard, Andrew; White, Douglas; Wise, Robert; Yeskey, Kevin

2014-01-01

BACKGROUND: System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS: Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning. CONCLUSIONS: System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises. PMID:25144713

Precision Clean Hardware: Maintenance of Fluid Systems Cleanliness

NASA Technical Reports Server (NTRS)

Sharp, Sheila; Pedley, Mike; Bond, Tim; Quaglino, Joseph; Lorenz, Mary Jo; Bentz, Michael; Banta, Richard; Tolliver, Nancy; Golden, John; Levesque, Ray

2003-01-01

The ISS fluid systems are so complex that fluid system cleanliness cannot be verified at the assembly level. A "build clean / maintain clean" approach was used by all major fluid systems: Verify cleanliness at the detail and subassembly level. Maintain cleanliness during assembly.

Effects of active noise reduction on noise levels at the tympanic membrane.

PubMed

Wagstaff, A S; Woxen, O J; Andersen, H T

1998-06-01

Active noise reduction (ANR) is an electronic system that works by continuous sampling of noise inside the earshell of the headset with a small microphone. This signal is inverted in phase through the headset speaker, thus reducing noise levels by destructive interference of the acoustic field. The system provides good low-frequency noise attenuation, but aircrew differ in their subjective opinion of ANR. The present study is an attempt to provide an objective assessment of the effect of ANR on noise levels at the tympanic membrane. There were 7 subjects with normal ears who were placed in an environment of recorded noise from a BO-105 helicopter. A microphone probe was inserted to within 5 mm of the tympanic membrane of each subject's right ear. Noise levels in the ear were measured without a headset and with two different ANR headsets. Measurements were performed with and without the ANR system on, and with and without white noise through the headset communication system. The white noise was used to simulate aircraft communication noise. The two headsets tested had differing levels of passive and active attenuation. The ANR system produced a substantial low-frequency attenuation. However, noise levels in the mid frequencies increased somewhat when the ANR system was switched on. This effect was augmented when white noise in the communications system was introduced, particularly for one of the two headsets. Low-frequency noise attenuation of ANR systems is substantial, but an increased mid- and high-frequency noise level caused by the ANR may affect both communication and overall noise levels. Our data provide advice on what factors should be taken into account when ANR is evaluated for use in an aviation operational environment.

A Systems Approach to Explaining Teachers' Leadership Behavior.

ERIC Educational Resources Information Center

Peterson, Mark F.; Cooke, Robert A.

This paper focuses on identifying the way that individual and organizational variables affect the classroom leadership behavior of teachers. Measured are the effects of one individual-level variable and six organizational variables--three at the organization system level and three at the classroom subsystem level. The individual-level variable is…

Energetics using the single point IMOMO (integrated molecular orbital+molecular orbital) calculations: Choices of computational levels and model system

NASA Astrophysics Data System (ADS)

Svensson, Mats; Humbel, Stéphane; Morokuma, Keiji

1996-09-01

The integrated MO+MO (IMOMO) method, recently proposed for geometry optimization, is tested for accurate single point calculations. The principle idea of the IMOMO method is to reproduce results of a high level MO calculation for a large ``real'' system by dividing it into a small ``model'' system and the rest and applying different levels of MO theory for the two parts. Test examples are the activation barrier of the SN2 reaction of Cl-+alkyl chlorides, the C=C double bond dissociation of olefins and the energy of reaction for epoxidation of benzene. The effects of basis set and method in the lower level calculation as well as the effects of the choice of model system are investigated in detail. The IMOMO method gives an approximation to the high level MO energetics on the real system, in most cases with very small errors, with a small additional cost over the low level calculation. For instance, when the MP2 (Møller-Plesset second-order perturbation) method is used as the lower level method, the IMOMO method reproduces the results of very high level MO method within 2 kcal/mol, with less than 50% of additional computer time, for the first two test examples. When the HF (Hartree-Fock) method is used as the lower level method, it is less accurate and depends more on the choice of model system, though the improvement over the HF energy is still very significant. Thus the IMOMO single point calculation provides a method for obtaining reliable local energetics such as bond energies and activation barriers for a large molecular system.

Tunable electromagnetically induced transparency and absorption with dressed superconducting qubits

NASA Astrophysics Data System (ADS)

Ian, Hou; Liu, Yu-Xi; Nori, Franco

2010-06-01

Electromagnetically induced transparency and absorption (EIT and EIA) are usually demonstrated using three-level atomic systems. In contrast to the usual case, we theoretically study the EIT and EIA in an equivalent three-level system: a superconducting two-level system (qubit) dressed by a single-mode cavity field. In this equivalent system, we find that both the EIT and the EIA can be tuned by controlling the level-spacing of the superconducting qubit and hence controlling the dressed system. This tunability is due to the dressed relaxation and dephasing rates which vary parametrically with the level-spacing of the original qubit and thus affect the transition properties of the dressed qubit and the susceptibility. These dressed relaxation and dephasing rates characterize the reaction of the dressed qubit to an incident probe field. Using recent experimental data on superconducting qubits (charge, phase, and flux qubits) to demonstrate our approach, we show the possibility of experimentally realizing this proposal.

Protoflight photovoltaic power module system-level tests in the space power facility

NASA Technical Reports Server (NTRS)

Rivera, Juan C.; Kirch, Luke A.

1989-01-01

Work Package Four, which includes the NASA-Lewis and Rocketdyne, has selected an approach for the Space Station Freedom Photovoltaic (PV) Power Module flight certification that combines system level qualification and acceptance testing in the thermal vacuum environment: The protoflight vehicle approach. This approach maximizes ground test verification to assure system level performance and to minimize risk of on-orbit failures. The preliminary plans for system level thermal vacuum environmental testing of the protoflight PV Power Module in the NASA-Lewis Space Power Facility (SPF), are addressed. Details of the facility modifications to refurbish SPF, after 13 years of downtime, are briefly discussed. The results of an evaluation of the effectiveness of system level environmental testing in screening out incipient part and workmanship defects and unique failure modes are discussed. Preliminary test objectives, test hardware configurations, test support equipment, and operations are presented.

Periodontitis in coronary heart disease patients: strong association between bleeding on probing and systemic biomarkers.

PubMed

Bokhari, Syed Akhtar H; Khan, Ayyaz A; Butt, Arshad K; Hanif, Mohammad; Izhar, Mateen; Tatakis, Dimitris N; Ashfaq, Mohammad

2014-11-01

Few studies have examined the relationship of individual periodontal parameters with individual systemic biomarkers. This study assessed the possible association between specific clinical parameters of periodontitis and systemic biomarkers of coronary heart disease risk in coronary heart disease patients with periodontitis. Angiographically proven coronary heart disease patients with periodontitis (n = 317), aged >30 years and without other systemic illness were examined. Periodontal clinical parameters of bleeding on probing (BOP), probing depth (PD), and clinical attachment level (CAL) and systemic levels of high-sensitivity C-reactive protein (CRP), fibrinogen (FIB) and white blood cells (WBC) were noted and analyzed to identify associations through linear and stepwise multiple regression analyses. Unadjusted linear regression showed significant associations between periodontal and systemic parameters; the strongest association (r = 0.629; p < 0.001) was found between BOP and CRP levels, the periodontal and systemic inflammation marker, respectively. Stepwise regression analysis models revealed that BOP was a predictor of systemic CRP levels (p < 0.0001). BOP was the only periodontal parameter significantly associated with each systemic parameter (CRP, FIB, and WBC). In coronary heart disease patients with periodontitis, BOP is strongly associated with systemic CRP levels; this association possibly reflects the potential significance of the local periodontal inflammatory burden for systemic inflammation. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

The C130 Hercules Acquisition Program: A Case Study of the Potential Impact of a System Level Warranty Application.

DTIC Science & Technology

1986-09-01

Orfice in the Aeronautical Systems Division, and the Air Force Contract Law Center, provided support that ensured success from the very start. Last, but...76 Recommendations for Future Researcn ........ .. 79 Appendix A: Air Force Contract Law Center Suggested Systems Level Warranty...analysis of the findings was accomplisned by the Air Force Contract Law Center.’ Benefits from applying a system level warranty to the C-hiO were

A Cost and Performance System (CAPS) in a Federal agency

NASA Technical Reports Server (NTRS)

Huseonia, W. F.; Penton, P. G.

1994-01-01

Cost and Performance System (CAPS) is an automated system used from the planning phase through implementation to analysis and documentation. Data is retrievable or available for analysis of cost versus performance anomalies. CAPS provides a uniform system across intra- and international elements. A common system is recommended throughout an entire cost or profit center. Data can be easily accumulated and aggregated into higher levels of tracking and reporting of cost and performance.The level and quality of performance or productivity is indicated in the CAPS model and its process. The CAPS model provides the necessary decision information and insight to the principal investigator/project engineer for a successful project management experience. CAPS provides all levels of management with the appropriate detailed level of data.

Observation and quantification of the quantum dynamics of a strong-field excited multi-level system.

PubMed

Liu, Zuoye; Wang, Quanjun; Ding, Jingjie; Cavaletto, Stefano M; Pfeifer, Thomas; Hu, Bitao

2017-01-04

The quantum dynamics of a V-type three-level system, whose two resonances are first excited by a weak probe pulse and subsequently modified by another strong one, is studied. The quantum dynamics of the multi-level system is closely related to the absorption spectrum of the transmitted probe pulse and its modification manifests itself as a modulation of the absorption line shape. Applying the dipole-control model, the modulation induced by the second strong pulse to the system's dynamics is quantified by eight intensity-dependent parameters, describing the self and inter-state contributions. The present study opens the route to control the quantum dynamics of multi-level systems and to quantify the quantum-control process.

Robust fault diagnosis of physical systems in operation. Ph.D. Thesis - Rutgers - The State Univ.

NASA Technical Reports Server (NTRS)

Abbott, Kathy Hamilton

1991-01-01

Ideas are presented and demonstrated for improved robustness in diagnostic problem solving of complex physical systems in operation, or operative diagnosis. The first idea is that graceful degradation can be viewed as reasoning at higher levels of abstraction whenever the more detailed levels proved to be incomplete or inadequate. A form of abstraction is defined that applies this view to the problem of diagnosis. In this form of abstraction, named status abstraction, two levels are defined. The lower level of abstraction corresponds to the level of detail at which most current knowledge-based diagnosis systems reason. At the higher level, a graph representation is presented that describes the real-world physical system. An incremental, constructive approach to manipulating this graph representation is demonstrated that supports certain characteristics of operative diagnosis. The suitability of this constructive approach is shown for diagnosing fault propagation behavior over time, and for sometimes diagnosing systems with feedback. A way is shown to represent different semantics in the same type of graph representation to characterize different types of fault propagation behavior. An approach is demonstrated that threats these different behaviors as different fault classes, and the approach moves to other classes when previous classes fail to generate suitable hypotheses. These ideas are implemented in a computer program named Draphys (Diagnostic Reasoning About Physical Systems) and demonstrated for the domain of inflight aircraft subsystems, specifically a propulsion system (containing two turbofan systems and a fuel system) and hydraulic subsystem.

Association between Polycystic Ovary Syndrome, Oral Microbiota and Systemic Antibody Responses

PubMed Central

Akcalı, Aliye; Bostanci, Nagihan; Özçaka, Özgün; Öztürk-Ceyhan, Banu; Gümüş, Pınar; Buduneli, Nurcan; Belibasakis, Georgios N.

2014-01-01

Polycystic ovary syndrome (PCOS) is a hormonal disorder of women that not only is the leading cause of infertility but also shows a reciprocal link with oral health. This study aimed to investigate the hypothesis that the levels of putative periodontal pathogens in saliva and their antibody response in serum are elevated in PCOS, compared to systemic health. A total of 125 women were included in four groups; 45 women with PCOS and healthy periodontium, 35 women with PCOS and gingivitis, 25 systemically and periodontally healthy women, 20 systemically healthy women with gingivitis. Salivary levels of seven putative periodontal pathogens were analyzed by quantitative real-time polymerase chain reaction and serum antibody levels were analyzed by ELISA. In women with PCOS, salivary Porphyromonas gingivalis, Fusobacterium nucleatum, Streptococcus oralis and Tannerella forsythia levels were higher than matched systemically healthy women, particularly in the case of gingivitis. Aggregatibacter actinomycetemcomitans and Treponema denticola levels were similar among study groups. The presence of PCOS also enhanced P. gingivalis, Prevotella intermedia and S. oralis serum antibody levels, when gingivitis was also present. Gingival inflammation correlated positively with levels of the studied taxa in saliva, particularly in PCOS. The presence of P. gingivalis and F. nucleatum in saliva also exhibited a strong positive correlation with the corresponding serum antibody levels. In conclusion, as an underlying systemic endocrine condition, PCOS may quantitatively affect the composition of oral microbiota and the raised systemic response to selective members of this microbial community, exerting a confounding role in resultant gingival inflammation and periodontal health. The most consistent effect appeared to be exerted on P. gingivalis. PMID:25232962

Wind Turbine Optimization with WISDEM

DOE Office of Scientific and Technical Information (OSTI.GOV)

Dykes, Katherine L; Damiani, Rick R; Graf, Peter A

This presentation for the Fourth Wind Energy Systems Engineering Workshop explains the NREL wind energy systems engineering initiative-developed analysis platform and research capability to capture important system interactions to achieve a better understanding of how to improve system-level performance and achieve system-level cost reductions. Topics include Wind-Plant Integrated System Design and Engineering Model (WISDEM) and multidisciplinary design analysis and optimization.

The architecture of a network level intrusion detection system

DOE Office of Scientific and Technical Information (OSTI.GOV)

Heady, R.; Luger, G.; Maccabe, A.

1990-08-15

This paper presents the preliminary architecture of a network level intrusion detection system. The proposed system will monitor base level information in network packets (source, destination, packet size, and time), learning the normal patterns and announcing anomalies as they occur. The goal of this research is to determine the applicability of current intrusion detection technology to the detection of network level intrusions. In particular, the authors are investigating the possibility of using this technology to detect and react to worm programs.

77 FR 56133 - Dinotefuran; Pesticide Tolerances

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-12

... is the nervous system but effects on the nervous system were only observed at high doses. Nervous... cholinergic nervous system seen after repeated dosing. Typically, low to moderate levels of neonicotinoids... peripheral nervous system (PNS). High levels of neonicotinoids can over stimulate the PNS, maintaining cation...

Intermediate Levels of Autonomy within the SSM/PMAD Breadboard

NASA Technical Reports Server (NTRS)

Dugal-Whitehead, Norma R.; Walls, Bryan

1995-01-01

The Space Station Module Power Management and Distribution (SSM/PMAD) bread-board is a test bed for the development of advanced power system control and automation. Software control in the SSM/PMAD breadboard is through co-operating systems, called Autonomous Agents. Agents can be a mixture of algorithmic software and expert systems. The early SSM/PMAD system was envisioned as being completely autonomous. It soon became apparent, though, that there would always be a need for human intervention, at least as long as a human interacts with the system in any way. In a system designed only for autonomous operation, manual intervention meant taking full control of the whole system, and loosing whatever expertise was in the system. Several methods for allowing humans to interact at an appropriate level of control were developed. This paper examines some of these intermediate modes of autonomy. The least humanly intrusive mode is simple monitoring. The ability to modify future behavior by altering a schedule involves high-level interaction. Modification of operating activities comes next. The coarsest mode of control is individual, unplanned operation of individual Power System components. Each of these levels is integrated into the SSM/PMAD breadboard, with support for the user (such as warnings of the consequences of control decisions) at every level.

A global "imaging'' view on systems approaches in immunology.

PubMed

Ludewig, Burkhard; Stein, Jens V; Sharpe, James; Cervantes-Barragan, Luisa; Thiel, Volker; Bocharov, Gennady

2012-12-01

The immune system exhibits an enormous complexity. High throughput methods such as the "-omic'' technologies generate vast amounts of data that facilitate dissection of immunological processes at ever finer resolution. Using high-resolution data-driven systems analysis, causal relationships between complex molecular processes and particular immunological phenotypes can be constructed. However, processes in tissues, organs, and the organism itself (so-called higher level processes) also control and regulate the molecular (lower level) processes. Reverse systems engineering approaches, which focus on the examination of the structure, dynamics and control of the immune system, can help to understand the construction principles of the immune system. Such integrative mechanistic models can properly describe, explain, and predict the behavior of the immune system in health and disease by combining both higher and lower level processes. Moving from molecular and cellular levels to a multiscale systems understanding requires the development of methodologies that integrate data from different biological levels into multiscale mechanistic models. In particular, 3D imaging techniques and 4D modeling of the spatiotemporal dynamics of immune processes within lymphoid tissues are central for such integrative approaches. Both dynamic and global organ imaging technologies will be instrumental in facilitating comprehensive multiscale systems immunology analyses as discussed in this review. © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Combining urbanization and hydrodynamics data to evaluate sea level rise impacts on coastal water resources

NASA Astrophysics Data System (ADS)

Young, C. R.; Martin, J. B.

2016-02-01

Assessments of the potential for salt water intrusion due to sea level rise require consideration of both coastal hydrodynamic and human activity thresholds. In siliciclastic systems, sea level rise may cause salt intrusion to coastal aquifers at annual or decadal scales, whereas in karst systems salt intrudes at the tidal scalse. In both cases, human activity impacts the freshwater portion of the system by altering the water demand on the aquifer. We combine physicochemical and human activity data to evaluate impact of sea level rise on salt intrusion to siliclastic (Indian River Lagoon, Fl, USA) and karst (Puerto Morelos, Yucatan, Mexico) systems under different sea level rise rate scenarios. Two hydrodynamic modeling scenarios are considered; flux controlled and head controlled. Under a flux controlled system hydraulic head gradients remain constant during sea level rise while under a head controlled system hydraulic graidents diminish, allowing saltwater intrusion. Our model contains three key terms; aquifer recharge, groundwater discharge and hydraulic conductivity. Groundwater discharge and hydraulic conductivity were calculated based on high frequency (karst system) and decadal (siliciclastic system) field measurements. Aquifer recharge is defined as precipitation less evapotranspiration and water demand was evaluated based on urban planning data that provided the regional water demand. Water demand includes agricultural area, toursim, traffic patterns, garbage collection and total population. Water demand was initially estimated using a partial leaset squares regression based on these variables. Our model indicates that water demand depends most on agricultural area, which has changed significantly over the last 30 years. In both systems, additional water demand creates a head controlled scenario, thus increaseing the protential fo salt intrusion with projected sea level rise.

Reliable Change and Outcome Trajectories Across Levels of Care in a Mental Health System for Youth.

PubMed

Jackson, David S; Keir, Scott S; Sender, Max; Mueller, Charles W

2017-01-01

Knowledge of mental health treatment outcome trajectories across various service types can be valuable for both system- and client-level decision-making. Using longitudinal youth functional impairment scores across 2807 treatment episodes, this study examined outcome trajectories and estimated the number of months required for reliable change across nine major services (or levels of care). Results indicate logarithmic improvement trajectories for a majority of levels of care and significant differences in time until improvement ranging from 4 to 12 months. Findings can guide system-level policies on lengths of treatment and service authorizations and provide expected treatment response data for client-level treatment decisions.

Access to the Albanian VET System: Social, Individual and School-Based Barriers

ERIC Educational Resources Information Center

Xhumari, Merita; Dibra, Sidita

2016-01-01

This article analyses the determinants of access to the VET system in Albania and its impact on the inclusion of young people and vulnerable groups. The VET system often attracts students who have completed the compulsory levels of education with weak academic results. Many come from families with a low level of income and a low education level.…

A Systems-Level Approach to Building Sustainable Assessment Cultures: Moderation, Quality Task Design and Dependability of Judgement

ERIC Educational Resources Information Center

Colbert, Peta; Wyatt-Smith, Claire; Klenowski, Val

2012-01-01

This article considers the conditions that are necessary at system and local levels for teacher assessment to be valid, reliable and rigorous. With sustainable assessment cultures as a goal, the article examines how education systems can support local-level efforts for quality learning and dependable teacher assessment. This is achieved through…

Advancement of Bi-Level Integrated System Synthesis (BLISS)

NASA Technical Reports Server (NTRS)

Sobieszczanski-Sobieski, Jaroslaw; Emiley, Mark S.; Agte, Jeremy S.; Sandusky, Robert R., Jr.

2000-01-01

Bi-Level Integrated System Synthesis (BLISS) is a method for optimization of an engineering system, e.g., an aerospace vehicle. BLISS consists of optimizations at the subsystem (module) and system levels to divide the overall large optimization task into sets of smaller ones that can be executed concurrently. In the initial version of BLISS that was introduced and documented in previous publications, analysis in the modules was kept at the early conceptual design level. This paper reports on the next step in the BLISS development in which the fidelity of the aerodynamic drag and structural stress and displacement analyses were upgraded while the method's satisfactory convergence rate was retained.

Influence of Periodontal Therapy on Systemic Lipopolysaccharides in Children with Localized Aggressive Periodontitis.

PubMed

Kalash, D; Vovk, A; Huang, H; Aukhil, I; Wallet, S M; Shaddox, L M

2015-01-01

A previous study has shown that children with localized aggressive periodontitis (LAP) demonstrate a lipopolysaccharide (LPS) hyper-responsiveness in addition to elevated levels of systemic LPS when compared to periodontally healthy children. The purpose of this study was to evaluate whether periodontal therapy modulates systemic lipopolysaccharide levels and whether these levels may influence clinical outcomes. Peripheral blood samples and clinical parameters (probing depth [PD], clinical attachment levels [CAL], percent sites greater than four mm, bleeding on probing [BoP], and visible plaque [P]) were collected from 29 LAP patients prior to and at three, six, and 12 months following scaling and root planning and systemic antibiotics. Serum LPS levels were quantified using a chromogenic assay. Twenty-five patients were compliant with the prescribed antibiotic treatment and demonstrated a significant reduction in LPS as well as overall PD, CAL, and plaque at all time points post-therapy. Additionally LPS reductions correlated with reductions in PD, CAL, and plaque. Localized aggressive periodontitis therapy with antibiotics plays an important role in reducing systemic lipopolysaccharide levels. Since LPS is a key mediator of the LAP hyperinflammatory response, its systemic reduction is especially important for the successful management of these children.

[Stakeholder representations of the role of the intermediate level of the DRC health system].

PubMed

Mbeva, Jean Bosco Kahindo; Karemere, Hermès; Schirvel, Carole; Porignon, Denis

2014-01-01

Intermediate health care structures in the DRC were designed during the setting-up of primary health care in a perspective of health district support. This study was designed to describe stakeholder representations of the intermediate level of the DRC health system during the first 30 years of the primary health care system. This case study was based on inductive analysis of data from 27 key informant interviews.. The intermediate level of the health system, lacking sufficient expertise and funding during the 1980s, was confined to inspection and control functions, answering to the central level of the Ministry of health and provincial authorities. Since the 1990s, faced with the pressing demand for support from health district teams, whose self-management had to deal with humanitarian emergencies, the need to integrate vertical programmes, and cope with the logistics of many different actors, the intermediate heath system developed methods and tools to support heath districts. This resulted in a subsidiary model of the intermediate level, the perceived efficacy of which varies according to the province over recent years. The "subsidiary" model of the intermediary health system level seems a good alternative to the "control" model in DRC.

A review of HIV/AIDS system-level interventions

PubMed Central

Bauermeister, José A.; Tross, Susan; Ehrhardt, Anke A.

2010-01-01

The escalating HIV/AIDS epidemic worldwide demands that on-going prevention efforts be strengthened, disseminated, and scaled-up. System-level interventions refer to programs aiming to improve the functioning of an agency as well as the delivery of its services to the community. System-level interventions are a promising approach to HIV/AIDS prevention because they focus on (a) improving the agency’s ability to adopt evidence-based HIV prevention and care programs; (b) develop and establish policies and procedures that maximize the sustainability of on-going prevention and care efforts; and (c) improve decision-making processes such as incorporating the needs of communities into their tailored services. We reviewed studies focusing on system-level interventions by searching multiple electronic abstracting indices, including PsycInfo, PubMed, and ProQuest. Twenty-three studies out of 624 peer-reviewed studies (published from January 1985 to February 2007) met study criteria. Most of the studies focused on strengthening agency infrastructure, while other studies included collaborative partnerships and technical assistance programs. Our findings suggest that system-level interventions are promising in strengthening HIV/AIDS prevention and treatment efforts. Based on our findings, we propose recommendations for future work in developing and evaluating system-level interventions. PMID:18369722

How does undergraduate college biology students' level of understanding, in regard to the role of the seed plant root system, relate to their level of understanding of photosynthesis?

NASA Astrophysics Data System (ADS)

Njeng'ere, James Gicheha

This research study investigated how undergraduate college biology students' level of understanding of the role of the seed plant root system relates to their level of understanding of photosynthesis. This research was conducted with 65 undergraduate non-majors biology who had completed 1 year of biology at Louisiana State University in Baton Rouge and Southeastern Louisiana University in Hammond. A root probe instrument was developed from some scientifically acceptable propositional statements about the root system, the process of photosynthesis, as well as the holistic nature of the tree. These were derived from research reviews of the science education and the arboriculture literature. This was administered to 65 students selected randomly from class lists of the two institutions. Most of the root probe's items were based on the Live Oak tree. An in-depth, clinical interview-based analysis was conducted with 12 of those tested students. A team of root experts participated by designing, validating and answering the same questions that the students were asked. A "systems" lens as defined by a team of college instructors, root experts (Shigo, 1991), and this researcher was used to interpret the results. A correlational coefficient determining students' level of understanding of the root system and their level of understanding of the process of photosynthesis was established by means of Pearson's r correlation (r = 0.328) using the SAS statistical analysis (SAS, 1987). From this a coefficient of determination (r2 = 0.104) was determined. Students' level of understanding of the Live Oak root system (mean score 5.94) was not statistically different from their level of understanding of the process of photosynthesis (mean score 5.54) as assessed by the root probe, t (129) = 0.137, p > 0.05 one tailed-test. This suggests that, to some degree, level of the root system limits level of understanding of photosynthesis and vice versa. Analysis of quantitative and qualitative data revealed that students who applied principles of systems thinking performed better than those who did not. Students' understanding of the root system of the Live Oak tree was hindered by understanding of, plant food, the nonwoody roots, and the tree as a system.

Occurrence of lead-related symptoms below the current occupational safety and health act allowable blood lead levels.

PubMed

Rosenman, Kenneth D; Sims, Amy; Luo, Zhehui; Gardiner, Joseph

2003-05-01

To determine the occurrence of symptoms of lead toxicity at levels below the current allowable Occupational Safety and Health Act blood lead level of 50 micrograms/dL, standardized telephone interviews were conducted of individuals reported to a statewide laboratory-based surveillance system. Four hundred and ninety-seven, or 75%, of the eligible participants were interviewed. Gastrointestinal, musculoskeletal, and nervous system symptoms increased with increasing blood lead levels. Nervous, gastrointestinal, and musculoskeletal symptoms all began to be increased in individuals with blood leads between 30-39 micrograms/dL and possibly at levels as low as 25-30 micrograms/dL for nervous system symptoms. The results of this study of increased symptoms are consistent with and provide added weight to previous results showing subclinical changes in the neurologic and renal systems and sperm counts at blood lead levels currently allowed by the Occupational Safety and Health Act.

Integration of supercapacitive storage in renewable energy system to compare the response of two level and five level inverter with RL type load

NASA Astrophysics Data System (ADS)

Jana, Suman; Biswas, Pabitra Kumar; Das, Upama

2018-04-01

The analytical and simulation-based study in this presented paper shows a comparative report between two level inverter and five-level inverter with the integration of Supercapacitive storage in Renewable Energy system. Sometime dependent numerical models are used to measure the voltage and current response of two level and five level inverter in MATLAB Simulink based environment. In this study supercapacitive sources, which are fed by solar cells are used as input sources to experiment the response of multilevel inverter with integration of su-percapacitor as a storage device of Renewable Energy System. The RL load is used to compute the time response in MATLABSimulink based environment. With the simulation results a comparative study has been made of two different level types of inverters. Two basic types of inverter are discussed in the study with reference to their electrical behavior. It is also simulated that multilevel inverter can convert stored energy within supercapacitor which is extracted from Renewable Energy System.

Interactive classification and content-based retrieval of tissue images

NASA Astrophysics Data System (ADS)

Aksoy, Selim; Marchisio, Giovanni B.; Tusk, Carsten; Koperski, Krzysztof

2002-11-01

We describe a system for interactive classification and retrieval of microscopic tissue images. Our system models tissues in pixel, region and image levels. Pixel level features are generated using unsupervised clustering of color and texture values. Region level features include shape information and statistics of pixel level feature values. Image level features include statistics and spatial relationships of regions. To reduce the gap between low-level features and high-level expert knowledge, we define the concept of prototype regions. The system learns the prototype regions in an image collection using model-based clustering and density estimation. Different tissue types are modeled using spatial relationships of these regions. Spatial relationships are represented by fuzzy membership functions. The system automatically selects significant relationships from training data and builds models which can also be updated using user relevance feedback. A Bayesian framework is used to classify tissues based on these models. Preliminary experiments show that the spatial relationship models we developed provide a flexible and powerful framework for classification and retrieval of tissue images.

Medical education in cyberspace: critical considerations in the health system

PubMed Central

YAZDANI, SHAHRAM; KHOSHGOFTAR, ZOHREH; AHMADY, SOLEIMAN; RASTEGARPOUR, HASSAN; FOROUTAN, SEYED ABBAS

2017-01-01

Introduction: Over the past few decades, two revolutionary approaches have emerged as a new form of medical education: Electronic Medical Education and Web-based Medical Education. A number of well-known medical institutions, such as Harvard and Johns Hopkins used a wide range of cyberspace capabilities to increase their competitiveness. Researchers have expressed that cyberspace will change health system’s main objective of training physicians and medical education. We conducted this study to identify the health system critical considerations on core issues, involving the development of medical education on cyberspace. Methods: In order to conduct this study, we observed the steps of a critical literature review, combined with the ‘Four-phase method’ adopted by Carnwell and Daly. We focused on particular literature on health and cyber system functions; it was associated with systemic approach. Results: We developed a six-level taxonomy, Cyber level, Governance level, Ministerial level, Organizational level, Program level and Performance level, as a key solution that can be applied for the success of medical education on cyberspace. The results were summarized and appraised in more details. Conclusion: Medical education on cyberspace is a complex interdisciplinary system. It is important that all aspects of the health systems be involved as integral to the development of cyber based medical education; without this convergence, we will be confused by the decisions made by others within the system. Health system should also communicate with those external sectors that are critical to achieving better learning on cyberspace. Integrated planning, governance and management of medical education in cyberspace are pivotal elements for the promotion. PMID:28124017

A particle swarm model for estimating reliability and scheduling system maintenance

NASA Astrophysics Data System (ADS)

Puzis, Rami; Shirtz, Dov; Elovici, Yuval

2016-05-01

Modifying data and information system components may introduce new errors and deteriorate the reliability of the system. Reliability can be efficiently regained with reliability centred maintenance, which requires reliability estimation for maintenance scheduling. A variant of the particle swarm model is used to estimate reliability of systems implemented according to the model view controller paradigm. Simulations based on data collected from an online system of a large financial institute are used to compare three component-level maintenance policies. Results show that appropriately scheduled component-level maintenance greatly reduces the cost of upholding an acceptable level of reliability by reducing the need in system-wide maintenance.

Assessment of the impact of dipped guideways on urban rail transit systems: Ventilation and safety requirements

NASA Technical Reports Server (NTRS)

1982-01-01

The ventilation and fire safety requirements for subway tunnels with dipped profiles between stations as compared to subway tunnels with level profiles were evaluated. This evaluation is based upon computer simulations of a train fire emergency condition. Each of the tunnel configurations evaluated was developed from characteristics that are representative of modern transit systems. The results of the study indicate that: (1) The level tunnel system required about 10% more station cooling than dipped tunnel systems in order to meet design requirements; and (2) The emergency ventilation requirements are greater with dipped tunnel systems than with level tunnel systems.

A Read-Aloud Storybook Selection System for Prereaders at the Preschool Language Level: A Pilot Study

PubMed Central

van Kleeck, Anne; Beaton, Derek; Horne, Erin; MacKenzie, Heather; Abdi, Hervé

2015-01-01

Purpose Many well-accepted systems for determining difficulty level exist for books children read independently, but few are available for determining the wide range of difficulty levels of storybooks read aloud to preschoolers. Also, the available tools list book characteristics only on the basis of parents' or authors' opinions. We created an empirically derived difficulty-level system on the basis of 22 speech-language pathologists' (SLPs) judgments of specific storybooks used in preschooler read-alouds. Method SLPs sorted 11 storybooks into ranked stacks on the basis of how difficult they thought the storybooks would be for preschoolers to understand when read aloud. SLPs described each stack globally as well as why they assigned each storybook to a particular stack. From transcriptions of the explanations, we derived a glossary of book characteristics using content analysis. We created a difficulty-level scale using a multivariate analysis technique that simultaneously analyzed book sorts and glossary terms. Results The book selection system includes a glossary of book characteristics, a 4-level difficulty scale, and exemplar books for each level. Conclusion This empirically derived difficulty-level system created for storybooks read aloud to preschoolers represents a step toward filling a gap in the read-aloud literature. PMID:26089030

Opening up closure. Semiotics across scales

PubMed

Lemke

2000-01-01

The dynamic emergence of new levels of organization in complex systems is related to the semiotic reorganization of discrete/continuous variety at the level below as continuous/discrete meaning for the level above. In this view both the semiotic and the dynamic closure of system levels is reopened to allow the development and evolution of greater complexity.

Maturity analysis of the innovation system in the livestock industries of West Sumatra, Indonesia

NASA Astrophysics Data System (ADS)

Suresti, A.; Dinata, U. G. S.; Wati, R.

2018-02-01

The main objective of this study was to analyse the ANIS of Livestock industry in West Sumatera according to its main determinants. This research aims to know and understand the maturity level of the regional innovationsystem of West Sumatra livestock industries, including recommendation for improvements. The maturity level of the regional innovation system was analyzed with the ANIS method by using an opinion survey to some experts from businessmen, government and universities. This expert opinion survey was conducted to measure expert perceptions on the implementations of determinants of west Sumatera regional innovations systems on livestock industries on macro level (innovations policy), mezzo level (innovation institutions and programs) and micro level (innovation capacity). By using Likert method, the result showed maturity level for the West Sumatra livestock industries innovation system was still develop. This is caused by low maturity in the macro and meso determinants which are at the central and regional government side. This research result may be useful as recommendations for the government for improving the maturity level and may be a basic for incoming researches to identify regional innovation system determinants with low maturity to improve.

Groundwater-level trends in the U.S. glacial aquifer system, 1964-2013

USGS Publications Warehouse

Hodgkins, Glenn A.; Dudley, Robert W.; Nielsen, Martha G.; Renard, Benjamin; Qi, Sharon L.

2017-01-01

The glacial aquifer system in the United States is a major source of water supply but previous work on historical groundwater trends across the system is lacking. Trends in annual minimum, mean, and maximum groundwater levels for 205 monitoring wells were analyzed across three regions of the system (East, Central, West Central) for four time periods: 1964-2013, 1974-2013, 1984-2013, and 1994-2013. Trends were computed separately for wells in the glacial aquifer system with low potential for human influence on groundwater levels and ones with high potential influence from activities such as groundwater pumping. Generally there were more wells with significantly increasing groundwater levels (levels closer to ground surface) than wells with significantly decreasing levels. The highest numbers of significant increases for all four time periods were with annual minimum and/or mean levels. There were many more wells with significant increases from 1964 to 2013 than from more recent periods, consistent with low precipitation in the 1960s. Overall there were low numbers of wells with significantly decreasing trends regardless of time period considered; the highest number of these were generally for annual minimum groundwater levels at wells with likely human influence. There were substantial differences in the number of wells with significant groundwater-level trends over time, depending on whether the historical time series are assumed to be independent, have short-term persistence, or have long-term persistence. Mean annual groundwater levels have significant lag-one-year autocorrelation at 26.0% of wells in the East region, 65.4% of wells in the Central region, and 100% of wells in the West Central region. Annual precipitation across the glacial aquifer system, on the other hand, has significant autocorrelation at only 5.5% of stations, about the percentage expected due to chance.

Laser-activated remote phosphor light engine for projection applications

NASA Astrophysics Data System (ADS)

Daniels, Martin; Mehl, Oliver; Hartwig, Ulrich

2015-09-01

Recent developments in blue emitting laser diodes enable attractive solutions in projection applications using phosphors for efficient light conversion with very high luminance levels. Various commercially available projectors incorporating this technology have entered the market in the past years. While luminous flux levels are still comparable to lamp-based systems, lifetime expectations of classical lamp systems are exceeded by far. OSRAM GmbH has been exploring this technology for several years and has introduced the PHASER® brand name (Phosphor + laser). State-of-the-art is a rotating phosphor wheel excited by blue laser diodes to deliver the necessary primary colors, either sequentially for single-imager projection engines, or simultaneously for 3-panel systems. The PHASER® technology enables flux and luminance scaling, which allows for smaller imagers and therefore cost-efficient projection solutions. The resulting overall efficiency and ANSI lumen specification at the projection screen of these systems is significantly determined by the target color gamut and the light transmission efficiency of the projection system. With increasing power and flux level demand, thermal issues, especially phosphor conversion related, dominate the opto-mechanical system design requirements. These flux levels are a great challenge for all components of an SSL-projection system (SSL:solid-state lighting). OSRAḾs PHASER® light engine platform is constantly expanded towards higher luminous flux levels as well as higher luminance levels for various applications. Recent experiments employ blue laser pump powers of multiple 100 Watts to excite various phosphors resulting in luminous flux levels of more than 40 klm.

System modeling of the Thirty Meter Telescope alignment and phasing system

NASA Astrophysics Data System (ADS)

Dekens, Frank G.; Seo, Byoung-Joon; Troy, Mitchell

2014-08-01

We have developed a system model using the System Modeling Language (SysML) for the Alignment and Phasing System (APS) on the Thirty Meter Telescope (TMT). APS is a Shack-Hartmann wave-front sensor that will be used to measure the alignment and phasing of the primary mirror segments, and the alignment of the secondary and tertiary mirrors. The APS system model contains the ow-down of the Level 1 TMT requirements to APS (Level 2) requirements, and from there to the APS sub-systems (Level 3) requirements. The model also contains the operating modes and scenarios for various activities, such as maintenance alignment, post-segment exchange alignment, and calibration activities. The requirements ow-down is captured in SysML requirements diagrams, and we describe the process of maintaining the DOORS database as the single-source-of-truth for requirements, while using the SysML model to capture the logic and notes associated with the ow-down. We also use the system model to capture any needed communications from APS to other TMT systems, and between the APS sub-systems. The operations are modeled using SysML activity diagrams, and will be used to specify the APS interface documents. The modeling tool can simulate the top level activities to produce sequence diagrams, which contain all the communications between the system and subsystem needed for that activity. By adding time estimates for the lowest level APS activities, a robust estimate for the total time on-sky that APS requires to align and phase the telescope can be obtained. This estimate will be used to verify that the time APS requires on-sky meets the Level 1 TMT requirements.

Pulse design for multilevel systems by utilizing Lie transforms

NASA Astrophysics Data System (ADS)

Kang, Yi-Hao; Chen, Ye-Hong; Shi, Zhi-Cheng; Huang, Bi-Hua; Song, Jie; Xia, Yan

2018-03-01

We put forward a scheme to design pulses to manipulate multilevel systems with Lie transforms. A formula to reverse construct a control Hamiltonian is given and is applied in pulse design in the three- and four-level systems as examples. To demonstrate the validity of the scheme, we perform numerical simulations, which show the population transfers for cascaded three-level and N -type four-level Rydberg atoms can be completed successfully with high fidelities. Therefore, the scheme may benefit quantum information tasks based on multilevel systems.

High-Level Data-Abstraction System

NASA Technical Reports Server (NTRS)

Fishwick, P. A.

1986-01-01

Communication with data-base processor flexible and efficient. High Level Data Abstraction (HILDA) system is three-layer system supporting data-abstraction features of Intel data-base processor (DBP). Purpose of HILDA establishment of flexible method of efficiently communicating with DBP. Power of HILDA lies in its extensibility with regard to syntax and semantic changes. HILDA's high-level query language readily modified. Offers powerful potential to computer sites where DBP attached to DEC VAX-series computer. HILDA system written in Pascal and FORTRAN 77 for interactive execution.

Resource Management in Constrained Dynamic Situations

NASA Astrophysics Data System (ADS)

Seok, Jinwoo

Resource management is considered in this dissertation for systems with limited resources, possibly combined with other system constraints, in unpredictably dynamic environments. Resources may represent fuel, power, capabilities, energy, and so on. Resource management is important for many practical systems; usually, resources are limited, and their use must be optimized. Furthermore, systems are often constrained, and constraints must be satisfied for safe operation. Simplistic resource management can result in poor use of resources and failure of the system. Furthermore, many real-world situations involve dynamic environments. Many traditional problems are formulated based on the assumptions of given probabilities or perfect knowledge of future events. However, in many cases, the future is completely unknown, and information on or probabilities about future events are not available. In other words, we operate in unpredictably dynamic situations. Thus, a method is needed to handle dynamic situations without knowledge of the future, but few formal methods have been developed to address them. Thus, the goal is to design resource management methods for constrained systems, with limited resources, in unpredictably dynamic environments. To this end, resource management is organized hierarchically into two levels: 1) planning, and 2) control. In the planning level, the set of tasks to be performed is scheduled based on limited resources to maximize resource usage in unpredictably dynamic environments. In the control level, the system controller is designed to follow the schedule by considering all the system constraints for safe and efficient operation. Consequently, this dissertation is mainly divided into two parts: 1) planning level design, based on finite state machines, and 2) control level methods, based on model predictive control. We define a recomposable restricted finite state machine to handle limited resource situations and unpredictably dynamic environments for the planning level. To obtain a policy, dynamic programing is applied, and to obtain a solution, limited breadth-first search is applied to the recomposable restricted finite state machine. A multi-function phased array radar resource management problem and an unmanned aerial vehicle patrolling problem are treated using recomposable restricted finite state machines. Then, we use model predictive control for the control level, because it allows constraint handling and setpoint tracking for the schedule. An aircraft power system management problem is treated that aims to develop an integrated control system for an aircraft gas turbine engine and electrical power system using rate-based model predictive control. Our results indicate that at the planning level, limited breadth-first search for recomposable restricted finite state machines generates good scheduling solutions in limited resource situations and unpredictably dynamic environments. The importance of cooperation in the planning level is also verified. At the control level, a rate-based model predictive controller allows good schedule tracking and safe operations. The importance of considering the system constraints and interactions between the subsystems is indicated. For the best resource management in constrained dynamic situations, the planning level and the control level need to be considered together.

Talking about quality: exploring how 'quality' is conceptualized in European hospitals and healthcare systems.

PubMed

Wiig, Siri; Aase, Karina; von Plessen, Christian; Burnett, Susan; Nunes, Francisco; Weggelaar, Anne Marie; Anderson-Gare, Boel; Calltorp, Johan; Fulop, Naomi

2014-10-11

Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study. This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics). The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided. The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.

How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study.

PubMed

Chieregato, Arturo; Volpi, Annalisa; Gordini, Giovanni; Ventura, Chiara; Barozzi, Marco; Caspani, Maria Luisa Rita; Fabbri, Andrea; Ferrari, Anna Maria; Ferri, Enrico; Giugni, Aimone; Marino, Massimiliano; Martino, Costanza; Pizzamiglio, Mario; Ravaldini, Maurizio; Russo, Emanuele; Trabucco, Laura; Trombetti, Susanna; De Palma, Rossana

2017-09-29

To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system. ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million. 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only. A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit. The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study

PubMed Central

Volpi, Annalisa; Gordini, Giovanni; Ventura, Chiara; Barozzi, Marco; Caspani, Maria Luisa Rita; Fabbri, Andrea; Ferrari, Anna Maria; Ferri, Enrico; Giugni, Aimone; Marino, Massimiliano; Martino, Costanza; Pizzamiglio, Mario; Ravaldini, Maurizio; Russo, Emanuele; Trabucco, Laura; Trombetti, Susanna; De Palma, Rossana

2017-01-01

Objective To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system. Setting ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million. Participants 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only. Results A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit. Conclusion The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems. PMID:28965094

Document Level Assessment of Document Retrieval Systems in a Pairwise System Evaluation

ERIC Educational Resources Information Center

Rajagopal, Prabha; Ravana, Sri Devi

2017-01-01

Introduction: The use of averaged topic-level scores can result in the loss of valuable data and can cause misinterpretation of the effectiveness of system performance. This study aims to use the scores of each document to evaluate document retrieval systems in a pairwise system evaluation. Method: The chosen evaluation metrics are document-level…

Extent of Integration of Priority Interventions into General Health Systems: A Case Study of Neglected Tropical Diseases Programme in the Western Region of Ghana.

PubMed

Mensah, Ernest O; Aikins, Moses K; Gyapong, Margaret; Anto, Francis; Bockarie, Moses J; Gyapong, John O

2016-05-01

The global health system has a large arsenal of interventions, medical products and technologies to address current global health challenges. However, identifying the most effective and efficient strategies to deliver these resources to where they are most needed has been a challenge. Targeted and integrated interventions have been the main delivery strategies. However, the health system discourse increasingly favours integrated strategies in the context of functionally merging targeted interventions with multifunctional health care delivery systems with a focus on strengthening country health systems to deliver needed interventions. Neglected Tropical Diseases (NTD) have been identified to promote and perpetuate poverty hence there has been global effort to combat these diseases. The Neglected Tropical Diseases Programme (NTDP) in Ghana has a national programme team and office, however, it depends on the multifunctional health delivery system at the regional and district level to implement interventions. The NTDP seeks further health system integration to accelerate achievement of coverage targets. The study estimated the extent of integration of the NTDP at the national, regional and district levels to provide evidence to guide further integration. The research design was a descriptive case study that interviewed key persons involved in the programme at the three levels of the health system as well as extensive document review. Integration was assessed on two planes-across health system functions-stewardship and governance, financing, planning, service delivery, monitoring and evaluation and demand generation; and across three administrative levels of the health system-national, regional and district. A composite measure of integration designated Cumulative Integration Index (CII) with a range of 0.00-1.00 was used to estimate extent of integration at the three levels of the health system. Service delivery was most integrated while financing and planning were least integrated. Extent of integration was partial at all levels of the health system with a CII of 0.48-0.68; however it was higher at the district compared to the national and regional levels. To ensure further integration of the NTDP, planning and finance management activities must be decentralized to involve regional and district levels of the health system. The study provides an empirical measure of extent of integration and indicators to guide further integration.

PsiQuaSP-A library for efficient computation of symmetric open quantum systems.

PubMed

Gegg, Michael; Richter, Marten

2017-11-24

In a recent publication we showed that permutation symmetry reduces the numerical complexity of Lindblad quantum master equations for identical multi-level systems from exponential to polynomial scaling. This is important for open system dynamics including realistic system bath interactions and dephasing in, for instance, the Dicke model, multi-Λ system setups etc. Here we present an object-oriented C++ library that allows to setup and solve arbitrary quantum optical Lindblad master equations, especially those that are permutationally symmetric in the multi-level systems. PsiQuaSP (Permutation symmetry for identical Quantum Systems Package) uses the PETSc package for sparse linear algebra methods and differential equations as basis. The aim of PsiQuaSP is to provide flexible, storage efficient and scalable code while being as user friendly as possible. It is easily applied to many quantum optical or quantum information systems with more than one multi-level system. We first review the basics of the permutation symmetry for multi-level systems in quantum master equations. The application of PsiQuaSP to quantum dynamical problems is illustrated with several typical, simple examples of open quantum optical systems.

The structure of the clouds distributed operating system

NASA Technical Reports Server (NTRS)

Dasgupta, Partha; Leblanc, Richard J., Jr.

1989-01-01

A novel system architecture, based on the object model, is the central structuring concept used in the Clouds distributed operating system. This architecture makes Clouds attractive over a wide class of machines and environments. Clouds is a native operating system, designed and implemented at Georgia Tech. and runs on a set of generated purpose computers connected via a local area network. The system architecture of Clouds is composed of a system-wide global set of persistent (long-lived) virtual address spaces, called objects that contain persistent data and code. The object concept is implemented at the operating system level, thus presenting a single level storage view to the user. Lightweight treads carry computational activity through the code stored in the objects. The persistent objects and threads gives rise to a programming environment composed of shared permanent memory, dispensing with the need for hardware-derived concepts such as the file systems and message systems. Though the hardware may be distributed and may have disks and networks, the Clouds provides the applications with a logically centralized system, based on a shared, structured, single level store. The current design of Clouds uses a minimalist philosophy with respect to both the kernel and the operating system. That is, the kernel and the operating system support a bare minimum of functionality. Clouds also adheres to the concept of separation of policy and mechanism. Most low-level operating system services are implemented above the kernel and most high level services are implemented at the user level. From the measured performance of using the kernel mechanisms, we are able to demonstrate that efficient implementations are feasible for the object model on commercially available hardware. Clouds provides a rich environment for conducting research in distributed systems. Some of the topics addressed in this paper include distributed programming environments, consistency of persistent data and fault-tolerance.

A Human Factors Approach to Bridging Systems and Introducing New Technologies

NASA Technical Reports Server (NTRS)

Kanki, Barbara G.

2011-01-01

The application of human factors in aviation has grown to cover a wide range of disciplines and methods capable of assessing human-systems integration at many levels. For example, at the individual level, pilot workload may be studied while at the team level, coordinated workload distribution may be the focal point. At the organizational level, the way in which individuals and teams are supported by training and standards, policies and procedures may introduce additional, relevant topics. A consideration of human factors at each level contributes to our understanding of successes and failures in pilot performance, but this system focused on the flight deck alone -- is only one part of the airspace system. In the FAA's NextGen plan to overhaul the National Airspace System (NAS), new capabilities will enhance flightdeck systems (pilots), flight operations centers (dispatchers) and air traffic control systems (controllers and air traffic managers). At a minimum, the current roles and responsibilities of these three systems are likely to change. Since increased automation will be central to many of the enhancements, the role of automation is also likely to change. Using NextGen examples, a human factors approach for bridging complex airspace systems will be the main focus of this presentation. It is still crucial to consider the human factors within each system, but the successful implementation of new technologies in the NAS requires an understanding of the collaborations that occur when these systems intersect. This human factors approach to studying collaborative systems begins with detailed task descriptions within each system to establish a baseline of the current operations. The collaborative content and context are delineated through the review of regulatory and advisory materials, letters of agreement, policies, procedures and documented practices. Field observations and interviews also help to fill out the picture. Key collaborative functions across systems are identified and placed on a phase-of-flight timeline including information requirements, decision authority and use of automation, as well as level of frequency and criticality.

Predicting in vivo effect levels for repeat-dose systemic toxicity using chemical, biological, kinetic and study covariates.

PubMed

Truong, Lisa; Ouedraogo, Gladys; Pham, LyLy; Clouzeau, Jacques; Loisel-Joubert, Sophie; Blanchet, Delphine; Noçairi, Hicham; Setzer, Woodrow; Judson, Richard; Grulke, Chris; Mansouri, Kamel; Martin, Matthew

2018-02-01

In an effort to address a major challenge in chemical safety assessment, alternative approaches for characterizing systemic effect levels, a predictive model was developed. Systemic effect levels were curated from ToxRefDB, HESS-DB and COSMOS-DB from numerous study types totaling 4379 in vivo studies for 1247 chemicals. Observed systemic effects in mammalian models are a complex function of chemical dynamics, kinetics, and inter- and intra-individual variability. To address this complex problem, systemic effect levels were modeled at the study-level by leveraging study covariates (e.g., study type, strain, administration route) in addition to multiple descriptor sets, including chemical (ToxPrint, PaDEL, and Physchem), biological (ToxCast), and kinetic descriptors. Using random forest modeling with cross-validation and external validation procedures, study-level covariates alone accounted for approximately 15% of the variance reducing the root mean squared error (RMSE) from 0.96 log 10 to 0.85 log 10  mg/kg/day, providing a baseline performance metric (lower expectation of model performance). A consensus model developed using a combination of study-level covariates, chemical, biological, and kinetic descriptors explained a total of 43% of the variance with an RMSE of 0.69 log 10  mg/kg/day. A benchmark model (upper expectation of model performance) was also developed with an RMSE of 0.5 log 10  mg/kg/day by incorporating study-level covariates and the mean effect level per chemical. To achieve a representative chemical-level prediction, the minimum study-level predicted and observed effect level per chemical were compared reducing the RMSE from 1.0 to 0.73 log 10  mg/kg/day, equivalent to 87% of predictions falling within an order-of-magnitude of the observed value. Although biological descriptors did not improve model performance, the final model was enriched for biological descriptors that indicated xenobiotic metabolism gene expression, oxidative stress, and cytotoxicity, demonstrating the importance of accounting for kinetics and non-specific bioactivity in predicting systemic effect levels. Herein, we generated an externally predictive model of systemic effect levels for use as a safety assessment tool and have generated forward predictions for over 30,000 chemicals.

Performance Evaluation of Multimodal Multifeature Authentication System Using KNN Classification.

PubMed

Rajagopal, Gayathri; Palaniswamy, Ramamoorthy

2015-01-01

This research proposes a multimodal multifeature biometric system for human recognition using two traits, that is, palmprint and iris. The purpose of this research is to analyse integration of multimodal and multifeature biometric system using feature level fusion to achieve better performance. The main aim of the proposed system is to increase the recognition accuracy using feature level fusion. The features at the feature level fusion are raw biometric data which contains rich information when compared to decision and matching score level fusion. Hence information fused at the feature level is expected to obtain improved recognition accuracy. However, information fused at feature level has the problem of curse in dimensionality; here PCA (principal component analysis) is used to diminish the dimensionality of the feature sets as they are high dimensional. The proposed multimodal results were compared with other multimodal and monomodal approaches. Out of these comparisons, the multimodal multifeature palmprint iris fusion offers significant improvements in the accuracy of the suggested multimodal biometric system. The proposed algorithm is tested using created virtual multimodal database using UPOL iris database and PolyU palmprint database.

Performance Evaluation of Multimodal Multifeature Authentication System Using KNN Classification

PubMed Central

Rajagopal, Gayathri; Palaniswamy, Ramamoorthy

2015-01-01

This research proposes a multimodal multifeature biometric system for human recognition using two traits, that is, palmprint and iris. The purpose of this research is to analyse integration of multimodal and multifeature biometric system using feature level fusion to achieve better performance. The main aim of the proposed system is to increase the recognition accuracy using feature level fusion. The features at the feature level fusion are raw biometric data which contains rich information when compared to decision and matching score level fusion. Hence information fused at the feature level is expected to obtain improved recognition accuracy. However, information fused at feature level has the problem of curse in dimensionality; here PCA (principal component analysis) is used to diminish the dimensionality of the feature sets as they are high dimensional. The proposed multimodal results were compared with other multimodal and monomodal approaches. Out of these comparisons, the multimodal multifeature palmprint iris fusion offers significant improvements in the accuracy of the suggested multimodal biometric system. The proposed algorithm is tested using created virtual multimodal database using UPOL iris database and PolyU palmprint database. PMID:26640813

Wireless Fluid-Level Measurement System Equips Boat Owners

NASA Technical Reports Server (NTRS)

2008-01-01

While developing a measurement acquisition system to be used to retrofit aging aircraft with vehicle health monitoring capabilities, Langley Research Center developed an innovative wireless fluid-level measurement system. The NASA technology was of interest to Tidewater Sensors LLC, of Newport News, Virginia, because of its many advantages over conventional fuel management systems, including its ability to provide an accurate measurement of volume while a boat is experiencing any rocking motion due to waves or people moving about on the boat. These advantages led the company to license this novel fluid-level measurement system from NASA for marine applications.

Vehicle-Level Reasoning Systems: Integrating System-Wide Data to Estimate the Instantaneous Health State

NASA Technical Reports Server (NTRS)

Srivastava, Ashok N.; Mylaraswmay, Dinkar; Mah, Robert W.; Cooper, Eric G.

2011-01-01

At the aircraft level, a Vehicle-Level Reasoning System (VLRS) can be developed to provide aircraft with at least two significant capabilities: improvement of aircraft safety due to enhanced monitoring and reasoning about the aircrafts health state, and also potential cost savings by enabling Condition Based Maintenance (CBM). Along with the benefits of CBM, an important challenge facing aviation safety today is safeguarding against system and component failures and malfunctions. Faults can arise in one or more aircraft subsystem their effects in one system may propagate to other subsystems, and faults may interact.

The effects of aquaculture production noise on the growth, condition factor, feed conversion, and survival of rainbow trout, Oncorhynchus mykiss

USDA-ARS?s Scientific Manuscript database

Intensive aquaculture systems, particularly recirculating systems, utilize equipment such as aerators, air and water pumps, blowers, and filtration systems that inadvertently increase noise levels in fish culture tanks. Sound levels and frequencies measured within intensive aquaculture systems are w...

A Study of Information Systems Outsourcing Influential Factors.

ERIC Educational Resources Information Center

Claver, Enrique; Gonzalez, Reyes; Gasco, Jose; Llopis, Juan

2002-01-01

Surveyed information systems managers at Spanish public universities to determine the level of information systems outsourcing. Also determined how factors such as the size of universities and their information systems departments, as well as the degree of involvement of rector's and general manager's teams, influence outsourcing levels. (EV)

A preliminary classification system for vegetation of Alaska.

Treesearch

Leslie A. Viereck; C.T. Dyrness

1980-01-01

A hierarchical system, with five levels of resolution, is proposed for classifying Alaska vegetation. The system, which is agglomerative, starts with 415 known Alaska plant communities which are listed and referenced. At the broadest level of resolution the system contains five formations - forest, tundra, shrubland, herbaceous vegetation, and aquatic vegetation.

Wage Payment Systems. Supervising: Economic and Financial Aspects. The Choice Series #73. A Self Learning Opportunity.

ERIC Educational Resources Information Center

Carlisle, Ysanne

This student guide is intended to assist persons employed as supervisors in understanding various wage payment systems. Discussed in the first four sections are the following topics: the aims and determination of payment (aims of a payment system, the economy and wage levels, the government and wage levels, and method of pay and wage levels); main…

Petri net-based dependability modeling methodology for reconfigurable field programmable gate arrays

NASA Astrophysics Data System (ADS)

Graczyk, Rafał; Orleański, Piotr; Poźniak, Krzysztof

2015-09-01

Dependability modeling is an important issue for aerospace and space equipment designers. From system level perspective, one has to choose from multitude of possible architectures, redundancy levels, component combinations in a way to meet desired properties and dependability and finally fit within required cost and time budgets. Modeling of such systems is getting harder as its levels of complexity grow together with demand for more functional and flexible, yet more available systems that govern more and more crucial parts of our civilization's infrastructure (aerospace transport systems, telecommunications, exploration probes). In this article promising method of modeling complex systems using Petri networks is introduced in context of qualitative and quantitative dependability analysis. This method, although with some limitation and drawback offer still convenient visual formal method of describing system behavior on different levels (functional, timing, random events) and offers straight correspondence to underlying mathematical engine, perfect for simulations and engineering support.

Multi-level analysis in information systems research: the case of enterprise resource planning system usage in China

NASA Astrophysics Data System (ADS)

Sun, Yuan; Bhattacherjee, Anol

2011-11-01

Information technology (IT) usage within organisations is a multi-level phenomenon that is influenced by individual-level and organisational-level variables. Yet, current theories, such as the unified theory of acceptance and use of technology, describe IT usage as solely an individual-level phenomenon. This article postulates a model of organisational IT usage that integrates salient organisational-level variables such as user training, top management support and technical support within an individual-level model to postulate a multi-level model of IT usage. The multi-level model was then empirically validated using multi-level data collected from 128 end users and 26 managers in 26 firms in China regarding their use of enterprise resource planning systems and analysed using the multi-level structural equation modelling (MSEM) technique. We demonstrate the utility of MSEM analysis of multi-level data relative to the more common structural equation modelling analysis of single-level data and show how single-level data can be aggregated to approximate multi-level analysis when multi-level data collection is not possible. We hope that this article will motivate future scholars to employ multi-level data and multi-level analysis for understanding organisational phenomena that are truly multi-level in nature.

Measuring healthcare productivity - from unit to system level.

PubMed

Kämäräinen, Vesa Johannes; Peltokorpi, Antti; Torkki, Paulus; Tallbacka, Kaj

2016-04-18

Purpose - Healthcare productivity is a growing issue in most Western countries where healthcare expenditure is rapidly increasing. Therefore, accurate productivity metrics are essential to avoid sub-optimization within a healthcare system. The purpose of this paper is to focus on healthcare production system productivity measurement. Design/methodology/approach - Traditionally, healthcare productivity has been studied and measured independently at the unit, organization and system level. Suggesting that productivity measurement should be done in different levels, while simultaneously linking productivity measurement to incentives, this study presents the challenges of productivity measurement at the different levels. The study introduces different methods to measure productivity in healthcare. In addition, it provides background information on the methods used to measure productivity and the parameters used in these methods. A pilot investigation of productivity measurement is used to illustrate the challenges of measurement, to test the developed measures and to prove the practical information for managers. Findings - The study introduces different approaches and methods to measure productivity in healthcare. Practical implications - A pilot investigation of productivity measurement is used to illustrate the challenges of measurement, to test the developed measures and to prove the practical benefits for managers. Originality/value - The authors focus on the measurement of the whole healthcare production system and try to avoid sub-optimization. Additionally considering an individual patient approach, productivity measurement is examined at the unit level, the organizational level and the system level.

Lateral Displacement and Shear Lag Effect of Combination of Diagrid-Frame

NASA Astrophysics Data System (ADS)

Abd. Samat, Roslida; Chua, Fong Teng; Mustakim, Nur Akmal Hayati Mohd; Saad, Sariffuddin; Abu Bakar, Suhaimi

2018-03-01

Diagrid system, which is the portmanteau of diagonal grid member, is an exterior lateral load resisting system for tall building that has gained a wide acceptance in the design of tall buildings. There is abundance of researches that studied the efficiency of diagrid systems, which are constructed from the ground level to the top of the buildings in resisting the lateral load. Nevertheless, no study had been performed on the effectiveness of the diagrid that is constructed above other tall building systems despite the existence of a few buildings in the world that employ such system. The objective of this research is to understand the behavior of the lateral displacement and shear lag effect due to wind load when the diagrid structure is constructed above a frame. Models of 60-story buildings with a footprint of 36m x 36m were analyzed by using Staad.Pro software. The level where the diagrid members started was altered. The lateral displacement was reduced to 60.6 percent and 41 percent of the lateral displacement of a building with full frame system when the combination of frame-diagrid that had the diagrid started at Level 1 and Level 45, respectively were employed. Furthermore, the shear lag ratio was reduced from 1.7 to 1.3 when the level where the diagrid started was increased from Level 1 to Level 45.

Multi-sensor physical activity recognition in free-living.

PubMed

Ellis, Katherine; Godbole, Suneeta; Kerr, Jacqueline; Lanckriet, Gert

Physical activity monitoring in free-living populations has many applications for public health research, weight-loss interventions, context-aware recommendation systems and assistive technologies. We present a system for physical activity recognition that is learned from a free-living dataset of 40 women who wore multiple sensors for seven days. The multi-level classification system first learns low-level codebook representations for each sensor and uses a random forest classifier to produce minute-level probabilities for each activity class. Then a higher-level HMM layer learns patterns of transitions and durations of activities over time to smooth the minute-level predictions. [Formula: see text].

Economic order quantity (EOQ) by game theory approach in probabilistic supply chain system under service level constraint for items with imperfect quality

NASA Astrophysics Data System (ADS)

Setiawan, R.

2018-03-01

In this paper, Economic Order Quantity (EOQ) of probabilistic two-level supply – chain system for items with imperfect quality has been analyzed under service level constraint. A firm applies an active service level constraint to avoid unpredictable shortage terms in the objective function. Mathematical analysis of optimal result is delivered using two equilibrium scheme concept in game theory approach. Stackelberg’s equilibrium for cooperative strategy and Stackelberg’s Equilibrium for noncooperative strategy. This is a new approach to game theory result in inventory system whether service level constraint is applied by a firm in his moves.

Integrating Omics Technologies to Study Pulmonary Physiology and Pathology at the Systems Level

PubMed Central

Pathak, Ravi Ramesh; Davé, Vrushank

2014-01-01

Assimilation and integration of “omics” technologies, including genomics, epigenomics, proteomics, and metabolomics has readily altered the landscape of medical research in the last decade. The vast and complex nature of omics data can only be interpreted by linking molecular information at the organismic level, forming the foundation of systems biology. Research in pulmonary biology/medicine has necessitated integration of omics, network, systems and computational biology data to differentially diagnose, interpret, and prognosticate pulmonary diseases, facilitating improvement in therapy and treatment modalities. This review describes how to leverage this emerging technology in understanding pulmonary diseases at the systems level –called a “systomic” approach. Considering the operational wholeness of cellular and organ systems, diseased genome, proteome, and the metabolome needs to be conceptualized at the systems level to understand disease pathogenesis and progression. Currently available omics technology and resources require a certain degree of training and proficiency in addition to dedicated hardware and applications, making them relatively less user friendly for the pulmonary biologist and clinicians. Herein, we discuss the various strategies, computational tools and approaches required to study pulmonary diseases at the systems level for biomedical scientists and clinical researchers. PMID:24802001

Theater Level Distribution Statement

DTIC Science & Technology

1992-06-19

The United States Military’s theater level distribution management system is analyzed for adequacy and efficiency through a review of the current...considered. In order to maximize efficiency within the distribution management system it is important that more specific doctrine governing theater level

Transferring data objects: A focused Ada investigation

NASA Technical Reports Server (NTRS)

Legrand, Sue

1988-01-01

The use of the Ada language does not guarantee that data objects will be in the same form or have the same value after they have been stored or transferred to another system. There are too many possible variables in such things as the formats used and other protocol conditions. Differences may occur at many different levels of support. These include program level, object level, application level, and system level. A standard language is only one aspect of making a complex system completely homogeneous. Many components must be standardized and the various standards must be integrated. The principal issues in providing for interaction between systems are of exchanging files and data objects between systems which may not be compatible in terms of their host computer, operating system or other factors. A typical resolution of the problem of invalidating data involves at least a common external form, for data objects and for representing the relationships and attributes of data collections. Some of the issues dealing with the transfer of data are listed and consideration is given on how these issues may be handled in the Ada language.