Perceived Barriers, Enablers, and Modifications to Tests Assessing Pediatric Lower Limb Neurological Impairment: An International Delphi Survey

Abstract

Objectives: Accurate, clinically meaningful outcome measures that are responsive to change are essential for selecting interventions and assessing their effects. Little guidance exists on the selection and administration of neurological impairment tests in children with a neurological condition. Clinicians, therefore, frequently modify adult assessments for use in children, yet the literature is inconsistent. This study aims to establish consensus on neurological conditions most likely to require neurological impairment test in pediatrics and the barriers, enablers and modifications perceived to enhance test reliability. Methods: Over a 2-round modified Delphi study, a panel of experts (n = 24) identified neurological conditions perceived to typically require pediatric neurological testing and the modifications to address barriers/enablers to testing. Experts comprised of physical therapists with evidence of advanced training or research in pediatrics. Using a 6-point Likert scale, (6 = strongly agree, 5 = agree, 4 = somewhat agree, 3 = somewhat disagree, 2 = disagree, 1 = strongly disagree), experts rated statements from existing literature. Thematic analyses were conducted on responses to open-ended questions. A-priori consensus was pre-set at 65% agreement/disagreement. Median, mode and interquartile ranges estimated perceived importance. Cessation was pre-determined by non-consensus items < 10% and panel fatigue. Results: Experts reached consensus on 107/112 (96%) items, including identifying 25/26 (96%) neurological conditions they perceived to require routine neurological testing. Experts strongly agreed with high importance that appropriately trained, experienced therapists are less variable when testing children. Communication modifications were perceived most important. Conclusions: High levels of consensus support the use of lower limb neurological testing in a range of pediatric neurological conditions. Trained clinicians should document modifications such as visual aid use. Using recommended modifications could encourage consistency amongst clinicians. Impact: This is the first study to identify the barriers and enablers to pediatric neurological testing. Barriers and enablers were partially addressed through suggested modifications. Further rigorous examination of these modifications is required to support their use.

International Delphi Recommendations for Pediatric Lower Limb Neurological Test Protocols for Muscle Strength, Reflexes, and Tactile Sensitivity

“…Twenty-six participants completed Questionnaire 1 and 24 completed both questionnaires (attrition rate of 14%). 21 Snowballing recruitment techniques meant a traditional response rate could not be calculated. 30 Participants were physical therapists based in 9 countries who worked in clinical and/or academic roles.…”

“…Participation and completion rates for each questionnaire round were calculated and summarized as a percentage. Responses on the 6-point Likert scale were translated into numerical scores (1-6) to summarize the strength of agreement and level of importance for items 21,30. The number of responses from 4 to 6 were summated and expressed as a percentage of agreement for each statement.…”

“…Questionnaire 1 consisted of 1 open-ended statement and 92 pregenerated statements as part of a larger Delphi study. 21 Participants rated their level of agreement on pregenerated statements using a 6-point Likert response scale (6 = "strongly agree," 5 = "agree," 4 = "somewhat agree," 3 = "somewhat disagree," 2 = "disagree," and 1 = "strongly disagree"). 30 Agreement was determined if 65% or more of the panel strongly agreed, agreed, or somewhat agreed with each item.…”

“…Recruitment targeted physical therapists experienced in pediatric neurological assessment from countries known to have pediatric special interest groups recognized by their national physical therapy associations and the World Congress of Physical Therapy. 21 To be included, physical therapists needed to have:…”

Pain Assessment and Management of Neurologic Impairments by Pediatric Physical Therapists; A Cross-Sectional Survey

“…Despite increased knowledge of pain among children, there has been little research led by a physical therapist on pain evaluation and treatment during physical therapy procedures in children. 1,2 There is little information available on physical therapists' practice patterns on this topic. Before making recommendations for best practices and doing research to support successful therapies for this demographic, it is critical to gather basic information on how pain and discomfort are evaluated and treated in this community.…”