Effectiveness of loaded sit-to-stand resistance exercise for children with mild spastic diplegia: a randomized clinical trial

Movement patterns during the process of standing up in children with spastic diplegia

AbstractThe analysis of the movement patterns of children with spastic diplegia (SD) during the process of standing up can contribute to a better understanding of postural control. The purpose of this study was to describe the movement patterns during this task in children with SD and typical development and to analyze the differences according to their age group. Participated 40 children (38-154 months), 20 children with SD and 20 children with typical development. The participants were instructed to lie down in a supine position and quickly stand up (10 trials). Motor task sessions were videotaped and subsequently analyzed. Children with SD had more asymmetrical and less efficient movement patterns in the Upper Limbs (UL), Axial Region (AR) and Lower Limbs (LL). The oldest group of children with SD did not have more mature and efficient movement patterns, and the oldest children with typical development have more mature and efficient movement patterns in the UL and AR.

The influence of seat heights and foot placement positions on postural control in children with cerebral palsy during a sit-to-stand task

This paper aimed to analyze, from both a kinetic and kinematic perspective, the postural control of children with cerebral palsy (CP) able to independently perform the sit-to-stand (STS) task (ICP) and children who needed support (SCP) typically developing children during the STS; and also investigate the influence of seats heights and foot placement positions on postural control of these children. Fourteen children with CP and fourteen typically developing controls were recruited. Based on the Gross Motor Function Classification System (GMFCS) the children with CP were divided into ICP (level I) and SCP (levels II and III). Balance was assessed using the Pediatric Balance Scale. Motor function was rated using the GMFCS. Kinematic and kinetic data were recorded and analyzed during the STS task at two different seat heights and foot placement positions. The SCP exhibited significantly less balance according to the PBS and smaller displacement of their center of pressure (COP) in anteroposterior (COPAP) and mediolateral (COPML) direction relative to the other two groups. ICP demonstrated significant greater in the COPML displacement than the other groups. Children with CP required more time to complete the STS than controls. Those in the SCP group had lower linear displacement of the shoulder and knee than others during the STS task. During the high bench condition, the linear displacements of the shoulder and knee were reduced also. We conclude that the SCP has less COPAP and COPML oscillation, what means the better postural control during STS than the other two groups, which may be related to the support provided. The ICP exhibited greater COPML oscillations than controls, suggesting that they utilized different strategies in the frontal plane during the STS task. The seat height and foot placement did not influence postural control in children with CP, at least in terms of kinetic parameters. Seat height influenced the kinematic variables, with a high bench reducing linear displacement of the shoulder (vertical and horizontal) and knee (vertical) both in children with CP and control children.

FAST CP: protocol of a randomised controlled trial of the efficacy of a 12-week combined Functional Anaerobic and Strength Training programme on muscle properties and mechanical gait deficiencies in adolescents and young adults with spastic-type cerebral palsy

INTRODUCTION

Individuals with cerebral palsy (CP) have muscles that are smaller, weaker and more resistant to stretch compared to typically developing people. Progressive resistance training leads to increases in muscle size and strength. In CP, the benefits of resistance training alone may not transfer to improve other activities such as walking; however, the transfer of strength improvements to improved mobility may be enhanced by performing training that involves specific functional tasks or motor skills. This study aims to determine the efficacy of combined functional anaerobic and strength training in (1) influencing muscle strength, structure and function and (2) to determine if any changes in muscle strength and structure following training impact on walking ability and gross motor functional capacity and performance in the short (following 3 months of training) and medium terms (a further 3 months post-training).

METHODS AND ANALYSIS

40 adolescents and young adults with CP will be recruited to undertake a 12-week training programme. The training programme will consist of 3 × 75 min sessions per week, made up of 5 lower limb resistance exercises and 2-3 functional anaerobic exercises per session. The calf muscles will be specifically targeted, as they are the most commonly impacted muscles in CP and are a key muscle group involved in walking. If, as we believe, muscle properties change following combined strength and functional training, there may be long-term benefits of this type of training in slowing the deterioration of muscle function in people with spastic-type CP.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the ethics committees at The University of Queensland (2014000066) and Children's Health Queensland (HREC/15/QRCH/30). The findings will be disseminated by publications in peer-reviewed journals, conferences and local research organisations' media.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ACTRN12614001217695).

Fortalecimento muscular em adolescentes com paralisia cerebral: avaliação de dois protocolos em desenho experimental de caso único

Objetivos: descrever mudanças na função motora de dois adolescentes com diplegia espástica, sendo um deles participante de um protocolo de fortalecimento muscular isolado (FMI) e o outro de protocolo de fortalecimento com tarefas funcionais (FTF). Métodos: desenho experimental de caso único, metodologia que revela a temporalidade do perfil de mudanças ao longo e após a terapia. Este desenho incluiu fases de baseline, de intervenção e de followup com quatro, seis e três semanas, respectivamente. Participantes foram duas adolescentes com displegia espástica submetidas, cada uma, a um protocolo de intervenção: fortalecimento muscular isolado (FMI) ou fortalecimento com tarefas funcionais (FTF). Os protocolos de intervenção incluíram exercícios de fortalecimento muscular isolado de extensores de quadril, extensores de joelho e flexores plantares (para a participante do FMI), ou de exercícios funcionais para as mesmas musculaturas (para a participante do FTF). Mensurações três vezes por semana avaliaram força muscular, velocidade de marcha, tempo para subir e descer escadas, tempo para se levantar do chão e tempo no teste Timed Get Up and Go. Os dados foram analisados com Celeration Line, Amplitude de Dois Desvios Padrão e Análise Visual. Resultados: ganhos de força muscular de membros inferiores foram observados nas adolescentes submetidas a ambos os protocolos. Mudanças nas atividades motoras foram observadas em 2 das 4 tarefas testadas em somente uma das adolescentes (p<0,05). Conclusões: a especificidade funcional do protocolo de fortalecimento FTF produziu modestos efeitos no desempenho de atividades motoras de uma das adolescentes com PC, em acréscimo aos ganhos de força muscular produzidos por ambos os protocolos.

The effect of exercise using a sliding rehabilitation machine on the gait function of children with cerebral palsy

[Purpose] The purpose of the present study was to examine the effect of strength training using a sliding rehabilitation machine (SRM) on the gait function of cerebral palsy children. [Subjects and Methods] Thirteen children aged 6-18 years participated in the SRM training for 8 weeks (30 min/day, 2 times/week). The SRM is designed for the performance of a closed-kinetic chain exercise in which a tilt table is moved up and down using wheels on the table. Participants began in a position of flexion of the 3 lower joints (hips, knees, and ankles) on the SRM. In each exercise session, they extended and flexed the 3 joints. The level of exercise was set by changing the inclination of the tilt table. Functional gait ability was measured with the 6-minute walk test (6MWT), 10-m walk test (10MWT), and timed up-and-go test (TUG) before and after the training. Muscle strength was also measured using an isokinetic dynamometer. [Results] Nine of the thirteen children completed the entire study. The peak torques of the knee extensor and flexor group muscles significantly improved after training with the SRM. The total distance of the 6 MWT significantly increased after training. The times of the 10 MWT and the TUG significantly improved after training. The changes in muscle tone were also investigated using the MAS (Modified Ashworth Scale) and Tardieu scale, but no significant changes were found in muscle tone between the pre- and post-test measurements. [Conclusion] The findings demonstrate the effect of the SRM intervention which resulted in improved muscle strength and functional gait.

Analysis of the relationships that body composition and muscular strength have with oxygen cost of walking in children with cerebral palsy

OBJECTIVE

To investigate whether body composition and lower extremity strength relate to oxygen cost of walking in children with cerebral palsy (CP), and to evaluate the relative contributions of these measures to explain variation in oxygen cost seen in this population.

METHODS

A total of 116 children with spastic diplegic CP, Gross Motor Function Classification System levels I-III, aged 8-18 participated. Strength, body composition (body mass index (BMI) and percent body fat) and oxygen cost were recorded. Pearson correlations assessed relationships between variables of body composition and strength to oxygen cost. Forward stepwise linear regression analyzed variance explained by strength and body composition measures. Oxygen data were analyzed by weight status classifications using one-way analysis of variance with significance set at p<0.05.

RESULTS

Total strength (r=-0.27) and total extensor strength (r=-0.27) had fair inverse relationships with oxygen cost. Total extensor strength explained 7.5% (r(2)=0.075, beta=-0.274, p<0.01) of the variance in oxygen cost. Body composition did not explain significant variance in oxygen cost, however significant differences were found in oxygen consumption (p=0.003) and walking velocity (p=0.042) based on BMI weight classifications.

CONCLUSIONS

For ambulatory children with CP, oxygen cost during walking can be partially explained by total extensor strength and not body composition. However, those categorized as obese may adjust to a slower walking speed to keep their oxygen cost sustainable, which may further affect their ability to keep up with typically developing peers and possibly lead to greater fatigue.

Health-related physical fitness for children with cerebral palsy

Low levels of physical activity are a global health concern for all children. Children with cerebral palsy have even lower physical activity levels than their typically developing peers. Low levels of physical activity, and thus an increased risk for related chronic diseases, are associated with deficits in health-related physical fitness. Recent research has provided therapists with the resources to effectively perform physical fitness testing and physical activity training in clinical settings with children who have cerebral palsy, although most testing and training data to date pertains to those who walk. Nevertheless, on the basis of the present evidence, all children with cerebral palsy should engage, to the extent they are able, in aerobic, anaerobic, and muscle-strengthening activities. Future research is required to determine the best ways to evaluate health-related physical fitness in nonambulatory children with cerebral palsy and foster long-term changes in physical activity behavior in all children with this condition.

Meta-analysis of the effect of strengthening interventions in individuals with cerebral palsy

This study aimed to investigate the evidence that strengthening interventions can improve muscle strength and activity in individuals with cerebral palsy. The search focused on studies that employed strength training for children with cerebral palsy for which six electronic databases were used to extract literature published from 2001 to 2012. The key terms used in these searches were combined strength training, strengthening, weight training, weight lifting, resistance, and cerebral palsy. The quality of each study was assessed using the PEDro (Physiotherapy Evidence Database) scale. Thirteen randomized controlled trial studies were selected and divided into categories according to program type, mode, and outcome measures. The overall effect sizes of each study and types of strengthening were large. Strengthening exercise improved muscle strength to a greater degree, when practiced 3 times per week in 40-50 min sessions than in other categories of session length, and greater improvement was observed in younger children than in older. The effect size of the activities and variables related to gait, except for gait endurance, were medium to large. The effect size of individual muscles was large, but the effect sizes for ankle plantar flexor, hip abductor/adductor, and extensor were insignificant. Strengthening interventions are useful for increasing muscle strength in individuals with cerebral palsy, specifically in youth and children, and optimal exercise consisted of 40- to 50-min sessions performed 3 times per week. Although strengthening interventions may improve activities, including gait, more studies that are rigorous are needed to determine the contributions to gross motor function.

Effects of task-specific training on functional ability in children with mild to moderate cerebral palsy

OBJECTIVE

To examine the relationship between Five times sit-to-stand Test (FTSST) and functional tests and investigate the effects of task-specific training on functional ability in children with mild to moderate cerebral palsy (CP).

METHODS

Twenty-one subjects were randomly assigned to experimental and control groups. Motor Assessment Scale (MAS: sit-to-stand), Pediatric Balance Scale (PBS), Functional Reach Test and FTSST were tested before training, after training and at follow-up at 6 weeks post training.

RESULTS

FTSST correlated significantly with MAS (ρ = -0.733) and with PBS (ρ = -0.813) in all children with CP. There were no significant differences in all outcomes between groups. However, FTSST and MAS in children with Gross Motor Function Classification System-Expanded and Revised levels I-II were significantly different between pre and post training within the experimental group (p = 0.03).

CONCLUSIONS

FTSST is a reliable and valid functional outcome measure after the task-specific training in children with mild to moderate CP.

Effect of strength training of ankle plantarflexors on selective voluntary motor control, gait parameters, and gross motor function of children with cerebral palsy

[Purpose] The purpose of this study was to investigate the effect of ankle plantarflexor strength training on selective voluntary motor control, gait parameters, and gross motor function of children with cerebral palsy (CP), focusing on changes in the strength and muscle activity of the ankle plantarflexors. [Methods] Six children aged between 4 and 10 years with CP participated in a 6 week strengthening program. The subjects were evaluated before and after the intervention in terms of ankle plantarflexor strength, muscle activity, gait velocity, cadence, step length, and D (standing) and E (walking, running, and jumping) dimensions of the Gross Motor Function Measure (GMFM). The data were analyzed using the non-parametric Wilcoxon signed-rank test. [Results] The strength of the plantarflexors increased in the majority of subjects. Significant and clinically meaningful post-intervention improvements in subject's gait velocity, cadence, and step length were found. [Conclusion] The controlled ankle plantarflexor strengthening program may lead to improvements in strength and spatiotemporal gait parameters of children with CP.

Validity and clinical utility of functional assessments in children with cerebral palsy

OBJECTIVE

To examine the validity and clinical utility of functional assessments (1-minute walk test, 10-meter walk test, Timed Up & Go [TUG] test, Timed Up and Down Stairs [TUDS] test, sit-to-stand [STS] test, and lateral step-up [LSU] test).

DESIGN

Cross-sectional study.

SETTING

Four special schools for adolescents with physical disabilities.

PARTICIPANTS

Adolescents with spastic tetraplegia and diplegia (at levels I-III) were selected through convenience sampling (N=35; mean age, 14.97±2.03y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

GMFM-88 (dimensions D and E), 1-minute walk, 10-meter walk, TUG, TUDS, STS, and LSU tests. Data were analyzed using Pearson intercorrelations, multiple regression analysis, and multivariate analysis of variance (MANOVA).

RESULTS

Significant moderate to high intercorrelations were found. Three significant positive predictors emerged (1-minute walk, 10-meter walk, and LSU) with the following regression equation: YGMFM-88 (dimensions D and E) = 5.708 + .402 × X1-minute walk + .920 × XLSU + .404 × X10-meter walk The MANOVA was significant (Λ=.163, F=14.732, P<.001, η(2)=.596), and post hoc comparisons revealed significant differences across Gross Motor Function Classification System Expanded and Revised levels in all paired comparisons for the 1-minute walk and LSU tests. For the 10-meter walk test, significant differences were evident in the level I versus level III and level II versus level III comparisons. No significant differences were found in the 10-meter walk test between levels I and II.

CONCLUSIONS

These functional assessments (1-minute walk, LSU, and 10-meter walk tests) are simple to administer, quick, low cost, and user-friendly. Although these assessments are not a substitute for the criterion standard (GMFM-88), they may be used for a quick assessment in adolescents with cerebral palsy (levels I-III) either at school or during rehabilitation, especially when time is limited.

A Home-Based Program Using Patterned Sensory Enhancement Improves Resistance Exercise Effects for Children With Cerebral Palsy

Background. Neurologic music therapy has demonstrated improved walking performance in persons with neurologic disease; however, little evidence supports the use of music with functional resistance exercise to improve motor capacity and daily functions for children with cerebral palsy. Objective. To investigate the effect of additional patterned sensory enhancement (PSE) music combined with exercise for children with spastic diplegia. Methods. An assessor-blind, randomized controlled trial with 6- and 12-week follow-ups was carried out. Thirty-six children with spastic diplegia, aged 5 to 13 years, were assigned to a PSE group (n = 18) or a no-music group (n = 18). Both groups received 6-week, home-based, loaded sit-to-stand exercise, but only the PSE group exercised with prerecorded PSE music. The primary outcome was Gross Motor Function Measure (GMFM). Secondary outcomes included Pediatric Evaluation of Disability Inventory (PEDI) mobility and self-care domains, 1-repetition maximum of sit-to-stand, and walking speeds. Results. Three children did not complete the program. Intention-to-treat analysis showed both groups improved in GMFM D, E, and Goal dimensions; Functional Skills Scales of PEDI mobility domain; and 1-repetition maximum of sit-to-stand at posttest and follow-ups ( P ≤ .005). The PSE group improved significantly greater than the no-music group in the GMFM D and Goal dimensions ( P < .005) after training, and the improvement persisted for at least 6 or 12 weeks ( P ≤ .013). No significant improvements in the rest PEDI scales and walking speeds were found. Conclusions. Adding neurologic music therapy to functional resistance exercise could induce greater improvements in gross motor capacity for children with cerebral palsy.

How much muscle strength is required to walk in a crouch gait?

Muscle weakness is commonly cited as a cause of crouch gait in individuals with cerebral palsy; however, outcomes after strength training are variable and mechanisms by which muscle weakness may contribute to crouch gait are unclear. Understanding how much muscle strength is required to walk in a crouch gait compared to an unimpaired gait may provide insight into how muscle weakness contributes to crouch gait and assist in the design of strength training programs. The goal of this study was to examine how much muscle groups could be weakened before crouch gait becomes impossible. To investigate this question, we first created muscle-driven simulations of gait for three typically developing children and six children with cerebral palsy who walked with varying degrees of crouch severity. We then simulated muscle weakness by systematically reducing the maximum isometric force of each muscle group until the simulation could no longer reproduce each subject's gait. This analysis indicated that moderate crouch gait required significantly more knee extensor strength than unimpaired gait. In contrast, moderate crouch gait required significantly less hip abductor strength than unimpaired gait, and mild crouch gait required significantly less ankle plantarflexor strength than unimpaired gait. The reduced strength required from the hip abductors and ankle plantarflexors during crouch gait suggests that weakness of these muscle groups may contribute to crouch gait and that these muscle groups are potential targets for strength training.

Physiotherapists' experiences of physiotherapy interventions in scientific physiotherapy publications focusing on interventions for children with cerebral palsy: a qualitative phenomenographic approach

Background

Physiotherapy research concerning interventions for children with CP is often focused on collecting evidence of the superiority of particular therapeutic methods or treatment modalities. Articulating and documenting the use of theory, instrumentation and research design and the assumptions underlying physiotherapy research interventions are important. Physiotherapy interventions focusing on children with Cerebral Palsy should, according to the literature, be based on a functional and environmental perspective with task-specific functional activity, motor learning processes and Family-Centred Service i.e. to enhance motor ability and improve capacity so that the child can perform the tasks necessary to participate actively in everyday life. Thus, it is important to coordinate the norms and values of the physiotherapist with those of the family and child. The aim of this study was to describe how physiotherapists’ experiences physiotherapy interventions for children with CP in scientific physiotherapy publications written by physiotherapists.

Methods

A qualitative phenomenographic approach was used. Twenty- one scientific articles, found in PubMed, strategically chosen according to year of publication (2001–2009), modality, journals and country, were investigated.

Results

Three qualitatively different descriptive categories were identified: A: Making it possible a functional-based intervention based on the biopsychosocial health paradigm, and the role of the physiotherapist as collaborative, interacting with the child and family in goal setting, intervention planning and evaluation, B: Making it work an impairment-based intervention built on a mixed health paradigm (biomedical and biopsychosocial), and the role of the physiotherapist as a coach, leading the goal setting, intervention planning and evaluation and instructing family members to carry out physiotherapist directed orders, and; C: Making it normal an impairment-based intervention built on a biomedical health paradigm, and the role of the physiotherapist as an authoritative expert who determine goals, intervention planning and evaluation.

Conclusions

Different paradigms of health and disability lead to different approaches to physiotherapy which influence the whole intervention process regarding strategies for the assessment and treatment, all of which influence Family-Centred Service and the child’s motor learning strategies. The results may deepen physiotherapists’ understanding of how different paradigms of health influence the way in which various physiotherapy approaches in research seek to solve the challenge of CP.

Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: a randomized controlled trial

The objective of the study was to evaluate the effectiveness of functional progressive resistance exercise (PRE) training on walking ability in children with cerebral palsy (CP). Fifty-one ambulant children with spastic CP (mean age 10 years 5 months, 29 boys) were randomized to an intervention (n=26) or control group (n=25, receiving usual care). The intervention consisted of 12 weeks functional PRE circuit training, for 3 times a week. Main outcome measures were walking ability and participation. Secondary outcomes were muscle strength and anaerobic muscle power. Possible adverse outcomes were spasticity and passive range of motion (ROM). Muscle strength increased significantly in the training group compared to the control group, but walking ability, participation and anaerobic muscle power did not change. Spasticity and ROM remained unchanged, except for a significant decrease in rectus femoris length in the intervention group. It is concluded that twelve weeks of functional PRE-training does not improve walking ability, despite improved muscle strength.

Characteristics associated with improved knee extension after strength training for individuals with cerebral palsy and crouch gait

Muscle weakness may contribute to crouch gait in individuals with cerebral palsy, and some individuals participate in strength training programs to improve crouch gait. Unfortunately, improvements in muscle strength and gait are inconsistent after completing strength training programs. The purpose of this study was to examine changes in knee extensor strength and knee extension angle during walking after strength training in individuals with cerebral palsy who walk in crouch gait and to determine subject characteristics associated with these changes. A literature review was performed of studies published since January 2000 that included strength training, three-dimensional motion analysis, and knee extensor strength measurements for individuals with cerebral palsy. Three studies met these criteria and individual subject data was obtained from the authors for thirty crouch gait subjects. Univariate regression analyses were performed to determine which of ten physical examination and motor performance variables were associated with changes in strength and knee extension during gait. Change in knee extensor strength ranged from a 25% decrease to a 215% increase, and change in minimum knee flexion angle during gait ranged from an improvement of 9° more knee extension to 15° more knee flexion. Individuals without hamstring spasticity had greater improvement in knee extension after strength training. Hamstring spasticity was associated with an undesired increase in knee flexion during walking. Subject-specific factors such as hamstring spasticity may be useful for predicting which subjects will benefit from strength training to improve crouch gait.

Reliability and validity of the five-repetition sit-to-stand test for children with cerebral palsy

Objective To investigate the psychometric properties of the five-repetition sit-to-stand test, a functional strength test, in children with spastic diplegia.

Design: Methodology study.

Settings: Hospital, laboratory or home.

Participants: In total, 108 children with spastic diplegia and 62 with typical development aged from five to 12 years were tested. For test-retest reliability, 22 children with spastic diplegia were tested twice within one week.

Interventions: Not applicable.

Main measures: The five-repetition sit-to-stand test measures time needed to complete five consecutive sit-to-stand cycles as quickly as possible. The higher the rate of five-repetition sit-to-stand (repetitions per second), the more strength a person has.

Results: The intraclass correlation coefficients of intra-session reliability and test-retest reliability were 0.95 and 0.99 respectively. The minimal detectable difference was 0.06 rep/sec. The convergent validity of the five-repetition sit-to-stand test was supported by significant correlation with one-repetition maximum of the loaded sit-to-stand test, isometric muscle strength, scores of Gross Motor Function Measure, and gait function ( r or rho = 0.40–0.78). For known group validity, children with typical development and children classified as Gross Motor Function Classification System level I performed higher rates of five-repetition sit-to-stand than children classified as level II, and children classified as level II performed higher rates than level III.

Conclusion: The five-repetition sit-to-stand test was a reliable and valid test to measure functional muscle strength in children with spastic diplegia in clinics.

Sit-to-stand movement in children with cerebral palsy: a critical review

Sit-to-stand (STS) movement is widely performed in daily life and an important pre requisite for acquisition of functional abilities. However, STS is a biomechanical demanding task which requires high levels of neuromuscular coordination, muscle strength and postural control. As children with cerebral palsy (CP) exhibit a series of impairments in body structures and functions, STS movement performance could be impaired in this population. Thus, this article aimed to review studies that had described how STS movement is performed by children with CP, the factors that influence it and the methodological procedures adopted in it analyses. A search was performed by one reviewer in relevant databases. In all, 12 articles were identified and 9 were selected for the present review. It was detected a large variation in sample characteristics and methodological issues among studies. In fact, standardization of the method applied to STS movement analysis is not fully established. With regard to STS performance, children with CP exhibited variations among them and also when compared with their typical peers. Moreover extrinsic factors appear to influence STS movement performance in these children and its manipulation could be incorporated into rehabilitation protocols. Moreover, the relationship between STS movement and functionality in reviewed articles was not reported. Therefore the review allowed to observe that STS movement has been under-explored in children with CP, with a lack of standardized methodologies and a not well established relationship between this movement and functionality. Thus, further studies about STS movement in CP are necessary.

Measuring changes in functional mobility in children with mild cerebral palsy

OBJECTIVE

To support the use of TUG and TUDS to detect changes in functional mobility in children with mild cerebral palsy.

METHODS

Six children with spastic cerebral palsy and classified by GMFCS as level I or II were enrolled in the study. The gross motor function was measured by the GMFM and functional mobility by the TUG and TUDS. The participants were assessed before and after an 8-week follow-up.

RESULTS

After this period, increased GMFM scores were found at dimensions D (standing) and E (walking, running and jumping). The time to complete TUG and TUDS was shorter after the follow-up period. Negative correlations were found between GMFM dimension E and the TUG and TUDS tests.

CONCLUSION

Changes in the gross motor skills measured by the GMFM may be accompanied by changes in the movement speed measured by TUG and TUDS. These tests may complement information provided by GMFM.

Muscle strengthening in children and adolescents with spastic cerebral palsy: considerations for future resistance training protocols

Resistance training of the lower limbs is now commonly used in clinical practice in children and adolescents with spastic cerebral palsy (CP). However, the effectiveness of this type of training is still disputed. The most recently published systematic review with meta-analysis included interventions such as electrical stimulation and resistance training and found insufficient evidence to support or refute the efficacy of these exercises in children with CP. Thus, the aim of this article is to evaluate the extent to which training protocols from the most recent randomized controlled trials are in keeping with the evidence for effective resistance training in children who are developing typically, as reflected in the training guidelines of the National Strength and Conditioning Association.

RECOMMENDATIONS

for resistance training protocols, based on this evidence and appropriate to children with CP, are provided to help guide both future research and clinical practice for resistance training in children with CP.

Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement

Botulinum neurotoxin type-A (BoNT-A) has been used in association with other interventions in the management of spasticity in children with cerebral palsy (CP) for almost two decades. This consensus statement is based on an extensive review of the literature by an invited international committee. The use of BoNT-A in the lower limbs of children with spasticity caused by CP is reported using the American Academy of Neurology Classification of Evidence for therapeutic intervention. Randomized clinical trials have been grouped into five areas of management, and the outcomes are presented as treatment recommendations. The assessment of children with CP and evaluation of outcomes following injection of BoNT-A are complex, and therefore, a range of measures and the involvement of a multidisciplinary team is recommended. The committee concludes that injection of BoNT-A in children with CP is generally safe although systemic adverse events may occur, especially in children with more physical limitations (GMFCS V). The recommended dose levels are intermediate between previous consensus statements. The committee further concludes that injection of BoNT-A is effective in the management of lower limb spasticity in children with CP, and when combined with physiotherapy and the use of orthoses, these interventions may improve gait and goal attainment.

Muscle strength and walking ability in diplegic cerebral palsy: implications for assessment and management

Muscle weakness is a recognised problem in children with Cerebral Palsy (CP). Changes in the understanding of motor control, and progress in the treatment of spasticity, have led to a greater appreciation that spastic muscles are also weak. In recent years weakness has been identified in isolated muscle groups, but studies quantifying the degree and distribution of weakness in multiple muscles remain limited. This study evaluated isometric lower limb muscle strength in 50 ambulant children with CP/Spastic Diplegia (mean age 11 years 7 months) at GMFCS levels I (n=14), II (n=26) and III (n=10). Muscle strength was compared with 15 control children (mean age 11 years 1 month) using the same protocol. Six muscle groups in both lower limbs were measured using a digital dynamometer. All lower limb muscles were significantly weaker in the CP children than in healthy children (p<0.05) except for the hip extensors. Muscle strength ranged from 43% to 90% of control values depending on the muscle group, with the knee extensors measured at 30° being the relatively weakest group. There was a significant difference in strength between GMFCS levels in 4/6 muscle groups with a progressive reduction in strength in all muscle groups with increasing walking difficulty from GMFCS levels I to III. The greatest difference in strength between independent walkers and those dependent on walking aids was in the hip abductors and knee extensors at 30°, which are key muscle groups in sagittal and coronal plane walking stability. This has implications in targetting strength training to maximise functional outcomes.

Immediate effects of therapeutic music on loaded sit-to-stand movement in children with spastic diplegia

The effects of patterned sensory enhancement (PSE) music on muscle power and movement control in children with spastic diplegia (SD) during loaded sit-to-stand (LSTS) were investigated. Twenty-three children with SD aged 5 to 12 years were recruited. Individualized PSE was composed by a music therapist based on each subject's sit-to-stand (STS) movement with 50% 1-repetition maximum load. Each subject performed LSTS continuously for eight repetitions under randomly assigned music or no-music (Control) conditions while the kinematic and kinetic data were measured simultaneously. For the music condition, PSE music was played only during the first five repetitions (PSE condition), and the following three repetitions were referred to as the Continuation condition. Paired t- or Wilcoxon signed rank tests were used to compare the variables between the PSE and Control conditions, and between the Continuation and Control conditions. Compared to the Control condition, greater peak knee extensor power (P=0.009), greater total extensor power (P=0.015), and better center-of-mass smoothness (P=0.01), but less movement time (P=0.003) were found in the PSE condition. Significant effects of the PSE music on the above variables were also found for Continuation condition. The current results showed that individualized PSE music helped improve the performance of LSTS in children with SD. The associated biomechanical features also continued to exist in subsequent movement cycles after the music had ceased. These findings suggest that therapy using LSTS combined with PSE music may be beneficial for rehabilitating children with SD.

A systematic review of common physiotherapy interventions in school-aged children with cerebral palsy

This systematic review focused on the common conventional physiotherapy interventions used with children with cerebral palsy (CP), aged 4 to 18 years, and critically appraised the recent evidence of each of these interventions using the Oxford Centre for Evidence-Based Medicine Levels of Evidence. The search strategy yielded 34 articles after inclusion and exclusion criteria were applied. The investigated physiotherapy interventions included strength and functional training, weight-supported treadmill training (WBSTT), and neurodevelopmental treatment (NDT). A category of treatment dosage was also included. Strength training was the most studied intervention with significant improvements found in the strength of selected muscle groups using dynamometry, with fewer studies showing significant improvement in function. Functional training showed improvements in gross motor function, endurance, and temperospatial measures, such as gait speed and stride length. Nonsignificant trends of improvement on the Gross Motor Function Measure (GMFM) and gait velocity were found for WBSTT by a few studies with low levels of evidence (case series). Of three studies that evaluated NDT, one high-level evidence study, i.e., randomized controlled trial (RCT) found significant improvements on the GMFM. All studies reviewing treatment dosage had high levels of evidence (RCTs), yet found no significant differences for different intensities of treatment. These results indicate that the levels of evidence for physiotherapy interventions, particularly strengthening and to a lesser extent functional training, in school-aged children with CP has improved; however, further high-level evidence is needed for other interventions.

Effectiveness of functional progressive resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: a randomized controlled trial

AIM

To evaluate the effectiveness of functional progressive resistance exercise (PRE) strength training on muscle strength and mobility in children with cerebral palsy (CP).

METHOD

Fifty-one children with spastic uni- and bilateral CP; (29 males, 22 females; mean age 10 y 5 mo, SD 1 y 10 mo, range 6 y 0 mo-13 y 10 mo; Gross Motor Function Classification System levels I-III) were randomized to the intervention group (n=26) or the control group (n=25, receiving usual care). The intervention group trained for 12 weeks, three times a week, on a five-exercise circuit, which included a leg-press and functional exercises. The training load progressively increased based on the child's maximum level of strength, determined by the eight-repetition maximum. Muscle strength (measured with hand-held dynamometry and a six-repetition maximum leg-press test), mobility (measured with the Gross Motor Function Measure, two functional tests, and a mobility questionnaire), and spasticity (measured by the appearance of a catch) were evaluated before, during, directly after, and 6 weeks after the end of training by two blinded research assistants.

RESULTS

Directly after training, there was a statistically significant effect (p<0.05) on muscle strength (knee extensors +12% [0.56 N/kg; 95% confidence interval {CI} 0.13-0.99]; hip abductors +11% [0.27 N/kg; 95% CI 0.00-0.54]; total +8% [1.30 N/kg; 95% CI 0.56-2.54]; six-repetition maximum +14% [14%; 95% CI 1.99-26.35]), but not on mobility or spasticity. A detraining effect was seen after 6 weeks.

INTERPRETATION

Twelve weeks of functional PRE strength training increases muscle strength up to 14%. This strength gain did not lead to improved mobility.

Pediatric endurance and limb strengthening (PEDALS) for children with cerebral palsy using stationary cycling: a randomized controlled trial

BACKGROUND

Effective interventions to improve and maintain strength (force-generating capacity) and endurance are needed for children with cerebral palsy (CP).

OBJECTIVE

This study was performed to examine the effects of a stationary cycling intervention on muscle strength, locomotor endurance, preferred walking speed, and gross motor function in children with spastic diplegic CP.

DESIGN

This was a phase I randomized controlled trial with single blinding.

SETTING

The interventions were performed in community-based outpatient physical therapy clinics. Outcome assessments were performed in university laboratories.

PARTICIPANTS

Sixty-two ambulatory children aged 7 to 18 years with spastic diplegic CP and Gross Motor Function Classification System levels I to III participated in this study.

INTERVENTION AND MEASUREMENTS

Participants were randomly assigned to cycling or control (no-intervention) groups. Thirty intervention sessions occurred over 12 weeks. Primary outcomes were peak knee extensor and flexor moments, the 600-Yard Walk-Run Test, the Thirty-Second Walk Test, and the Gross Motor Function Measure sections D and E (GMFM-66).

RESULTS

Significant baseline-postintervention improvements were found for the 600-Yard Walk-Run Test, the GMFM-66, peak knee extensor moments at 120 degrees /s, and peak knee flexor moments at 30 degrees /s for the cycling group. Improved peak knee flexor moments at 120 degrees/s were found for the control group only, although not all participants could complete this speed of testing. Significant differences between the cycling and control groups based on change scores were not found for any outcomes. Limitations Heterogeneity of the patient population and intrasubject variability were limitations of the study.

CONCLUSIONS

Significant improvements in locomotor endurance, gross motor function, and some measures of strength were found for the cycling group but not the control group, providing preliminary support for this intervention. As statistical differences were not found in baseline-postintervention change scores between the 2 groups; the results did not demonstrate that stationary cycling was more effective than no intervention. The results of this phase I study provide guidance for future research.

Effects of weight resistance on the temporal parameters and electromyography of sit-to-stand movements in children with and without cerebral palsy

OBJECTIVE

The purpose of this study was to examine the differences in phase durations and electromyography between children with and without cerebral palsy during sit-to-stand movements with weight resistance.

DESIGN

Fifteen children with cerebral palsy and 15 age-matched children with typical development were recruited. They performed sit-to-stand movements while wearing a vest with four different loads (none, low, moderate, and high). Three phases during sit-to-stand and electromyography of vastus lateralis, gluteus maximus, and medial hamstring were recorded.

RESULTS

The ascending phase and peak electromyography of vastus lateralis showed a significant interaction between groups and resistance conditions. The children with cerebral palsy took a longer time to stand up than the control group when the load was high (P = 0.004). The peak electromyography of vastus lateralis increased with increasing resistance in the control group (P < 0.017) but not in children with cerebral palsy. Children with cerebral palsy had a higher cocontraction ratio of the medial hamstring/vastus lateralis than the control group (P = 0.001) at all resistance levels.

CONCLUSIONS

Children with cerebral palsy took a longer time for the task but did not increase agonist contraction as the control group in response to higher loads. Future research is suggested to see whether agonist contraction will be improved with strengthening therapy.

Muscle strengthening is not effective in children and adolescents with cerebral palsy: a systematic review

QUESTION

Do strengthening interventions increase strength without increasing spasticity and improve activity, and is there any carryover after cessation in children and adolescents with cerebral palsy?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Children with spastic cerebral palsy between school age and 20 years.

INTERVENTION

Strengthening interventions that involved repetitive, strong, or effortful muscle contractions and progressed as ability changed, such as biofeedback, electrical stimulation, and progressive resistance exercise.

OUTCOME MEASURES

Strength was measured as continuous measures of maximum voluntary force or torque production. Spasticity was measured as velocity-dependent resistance to passive stretch. Activity was measured as continuous measures, eg, 10-m Walk Test, or using scales eg, the Gross Motor Function Measure.

RESULTS

Six studies were identified and five had data that could be included in a metaanalysis. Strengthening interventions had no effect on strength (SMD 0.20, 95% CI -0.17 to 0.56), no effect on walking speed (MD 0.02 m/s, 95% CI -0.13 to 0.16), and had a small statistically-significant but not clinically-worthwhile effect on Gross Motor Function Measure (MD 2%, 95% CI 0 to 4). Only one study measured spasticity but did not report the between-group analysis.

CONCLUSION

In children and adolescents with cerebral palsy who are walking, the current evidence suggests that strengthening interventions are neither effective nor worthwhile.

The effects of a 'home-based' task-oriented exercise programme on motor and balance performance in children with spastic cerebral palsy and severe traumatic brain injury

OBJECTIVES

To evaluate the feasibility and the ability to recruit and retain children with severe traumatic brain injury or cerebral palsy, and their families, to a simple home-based exercise programme and to assess the immediate and short-term effects of such intervention on reducing impairment and improving function.

STUDY DESIGN

Randomized clinical trial.

PARTICIPANTS

Twenty children aged 7-13 years, with traumatic brain injury (N = 10) or cerebral palsy (N = 10) who were independent ambulators. Five children from each group were randomly assigned to a control group - regular daily activities, or to an experimental group - regular daily activities plus a home-based task-oriented exercise programme of sit-to-stand and step-up exercise, for six weeks.

OUTCOME MEASURES

Feasibility: The number of participants who completed the programme protocol.

EFFICACY

Timed Up and Go Test and Functional Reach Test were used as functional balance tests. Maximal isometric strength was assessed by using a hand-held dynamometer; walking performance was assessed by the 10 m walk test, 2-minute walk test and Energy Expenditure Index.

RESULTS

Nine children completed all parts of the training programme. At the end of the intervention period an increase of 3-4 cm in the mean Functional Reach Test and a reduction of 1.6 +/- 2.1 seconds in the Timed Up and Go Test were noted (P<0.01) in the experimental group while no changes were noted in the control group. In all other outcomes assessed no significant differences were noted between groups. The positive change in balance performance in the experimental group was maintained during a six-week follow-up period.

CONCLUSIONS

A home-based task-oriented exercise programme can improve balance performance in children with spastic cerebral palsy or severe traumatic brain injury.

Strength training in children and adolescents: raising the bar for young athletes?

CONTEXT

Strength training in children, in combination with plyometric and/or agility training, has become an increasingly popular tactic for athletes to gain a competitive edge during the off-season. The present review clarifies some common myths associated with strength training in children, and it outlines the most current recommendations.

EVIDENCE ACQUISITION

Relevant studies on strength training in children and adolescents were reviewed (search results included studies indexed in PubMed and MEDLINE from 1980 through 2008). Also reviewed were recommendations from consensus guidelines and position statements applicable to strength training in youth.

RESULTS

Children can improve strength by 30% to 50% after just 8 to 12 weeks of a well-designed strength training program. Youth need to continue to train at least 2 times per week to maintain strength. The case reports of injuries related to strength training, including epiphyseal plate fractures and lower back injuries, are primarily attributed to the misuse of equipment, inappropriate weight, improper technique, or lack of qualified adult supervision.

CONCLUSION

Youth-athletes and nonathletes alike-can successfully and safely improve their strength and overall health by participating in a well-supervised program. Trained fitness professionals play an essential role in ensuring proper technique, form, progression of exercises, and safety in this age group.

Lower limb strength training in children with cerebral palsy--a randomized controlled trial protocol for functional strength training based on progressive resistance exercise principles

Background

Until recently, strength training in children with cerebral palsy (CP) was considered to be inappropriate, because it could lead to increased spasticity or abnormal movement patterns. However, the results of recent studies suggest that progressive strength training can lead to increased strength and improved function, but low methodological quality and incomplete reporting on the training protocols hampers adequate interpretation of the results. This paper describes the design and training protocol of a randomized controlled trial to assess the effects of a school-based progressive functional strength training program for children with CP.

Methods/Results

Fifty-one children with Gross Motor Function Classification Systems levels I to III, aged of 6 to 13 years, were recruited. Using stratified randomization, each child was assigned to an intervention group (strength training) or a control group (usual care). The strength training was given in groups of 4–5 children, 3 times a week, for a period of 12 weeks. Each training session focussed on four exercises out of a 5-exercise circuit. The training load was gradually increased based on the child's maximum level of strength, as determined by the 8 Repetition Maximum (8 RM). To evaluate the effectiveness of the training, all children were evaluated before, during, directly after, and 6 weeks after the intervention period. Primary outcomes in this study were gross motor function (measured with the Gross Motor Function Measure and functional muscle strength tests) and walking ability (measured with the 10-meter, the 1-minute and the timed stair test). Secondary outcomes were lower limb muscle strength (measured with a 6 RM test, isometric strength tests, and a sprint capacity test), mobility (measured with a mobility questionnaire), and sport activities (measured with the Children's Assessment of Participation and Enjoyment). Spasticity and range of motion were assessed to evaluate any adverse events.

Conclusion

Randomized clinical trials are considered to present the highest level of evidence. Nevertheless, it is of utmost importance to report on the design, the applied evaluation methods, and all elements of the intervention, to ensure adequate interpretation of the results and to facilitate implementation of the intervention in clinical practice if the results are positive.

Trial Registration

Trial Register NTR1403

Walking ability is related to muscle strength in children with cerebral palsy

The purpose of this study was to assess the relation between muscle strength and walking ability in children with bilateral spastic cerebral palsy at GMFCS levels I-III. 55 children (mean age 10.7, range 5-15) were tested for muscle strength in eight lower limb muscle groups with a handheld myometer. They were also tested with the Gross Motor Function Measure domains for standing and walking, running and jumping. Muscle strength in the legs was below normative predicted value in most of the children, with muscle weakness most pronounced around the ankle, followed by the hip muscles. There was a significant difference in muscle strength between GMFCS levels. There was also a moderate to high correlation between muscle strength and the GMFM, indicating that muscle weakness affects walking ability. Independently walking children had more than 50% of predicted muscle strength values.

Muscle strength training to improve gait function in children with cerebral palsy

The aim of the study was to investigate the influence of muscle strength training on gait outcomes in children with cerebral palsy. Sixteen children (two females, 14 males, Gross Motor Function Classification System levels I-II, mean age 12y 6mo, range 9y 4mo-15y 4mo) underwent muscle strength measurement using a handheld device, Gross Motor Function Measure (GMFM) assessment, three-dimensional gait analysis, joint range of motion assessment, and grading of spasticity before and after 8 weeks of training. All participants had a diagnosis of spastic diplegia and could walk without aids. Training consisted of exercises for lower extremity muscles with free weights, rubber bands, and body weight for resistance, three times a week. Values for muscle strength below normal were identified in all children; this was most pronounced at the ankle, followed by the hip muscles. After training, muscle strength and GMFM scores increased, velocity was unchanged, stride length increased, and cadence was reduced. There was an increase in hip extensor moment and power generated at push off. Eight weeks of muscle strength training can increase muscle strength and improve gait function.

Effectiveness of physical therapy interventions for children with cerebral palsy: a systematic review

BACKGROUND

To assess the effectiveness of physical therapy (PT) interventions on functioning in children with cerebral palsy (CP).

METHODS

A search was made in Medline, Cinahl, PEDro and the Cochrane library for the period 1990 to February 2007. Only randomized controlled trials (RCTs) on PT interventions in children with diagnosed CP were included. Two reviewers independently assessed the methodological quality and extracted the data. The outcomes measured in the trials were classified using the International Classification of Functioning, Disability and Health (ICF).

RESULTS

Twenty-two trials were identified. Eight intervention categories were distinguished. Four trials were of high methodological quality. Moderate evidence of effectiveness was established for two intervention categories: effectiveness of upper extremity treatments on attained goals and active supination, and of prehensile hand treatment and neurodevelopmental therapy (NDT) or NDT twice a week on developmental status, and of constraint-induced therapy on amount and quality of hand use. Moderate evidence of ineffectiveness was found of strength training on walking speed and stride length. Conflicting evidence was found for strength training on gross motor function. For the other intervention categories the evidence was limited due to low methodological quality and the statistically insignificant results of the studies.

CONCLUSION

Due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of most PT interventions is available through RCTs. Moderate evidence was found for some effectiveness of upper extremity training. Well-designed trials are needed especially for focused PT interventions.

Quality medical homes: meeting children's needs for therapeutic and supportive services

OBJECTIVE

The objective of this study was to determine whether the quality of a medical home is associated with access to needed therapeutic and supportive services among children with special health care needs.

METHODS

Data from the 2000-2001 National Survey of Children With Special Health Care Needs were used in the analysis. The primary group of interest was children who were 0 to 17 years of age and needed therapeutic (n = 15,793) or supportive (n = 23,376) services. For each characteristic of a quality medical home, the percentage of children who needed and received therapeutic and supportive services was generated. Logistic regression was used to control for covariates while modeling the association between overall quality of a child's medical home and having unmet needs for therapeutic or supportive services.

RESULTS

Of all children identified as needing services, 16.2% had unmet therapeutic and 9.8% unmet supportive service needs. Only 23.9% of the children who needed therapeutic and 32.5% of children who needed supportive services met the criteria of having a quality medical home. High-quality care within medical homes was associated with a decreased likelihood of having unmet needs for therapeutic and supportive services. Each characteristic of a quality medical home was associated with unmet need, as were severity of the child's condition, family income of <200% of the federal poverty level, underinsurance, and maternal education beyond high school.

CONCLUSIONS

Among other factors, having a poor-quality medical home seems to be a barrier to receiving needed therapeutic or supportive services for children with special health care needs. Efforts on the part of pediatricians to establish quality medical homes for all children could have the added benefit of facilitating access to needed therapeutic and supportive services and promoting the health and well-being of children with special health care needs and their families.

Systematic review of progressive strength training in children and adolescents with cerebral palsy who are ambulatory

PURPOSE

To capture and analyze the evidence concerning the effects of progressive strength training on function and gait in children and adolescents with cerebral palsy (CP) who are ambulatory.

METHOD

A language-inclusive search was conducted for controlled or noncontrolled studies of strength training for subjects with CP who were ambulatory and aged 4 to 20 years, using objective outcome measures. Quality was assessed with the Maastricht-Amsterdam List. Data were extracted and analyzed.

RESULTS

The 13 included articles favored treatment without significant adverse effects. Function and gait improved more following isotonic rather than isokinetic training, and in younger rather than older subjects.

CONCLUSIONS

Function and gait improvements were greater in preadolescents.