Promotion of physical fitness and prevention of secondary conditions for children with cerebral palsy: section on pediatrics research summit proceedings

Can walking ability enhance the effectiveness of breathing exercise in children with spastic cerebral palsy?

[Purpose] The purpose of this study was to compare differences in respiratory pressure and pulmonary function and the effectiveness of respiratory feedback training according to walking ability in children with cerebral palsy (CP). [Subjects and Methods] Twenty-three children with spastic CP were enrolled in the final analysis and were divided into an independent walking group (n=12) and non-independent walking group. All children received respiratory feedback training for four weeks. Before and after the training, respiratory muscle strength was measured and a pulmonary function test was performed. [Results] Comparison of respiratory pressure and pulmonary function test results between the two revealed that the independent walking group had significantly higher respiratory function than the other group in all variables except peak expiratory flow. In comparison of changes in respiratory function between the two groups, the independent walking group showed significantly higher improvement of respiratory function in terms of maximal inspiratory pressure, maximal expiratory pressure, and forced vital capacity. [Conclusion] These findings showed that children with independent walking ability had better respiratory muscle strength and pulmonary function compared with children without independent walking ability. Understanding respiratory function and the effectiveness of respiratory training according to walking ability will be valuable clinical information for respiratory assessment and therapy in children with CP.

Reliability of a progressive maximal cycle ergometer test to assess peak oxygen uptake in children with mild to moderate cerebral palsy

BACKGROUND

Rehabilitation research in children with cerebral palsy (CP) is increasingly addressing cardiorespiratory fitness testing. However, evidence on the reliability of peak oxygen uptake (Vo2peak) measurements, considered the best indicator of aerobic fitness, is not available in this population.

OBJECTIVE

The objective of this study was to establish the reliability of a progressive maximal cycle ergometer test when assessing Vo2peak in children with mild to moderate CP.

DESIGN

Repeated measures were used to assess test-retest reliability.

METHODS

Eligible participants were ambulant, 6 to 14 years of age, and classified as level I, II, or III according to the Gross Motor Function Classification System (GMFCS). Two progressive maximal cycle ergometer tests were conducted (separated by 3 weeks), with the workload increasing every minute in steps of 3 to 11 W, dependent on height and GMFCS level. Reliability was determined by means of the intraclass correlation coefficient (ICC [2,1]) and smallest detectable change (SDC).

RESULTS

Twenty-one children participated (GMFCS I: n=4; GMFCS II: n=12; and GMFCS III: n=5). Sixteen of them (9 boys, 7 girls; GMFCS I: n=3; GMFCS II: n=11; and GMFCS III: n=2) performed 2 successful tests, separated by 9.5 days on average. Reliability for Vo2peak was excellent (ICC=.94, 95% confidence interval=.83-.98). The SDC was 5.72 mL/kg/min, reflecting 14.6% of the mean.

LIMITATIONS

The small sample size did not allow separate analysis of reliability per GMFCS level.

CONCLUSIONS

In children with CP of GMFCS levels I and II, a progressive maximal cycle ergometer test to assess Vo2peak is reliable and has the potential to detect change in cardiorespiratory fitness over time. Further study is needed to establish the reliability of Vo2peak in children of GMFCS level III.

Clinical use of objective measures of physical activity

With measurement of physical activity becoming more common in clinical practice, it is imperative that healthcare professionals become more knowledgeable about the different methods available to objectively measure physical activity behaviour. Objective measures do not rely on information provided by the patient, but instead measure and record the biomechanical or physiological consequences of performing physical activity, often in real time. As such, objective measures are not subject to the reporting bias or recall problems associated with self-report methods. The purpose of this article was to provide an overview of the different methods used to objectively measure physical activity in clinical practice. The review was delimited to heart rate monitoring, accelerometers and pedometers since their small size, low participant burden and relatively low cost make these objective measures appropriate for use in clinical practice settings. For each measure, strengths and weakness were discussed; and whenever possible, literature-based examples of implementation were provided.

'Every picture tells a story': Interviews and diaries with children with cerebral palsy about adapted cycling

AIMS

The study aims to explore the effect of participation in adapted cycling on quality of life for children with cerebral palsy (CP).

METHODS

The study used a qualitative approach developing creative mosaic methods using interviews and diaries. This study had two groups of children with CP: those who participated in adapted cycling and a control group who had not yet started. Children with CP aged 2-17 years who were already cycling were invited to take part in two interviews at the beginning and end of a 6-week period and keep a cycling diary during this time. The control group of children with CP aged 2-17 years were asked to keep a diary of physical activities over 6 weeks and to take part in one interview at the end. Welsh, English, Bengali and Arabic were the languages spoken, and some children used communication aids.

RESULTS

Results presented here include the first 25 children's interviews and diaries. The emergent themes from the analysis are: learning a new skill, the impact on wider family and friends, social participation and future aspirations. The diaries added an emotional dimension, by illustrations drawn by the children.

CONCLUSION

The children who took part in adapted cycling enjoyed this experience and it improved their sense of well-being. Some in the control group went on to participate in adapted cycling. Physiotherapists can carry out creative research to hear the voices of children and young people with CP and incorporate their views and ideas into the development of service model delivery and treatment programmes.

A physical fitness follow-up in children with cerebral palsy receiving 12-week individualized exercise training

Physical fitness in children with cerebral palsy (CP) is lower than in their peers. A 12-week individualized home-based exercise program completed by 11 children with CP 10 years earlier showed a favorable effect on physical fitness performance. We follow-up the physical fitness of those 11 children with CP, and compare their physical fitness and health-related quality of life (HRQoL) to children with CP without exercise training matched with age and motor levels. Eleven children with CP in the 2003 program as a follow-up group (FUG) and 12 volunteers recruited as a control group (CG) participated in this study. Physical fitness measures, including cardiopulmonary endurance, muscle strength, body mass index (BMI), flexibility, agility, balance, and the SF-36 Taiwan version, were assessed in both groups. After 10 years, the FUG showed better physical fitness in cardiopulmonary endurance and muscle strength (p<.05). Compared to the CG, the FUG demonstrated better muscle strength, agility, and balance (p<.05). However, the HRQoL did not show a significant difference between the FUG and the CG. Individualized home-based exercise training is beneficial for children with CP. Over 10 years, the FUG was more devoted to physical activity than was the CG. Physical exercise may not directly affect the HRQoL in this study.

"It's the participation that motivates him": physical activity experiences of youth with cerebral palsy and their parents

Youth with cerebral palsy (CP) face significant barriers to participation in physical activity (PA). There is little information available about the nature of these barriers. Seventeen (17) youth and/or their parents participated in focus groups and individual interviews to identify factors that make it easy or hard to be physically active. Four themes emerged across functional levels: environmental and personal factors, limitations related to impairment in body structure and function, the perception that health benefits alone do not motivate youth to be physically active, and variable preferences for activity delivery. Dialogue with participants revealed that interventions to promote PA in youth should mitigate the interactions between personal and environmental factors that act as barriers to PA, and enhance the interactions that facilitate PA. Partnerships between researchers, policy makers, service providers, and families must be developed to address system barriers and build capacity in youth with CP and their communities.

Exercise intensity levels in children with cerebral palsy while playing with an active video game console

BACKGROUND

Children with cerebral palsy (CP) are prone to secondary complications related to physical inactivity and poor cardiorespiratory capacity. This problem could be greatly attenuated through the use of video games that incorporate physical activity for 2 reasons: Video games already represent an important component of leisure time in younger people, and such games can lead to a high level of exercise intensity in people who are healthy.

OBJECTIVE

The study objective was to evaluate exercise intensity in children with spastic diplegic CP and children who were typically developing while playing with an active video game console.

DESIGN

This was a cross-sectional study.

METHODS

Ten children (7-12 years old) with spastic diplegic CP (Gross Motor Function Classification System level I or II) and 10 children who were age matched and typically developing were evaluated in a movement analysis laboratory. Four games were played with the active video game console (jogging, bicycling, snowboarding, and skiing) for 40 minutes. Heart rate was recorded during the entire playing period with a heart rate belt monitor. Exercise intensity was defined as the percentage of heart rate reserve (HRR). In addition, lower extremity motion analysis was carried out during the final minute of the playing period for the jogging and bicycling games.

RESULTS

No difference between groups was observed for any variables. A main effect of games was observed for the amount of time spent at an intensity greater than 40% of HRR. Specifically, more than 50% of the playing time for the jogging game and more than 30% of the playing time for the bicycling game were spent at an intensity greater than 40% of HRR. In addition, the jogging game produced a larger range of motion than the bicycling game.

LIMITATIONS

A limitation of this study was the relatively small and heterogeneous sample.

CONCLUSIONS

For all 4 games, similar exercise intensity levels were observed for children who were typically developing and children with CP, suggesting that children with CP could obtain exercise-related benefits similar to those obtained by children without CP while playing with an active video game console.

Cerebral palsy: definition, assessment and rehabilitation

Over the last 25 years the definition and classification of cerebral palsy (CP) have evolved, as well as the approach to rehabilitation. CP is a disorder of the development of movement and posture, causing activity limitations attributed to nonprogressive disturbances of the fetal or infant brain that may also affect sensation, perception, cognition, communication, and behavior. Motor control during reaching, grasping, and walking are disturbed by spasticity, dyskinesia, hyperreflexia, excessive coactivation of antagonist muscles, retained developmental reactions, and secondary musculoskeletal malformations, together with paresis and defective programing. Weakness and hypoextensibility of the muscles are due not only to inadequate recruitment of motor units, but also to changes in mechanical stresses and hormonal factors. Two methods, the General Movements Assessment and the Test of Infant Motor Performance, now permit the early detection of CP, while the development of valid and reliable outcome measures, particularly the Gross Motor Function Measure (GMFM), have made it possible to evaluate change over time and the effects of clinical interventions. The GMFM has further led to the development of predictive curves of motor function while the Gross Motor Classification System and the Manual Ability Classification System provide standardized means to classify the severity of the movement disability. With the emergence of the task-oriented approach, the focus of therapy in rehabilitation has shifted from eliminating deficits to enhancing function across all performance domains by emphasizing fitness, function, participation, and quality of life. There is growing evidence supporting selected interventions and interest for the therapy and social integration of adults with CP.

Physical activity in a total population of children and adolescents with cerebral palsy

The aims of this study were to describe the participation in physical activity of children with cerebral palsy (CP) at school and during leisure time and to identify characteristics associated with physical activity. The frequency of receiving physiotherapeutic interventions were described as a variable of interest. A total population of 364 children with verified CP aged 7-17 years living in the Skåne region in Sweden was studied using cross-sectional data from the CP follow-up programme (CPUP). Proportional odds ratios showed the most severe gross motor limitations Gross Motor Function Classification System Expanded and Revised (GMFCS-E&R) to be a characteristic for low participation in physical education at school (PE) and GMFCS-E&R level III to be a characteristic for low participation in regular physical leisure activity. The age group of 7-11 years and obesity were characteristics associated with high participation in PE, whereas thinness was associated with low participation in regular physical leisure time activities. The highest proportion of children receiving physiotherapeutic interventions was found in GMFCS-E&R level III, while mental retardation, especially if moderate or severe, proved to be an independent characteristic associated with low frequency of physiotherapeutic interventions. Gender and epilepsy did not influence the odds for participation in physical activities. Special considerations are needed when planning interventions for increased physical activity in children with CP, as the individual prerequisites differ, even among children with the same gross motor function level according to the GMFCS-E&R.

Systematic review of the clinimetric properties of laboratory- and field-based aerobic and anaerobic fitness measures in children with cerebral palsy

OBJECTIVE

To systematically evaluate the level of evidence of the clinimetric properties of measures of aerobic and anaerobic capacity used for children with cerebral palsy (CP).

DATA SOURCES

A systematic search of databases PubMed, Embase, SPORTDiscus, and PsycINFO through April 2011 was performed.

STUDY SELECTION

Two independent raters identified and examined studies that reported laboratory- or field-based measures of maximal aerobic or anaerobic capacity in children with CP aged 5 to 14 years.

DATA EXTRACTION

The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist was used by 2 independent raters to evaluate the methodologic quality of the included clinimetric studies and to identify measures used in these studies.

DATA SYNTHESIS

Twenty-four studies that used a maximal aerobic or anaerobic capacity measure were identified. Five studies reported clinimetric properties for 5 measures (2 aerobic and 3 anaerobic measures). Methodologic quality was excellent in 3 studies, showing good validity and reliability of field-based aerobic (Shuttle Run Test) and anaerobic (Muscle Power Sprint Test) measures. The studies on laboratory-based measures were rated fair, mainly because of inadequate statistics. The level of evidence was strong for good validity and reliability of the field-based tests. The level of evidence was unknown for validity and low to moderate for good reliability of laboratory-based tests.

CONCLUSIONS

There is a paucity of research on the clinimetric properties of measurement instruments to assess aerobic and anaerobic capacity for children with CP. Further clinimetric studies of laboratory-based measures in children with CP at all Gross Motor Function Classification System (GMFCS) levels, and clinimetric studies of field-based measures in children who are classified as GMFCS levels III to V are required.

A systematic review of the clinimetric properties of habitual physical activity measures in young children with a motor disability

Aim. To identify and systematically review the clinimetric properties of habitual physical activity (HPA) measures in young children with a motor disability. Method. Five databases were searched for measures of HPA including: children aged <6.0 years with a neuromuscular disorder, physical activity defined as "bodily movement produced by skeletal muscles causing caloric expenditure", reported HPA as duration, frequency, intensity, mode or energy expenditure, and evaluated clinimetric properties. The quality of papers was assessed using the COSMIN-checklist. A targeted search of identified measures found additional studies of typically developing young children (TDC). Results. Seven papers assessing four activity monitors met inclusion criteria. Four studies were of good methodological quality. The Minimod had good ability to measure continuous walking but the demonstrated poor ability to measure steps during free-living activities. The Intelligent Device for Energy Expenditure and Activity and Ambulatory Monitoring Pod showed poor ability to measure activity during both continuous walking and free-living activities. The StepWatch showed good ability to measure steps during continuous walking in TDC. Interpretation. Studies assessing the clinimetric properties of measures of HPA in this population are urgently needed to allow assessment of the relationship between HPA and health outcomes in this group.

Accelerometry: a feasible method to quantify physical activity in ambulatory and nonambulatory adolescents with cerebral palsy

Objective. To determine the feasibility of physical activity monitoring in adolescents with cerebral palsy (CP). Methods. A convenience sample of ambulatory and non-ambulatory adolescents (N = 23; 17 males, 6 females; mean age 13.5 y, SD 2.6 y; Gross Motor Function Classification System (GMFCS) distribution: n = 9 Level I, n = 5 Level II, n = 5 Level III, n = 4 Level IV) was recruited. Physical activity (PA) was objectively assessed using the ActiGraph GT1M activity monitor. Discomfort or adverse effects of wearing the accelerometers were recorded by participants. Levels of physical activity were determined as total PA, light PA (LPA), moderate PA (MPA), moderate-to-vigorous (MVPA), and vigorous PA (VPA) using cut-points recently validated for CP. Results. Most participants showed little reluctance. Mean daily MVPA for all participants was 30.7 minutes (SD 30.3), which corresponded to 2.7 (SD 2.4) minutes of MVPA per hour or 4.5% (SD 3.9) of the total monitoring time. Total PA and MVPA were greatest in ambulatory youth (GMFCS levels I and II) compared with youth who use a walking aid or wheelchair (GMFCS levels III and IV) (P < 0.05). Conclusion(s). The results support the use of the accelerometer as a feasible and useful measure of activity in ambulatory and nonambulatory adolescents with CP.

Ambulatory activity of children with cerebral palsy: which characteristics are important?

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. Ambulatory activity was measured during 1 week with a StepWatch activity monitor as steps per day, and time spent at medium and high step rates. Multiple linear regression analyses were performed following a backward selection procedure until only independent variables with p<0.05 remained in the model. Ambulatory activity outcome parameters served as dependent variables, and disease, personal, and environmental characteristics as independent variables. Ambulatory activity was corrected for body height.

RESULTS

Children took more steps during school days (5169 steps, SD 1641) than during weekend days (4158 steps, SD 2048; p<0.001). Higher GMFCS level, bilateral CP, and higher age were associated with lower ambulatory activity on school days (R(2) ranged from 43-53%), whereas bilateral CP, higher age, and no sport club participation were associated with lower ambulatory activity in the weekend (R(2) ranged from 21-42%). Correcting for body height decreased the association with age.

INTERPRETATION

Interventions should focus at increasing physical activity at the weekend for children with bilateral spastic CP.

Long-term outcomes of children and adolescents who had cerebral palsy with secondary osteoporosis

OBJECTIVE

To investigate the long-term efficacy and index of treatment with vitamin D alone or with a bisphosphonate in children and adolescents who have cerebral palsy (CP) with secondary osteoporosis.

RESEARCH DESIGN AND METHODS

Thirty patients diagnosed with CP and secondary osteoporosis were analyzed for 5 years, and the efficacy of treatment was compared. Treatment was divided into three groups: The monotherapy group, consisting of patients taking only alfacalcidol (0.03 µg/kg/day); the polytherapy group, consisting of those taking alfacalcidol and risedronate (0.05 mg/kg/day); and the control group, consisting of patients who discontinued taking their medications for reasons unrelated to these therapies. Bone mineral density (BMD), bone-specific alkaline phosphate (BAP), and N-telopeptides of type I collagen (NTX/Cr) were measured on each patient just before and at discontinuation of treatment, after 6 months, and again at 1 and 3 years, respectively. The changes in BMD (ΔBMD), BAP (ΔBAP), and NTX/Cr (ΔNTX/Cr) were evaluated at these intervals, because the normal value of each parameter varies over time during childhood.

RESULTS

ΔBMD significantly increased in the polytherapy group at ≥1 year (p = 0.006), and the difference in BMD between the polytherapy and the control groups at ≥1 year was also significant (p = 0.005). ΔBAP was increased in the monotherapy and polytherapy groups at ≥1 year (p = 0.021 and p = 0.033). ΔNTX/Cr decreased in the polytherapy group at ≥1 year, which was consistent with the polytherapy group of the period from 1 month to 1 year (p = 0.033). The relation between ΔBMD to ΔBAP was a positive correlation in the second period in the monotherapy group (r = 0.46). And the relations between ΔBMD to ΔNTX/Cr were not recognized negative correlations in the monotherapy and polytherapy groups. Thus, ΔBMD reflected ossification of secondary osteoporosis in patients with CP, and ΔBAP and ΔNTX/Cr was significantly related to the increase and decrease of ΔBMD. There were no effects of other factors except sexual maturity. Limitations of this study include that each index of examination was the evaluation according to rate of change. Therefore, the results of this study were limited to longitudinal evaluations.

CONCLUSION

Evaluation according to ΔBMD and both methods of monotherapy and polytherapy were useful for CP patient taking antiepileptic drugs (AEDs) and regardless of sex. Especially, polytherapy for longer than 1 year led to improvement in BMD in children who had CP with secondary osteoporosis. BAP and NTX/Cr were useful for the index of the progression osteoporosis with or without these therapies.

Validity of submaximal exercise testing in adults with athetospastic cerebral palsy

OBJECTIVE

To examine the validity of the multistage submaximal cycle ergometer test for adults with athetospastic cerebral palsy.

DESIGN

Cross-sectional and correlative study. Oxygen uptake and heart rates were recorded while the participants underwent the maximal cycle ergometer test and the multistage submaximal cycle ergometer test. Peak oxygen consumption (Vo(2)peak) was achieved by the maximal cycle test. Maximum oxygen consumption (VO(2)max) was predicted by the multistage submaximal cycle ergometer test.

SETTING

Research laboratory setting.

PARTICIPANTS

Adults with athetospastic cerebral palsy (N=16; 10 women and 6 men; mean age ± SD, 43.7±14.5y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Peak VO(2) was compared with the predicted VO(2)max.

RESULTS

Mean VO(2)peak and the predicted VO(2)max ± SD were 866.9±202.9 mL/min(-1) and 857.4±248.4 mL/min(-1), respectively. There was not a significant difference between VO(2)peak values and the predicted VO(2)max values (r=.28). And there was a significant correlation between VO(2)peak values and the predicted VO(2)max values (r=.94, P<.001). SE of the estimate (or SE for X to Y) was 71.2 mL/min(-1), equivalent to 7.4%.

CONCLUSIONS

The multistage submaximal cycle ergometer test may provide a valid VO(2)max estimate of adults with athetospastic cerebral palsy.

Kinematic and electromyographic studies on unaided, unilateral and bilateral crutch walking in adolescents with spastic diplegia

BACKGROUND

Back pain and ambulation deterioration among ambulatory individuals with cerebral palsy (CP) are common as they grow older and walking aids are often prescribed to improve stability and promote maximal weight-bear on lower limbs during gait.

OBJECTIVE

To investigate the effects of walking aids on back muscle activity and whole body kinematics among adolescents with spastic diplegia.

STUDY DESIGN

A repeated-measures design was adopted with participants tested under different walking conditions.

METHODS

Ten participants were recruited and Lofstrand forearm crutches were selected. Both the activity of lumbar erector spinae and the kinematics of head, trunk, pelvis and lower limbs during walking were monitored using telemetric electromyography and motion analysis system respectively.

RESULTS

Comparisons between walking unaided and walking with unilateral and bilateral crutch(es) were made. Significant decreases in speed, cadence, erector spinae activity and lower trunk extension were observed during crutch walking together with significantly increased stride time and anterior pelvic tilt.

CONCLUSIONS

These findings suggested that Lofstrand crutch(es) reduced muscular demands and lumbar lordosis with increased lower back mobility. The results shed light on the prescription of walking aid in the management and prevention of chronic back pain for ambulatory individuals with CP from a life span perspective.

Development of the Early Activity Scale for Endurance for children with cerebral palsy

PURPOSE

The Early Activity Scale for Endurance (EASE) was developed as a clinically feasible measure of endurance for physical activity in young children with cerebral palsy (CP). Validity and reliability were evaluated.

METHODS

Participants included 414 children with CP and 106 without CP. Parents completed the EASE, an 11-item self-report measure. For construct validity, EASE scores were compared by Gross Motor Function Classification System levels (0 assigned for children without CP), age, and gender. In subgroups, convergent validity with the 6-minute walk test and test-retest reliability with a second EASE were evaluated.

RESULTS

EASE scores differed significantly by Gross Motor Function Classification System, but not by age or gender. The EASE correlated moderately (rs = 0.57) with the 6-minute walk test. Test-retest reliability was high, intraclass correlation (2,1) = 0.95.

CONCLUSION

The EASE has acceptable psychometrics for use in practice and research to estimate endurance for physical activity in young children with CP.

Group swimming and aquatic exercise programme for children with autism spectrum disorders: a pilot study

OBJECTIVE

To evaluate the effectiveness of a 14-week aquatic exercise programme for children with autism spectrum disorders (ASD).

DESIGN

Non-randomized control trial.

METHODS

Twelve children participated in this pilot study with seven participants in the aquatic exercise group and five in the control group. The programme was held twice per week for 40 minutes per session. Swimming skills, cardiorespiratory endurance, muscular endurance, mobility skills and participant and parent satisfaction were measured before and after the intervention.

RESULTS

No significant between-group changes were found. Within-group improvements for swimming skills were found for the intervention group. Programme attendance was high. Parents and children were very satisfied with the programme activities and instructors.

CONCLUSIONS

This pilot programme was feasible and showed potential for improving swimming ability in children with ASD. Exercise intensity was low for some participants, most likely contributing to a lack of significant findings on fitness outcomes.

Perfil cognitivo, déficits motores e influência dos facilitadores para reabilitação de crianças com disfunções neurológicas

OBJETIVO: Investigar se crianças e adolescentes saudáveis e com doenças neurológicas podem ser reunidas em grupos distintos e homogêneos, usando como critérios o desempenho cognitivo, o funcionamento motor e as percepções dos pais quanto aos facilitadores para a reabilitação. MÉTODOS: Participaram deste estudo 15 crianças saudáveis (C) e 43 pacientes (28 com paralisia cerebral e 15 com acidente vascular cerebral), entre cinco e 18 anos. Foi aplicado aos pais o instrumento denominado Avaliação dos Fatores Ambientais relacionados à Reabilitação Neurológica Infantil (AFARNI). O comprometimento cognitivo foi avaliado por meio do Mini-Exame do Estado Mental, adaptado para essa faixa etária, e o comprometimento motor foi investigado por avaliação clínica. Para comparar os resultados, foi realizada uma análise de conglomerados e ANOVA. RESULTADOS: A análise de conglomerados identificou quatro grupos de pacientes com características clínicas e sociodemográficas distintas, confirmados pela ANOVA (p<0,001). Houve dissociação entre os grupos com relação ao comprometimento cognitivo e motor. Os pais de crianças com maior comprometimento avaliaram de forma mais positiva os facilitadores para a reabilitação. CONCLUSÕES: A qualificação dos facilitadores para a reabilitação por meio da AFARNI e a avaliação cognitiva com auxílio do Mini-Exame do Estado Mental podem contribuir para identificar as necessidades de suporte para crianças com deficiências neurológicas que apresentam comprometimento cognitivo e motor.

Measurement of habitual physical activity performance in adolescents with cerebral palsy: a systematic review

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 (10-18 y) with CP were included if at least 60% of items reported HPA performance in the domains of intensity, frequency, duration, and mode.

RESULTS

Seven measures of HPA performance met the criteria: StepWatch, pedometers, Uptimer, heart rate flex method, accelerometers, and self-report measures including the Children's Activity Participation and Enjoyment (CAPE) scale and the Physical Activity Questionnaire for Adolescents. The CAPE scale had the strongest validity and reliability but was limited by its inability to measure activity intensity. No study was identified that evaluated the psychometric properties of physical activity measures in non-ambulant adolescents with CP (GMFCS levels IV and V).

INTERPRETATION

When deciding on an appropriate measure of HPA in adolescents with CP, clinicians need to consider their research question including the domains of HPA they are evaluating and the population they wish to assess. Accelerometers provide the most robust information about the patterns of HPA, with some evidence of validity but limited data on reliability. Further research is needed to compare the use of tri- and uniaxial accelerometers.

Osteoporosis among young adults with complex physical disabilities

This study set out to explore the possible link between osteoporosis in people under 40 years of age, who have complex physical disabilities and live in long-term care facilities. A range of information was obtained from the participants including their bone mineral density (BMD). The results confirmed that immobility is associated with low BMD, and those who are fed using a percutaneous endoscopic gastrostomy (PEG) tube are particularly at a higher risk of low BMD. The study findings helped to change the evidence-based care pathway for patients with complex physical disabilities, and the physiotherapy and manual handling they receive.

Becoming and staying physically active in adolescents with cerebral palsy: protocol of a qualitative study of facilitators and barriers to physical activity

Background

Adolescents with cerebral palsy (CP) show a reduced physical activity (PA). Currently there are no interventions for adolescents with CP in this critical life phase that optimise and maintain the individuals' physical activity in the long term. To develop such a program it is important to fully understand the factors that influence physical activity behaviours in adolescents with CP. The aim of this study is to explore what makes it easy or hard for adolescents with CP to be and to become physically active.

Methods/Design

A qualitative research method is chosen to allow adolescents to voice their own opinion. Because we will investigate the lived experiences this study has a phenomenological approach. Thirty ambulatory and non-ambulatory adolescents (aged 10-18 years) with CP, classified as level I to IV on the Gross Motor Function Classification System and 30 parents of adolescents with CP will be invited to participate in one of the 6 focus groups or an individual interview. Therapists from all Children's Treatment Centres in Ontario, Canada, will be asked to fill in a survey. Focus groups will be audio- and videotaped and will approximately take 1.5 hours. The focus groups will be conducted by a facilitator and an assistant. In preparation of the focus groups, participants will fill in a demographic form with additional questions on physical activity. The information gathered from these questions and recent research on barriers and facilitators to physical activity will be used as a starting point for the content of the focus groups. Recordings of the focus groups will be transcribed and a content analysis approach will be used to code the transcripts. A preliminary summary of the coded data will be shared with the participants before themes will be refined.

Discussion

This study will help us gain insight and understanding of the participants' experiences and perspectives in PA, which can be of great importance when planning programs aimed at helping them to stay or to become physically active.

Continued ambulation gains through high school in a student with cerebral palsy: a case report

PURPOSE

The purpose of this case report is to describe school-based physical therapy services received throughout high school by a student with diplegic cerebral palsy and to share her functional gains.

KEY POINTS

This previously discharged 15-year-old freshman was re-referred due to a perceived walking regression using long-leg braces/reverse rolling walker and her desire to again try crutches. She subsequently resumed walking, typically 4 days per week at school and progressed to axillary crutches on level surfaces and stairs. Gross Motor Function Measure scores increased from 66.4% freshman year to 78.8% senior year, with the greatest dimension changes in standing (35.9%-69.2%) and walking, running, and jumping (8.3%-25.0%).

CONCLUSION

School-based physical therapists are uniquely positioned to work with students in natural environments to optimize activity and participation. This report shows that continued ambulation gains in individuals with cerebral palsy are possible throughout adolescence.

Causal relation between spasticity, strength, gross motor function, and functional outcome in children with cerebral palsy: a path analysis

AIM

This study examined the causal relation between spasticity, weakness, gross motor function, and functional outcome (expressed as activity limitation) in children with cerebral palsy (CP) and tested models of functional outcome mediated by gross motor function.

METHOD

Eighty-one children (50 males, 31 females) with CP were recruited for this cross-sectional study. Their mean age was 10 years 4 months (SD 1y 9mo). Strength was assessed using the Manual Muscle Test. Spasticity was assessed by the Modified Ashworth Scale. The Gross Motor Function Measure assessed gross motor function. The Functional Skills domain of the Pediatric Evaluation of Disability Inventory assessed functional outcome. Twenty-eight children (34.6%) had quadriplegia, 44 children (54.3%) had diplegia, and nine children (11.1%) had hemiplegia. Children were classified using the Gross Motor Function Classification System with 14 (17.3%) in level I, 9 (11.1%) in level II, 13 (16.0%) in level III, 5 (6.2%) in level IV, and 40 (49.4%) in level V.

RESULTS

The proposed path model showed good fit indices. The direct effects were significant between spasticity and gross motor function (β=-0.339), between strength and gross motor function (β=0.447), and between gross motor function and functional outcome (β=0.708). Spasticity had a significant negative indirect effect (β=-0.240) and strength had a significant positive indirect effect (β=0.317) on functional outcome through effects on gross motor function.

INTERPRETATION

Activity-based rather than impairment-based intervention is more important for reducing activity limitation in children with CP. The study established a base from which researchers can further develop a causal model between motor impairments and functional outcome.

Health-related fitness in children and adolescents

PURPOSE

The American Physical Therapy Association Section on Pediatrics developed a task force to summarize fitness guidelines for children and adolescents. The purposes of this article were to review components, measurement methods, and consequences of physical fitness, and to summarize evidence-based activity recommendations for youth.

SUMMARY OF KEY POINTS

Health-related fitness is comprised of body composition, flexibility, cardiorespiratory endurance, and muscular strength and endurance. Each of these components is reviewed in terms of definition, assessment, normative values, and recommendations.

CONCLUSIONS

The task force supports the guidelines of the US Department of Health and Human Services, which state that to promote overall health and wellness, youth should participate in 60 minutes or more of physical activity every day.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Physical therapists should apply research relevant to health-related fitness when treating youth. Promoting fitness, health, and wellness in our communities is a responsibility all therapists should assume.

Evaluation of lower body positive pressure supported treadmill training for children with cerebral palsy

PURPOSE

To examine the feasibility of using lower body positive pressure supported (LBPPS) treadmill training to improve the walking abilities, balance and lower extremity strength of children with cerebral palsy (CP).

METHODS

Nine children with CP (GMFCS II-IV) participated in LBPPS treadmill training 2 days per week for 6 weeks. Pre and post training measures of preferred walking speed, spatiotemporal kinematics, lower extremity strength, and the BESTest were used to assess potential improvements from LBPPS treadmill training.

RESULTS

LBPPS treadmill training resulted in significantly faster walking speed, less time in double support, improved overall balance, and strength of the lower extremity antigravity musculature.

CONCLUSIONS

It is feasible to use LBPPS treadmill training to improve the walking performance, balance, and strength of children with CP.

LEARN 2 MOVE 7-12 years: a randomized controlled trial on the effects of a physical activity stimulation program in children with cerebral palsy

BACKGROUND

Regular participation in physical activities is important for all children to stay fit and healthy. Children with cerebral palsy have reduced levels of physical activity, compared to typically developing children. The aim of the LEARN 2 MOVE 7-12 study is to improve physical activity by means of a physical activity stimulation program, consisting of a lifestyle intervention and a fitness training program.

METHODS/DESIGN

This study will be a 6-month single-blinded randomized controlled trial with a 6-month follow up. Fifty children with spastic cerebral palsy, aged 7 to 12 years, with Gross Motor Function Classification System levels I-III, will be recruited in pediatric physiotherapy practices and special schools for children with disabilities. The children will be randomly assigned to either the intervention group or control group. The children in the control group will continue with their regular pediatric physiotherapy, and the children in the intervention group will participate in a 6-month physical activity stimulation program. The physical activity stimulation program consists of a 6-month lifestyle intervention, in combination with a 4-month fitness training program. The lifestyle intervention includes counseling the child and the parents to adopt an active lifestyle through Motivational Interviewing, and home-based physiotherapy to practise mobility-related activities in the daily situation. Data will be collected just before the start of the intervention (T0), after the 4-month fitness training program (T4), after the 6-month lifestyle intervention (T6), and after six months of follow-up (T12). Primary outcomes are physical activity, measured with the StepWatch Activity Monitor and with self-reports. Secondary outcomes are fitness, capacity of mobility, social participation and health-related quality of life. A random coefficient analysis will be performed to determine differences in treatment effect between the control group and the intervention group, with primary outcomes and secondary outcomes as the dependent variables.

DISCUSSION

This is the first study that investigates the effect of a combined lifestyle intervention and fitness training on physical activity. Temporary effects of the fitness training are expected to be maintained by changes to an active lifestyle in daily life and in the home situation.

TRIAL REGISTRATION

This study is registered in the Dutch Trial Register as NTR2099.

Physical activity measurement instruments for children with cerebral palsy: a systematic review

AIM

this paper is a systematic review of physical activity measurement instruments for field-based studies involving children with cerebral palsy (CP).

METHOD

database searches using PubMed Central, MEDLINE, CINAHL Plus, PsycINFO, EMBASE, Cochrane Library, and PEDro located 12 research papers, identifying seven instruments that met the inclusion criteria of (1) having been developed for children aged 0 to 18 years, (2) having been used to evaluate a physical activity dimension, and (3) having been used in a field-based study involving children with CP. The instruments reviewed were the Activities Scale for Kids - Performance version (ASKp), the Canada Fitness Survey, the Children's Assessment of Participation and Enjoyment/Preferences for Activities of Children (CAPE/PAC), the Compendium of Physical Activities, the Physical Activity Questionnaire - Adolescents (PAQ-A), StepWatch, and the Uptimer. Second-round searches yielded 11 more papers, providing reliability and validity evidence for the instruments.

RESULTS

the instruments measure physical activity frequency, mode, domain, and duration. Although most instruments demonstrated adequate reliability and validity, only the ASKp and CAPE/PAC have established reliability and validity for children with physical disabilities; the Uptimer has established concurrent validity. No instrument measuring intensity in free-living has been validated or found reliable for children with CP.

INTERPRETATION

the findings suggest that further studies are needed to examine the methodological properties of physical activity measurement in children with CP. Combining subjective and objective instruments is recommended to achieve better understanding of physical activity participation.

Correlates of decline in gross motor capacity in adolescents with cerebral palsy in Gross Motor Function Classification System levels III to V: an exploratory study

AIM

To explore associations between clinical variables and decline in motor capacity in adolescents with cerebral palsy (CP).

METHOD

Participants included 76 males and 59 females, whose mean age at the beginning of the study was 14 years 6 months (SD 2.4, range 11.6-17.9); 51 at Gross Motor Function Classification System (GMFCS) level III, 47 at level IV, and 37 at level V. Ninety-six participants had tetraplegia, 32 had diplegia, and one had hemiplegia. Types of motor disorder were spastic n=98; mixed, n=11; dystonic, n=9; hypotonic, n=7; and ataxic n=3 (seven participants were not classified). Reliable raters collected data annually for 4 years on anthropometric characteristics, the Spinal Alignment and Range of Motion Measure, as well as the Gross Motor Function Measure, 66 items (GMFM-66); participants or their parents reported on health status (using the Health Utilities Questionnaire), pain, and exercise participation (using measures developed for this study). The predicted drop in GMFM-66 scores after childhood was calculated using data on the same children from an earlier study. Correlations were calculated between the drop in GMFM-66 scores and the average and change scores of the clinical variables (the alpha level for statistical significance of this exploratory study was 0.10).

RESULTS

The drop in GMFM-66 score was significantly correlated with limitations in range of motion (r=0.42) and spinal alignment (r=0.28), and pain (r=0.16). Increases in triceps skinfold (r=-0.19), mid-arm circumference (r=-0.23), and the ratio of mid-arm circumference to knee height (r=-0.23) were associated with less decline.

INTERPRETATION

Preventing range-of-motion limitations and pain experiences and optimizing nutrition might contribute to less decline in the gross motor capacity of adolescents with CP. Further investigation is required to clarify the role other factors that contribute to maintained function over time.

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.

Stationary cycling and children with cerebral palsy: case reports for two participants

These case reports describe a stationary cycling intervention and outcomes for two child participants (P1 and P2) with spastic diplegic cerebral palsy. Each child completed a 12-week, 30-session cycling intervention consisting of strengthening and cardiorespiratory fitness phases. P1 exhibited higher training intensities, particularly during the cardiorespiratory phase. Average training heart rates were 59% and 35% of maximum heart rate for P1 and P2, respectively. Lower extremity peak knee flexor and extensor moments, gross motor function (Gross Motor Function Measure (GMFM-66)), preferred walking speed (thirty-second walk test), and walking endurance (600-yard walk-run test) were measured pre- and postintervention. Changes in outcome measurements corresponded with differences in exercise intensity. Greater gains in peak knee extensor moments, GMFM-66 scores (+4.2 versus +0.9), 600-yard walk-run test (-29% versus 0%) occurred for P1 versus P2, respectively. Preferred walking speeds did not increase substantially for P1 and decreased for P2.

Obesity in disabled children and adolescents: an overlooked group of patients

BACKGROUND

There is an ongoing debate concerning the relationship between disability and obesity in childhood and adolescence.

METHODS

The literature available in Medline was selectively searched for the terms: "(children /OR/ adolescents) /AND/ disability /AND/ (overweight /OR/ obesity)". This search was complemented by inspection of journals in the fields of obesity, pediatrics, and neurology.

RESULTS

A total of 38 relevant articles were identified. All studies agreed that the prevalence of overweight and obesity in children with disabilities was almost twice that in their non-disabled peers. No effective, long-lasting interventions for obesity in disabled children and adolescents have been published.

CONCLUSION

Since a high proportion of disabled children and adolescents are overweight or obese, effective strategies for preventing and managing excess weight need to be developed so as not to further endanger their social participation. Moreover, risk factors for overweight in disabled children and adolescents should be identified and their weight status carefully monitored.

Systematic review of interventions for low bone mineral density in children with cerebral palsy

AIM

To systematically review the efficacy of interventions to improve low bone mineral density (LBMD) in children and adolescents with cerebral palsy (CP).

METHODS

We performed a systematic search for published randomized, controlled trials (RCTs) and controlled clinical trials (CCTs) of children with CP (aged 0-20 years, all Gross Motor Function Classification System [GMFCS] levels) who received various medical and physical interventions for LBMD compared with no intervention or standard care. Study validity was evaluated by using the Physiotherapy Evidence Database (PEDro) scale. Standardized mean differences (SMDs) were calculated when data were sufficient.

RESULTS

Eight of 2034 articles met the inclusion criteria (6 RCTs, 2 CCTs). There were 3 trials of bisphosphonates, one of which (Henderson RC, Lark RK, Kecskemethy HH, Miller F, Harcke HT, Bachrach SJ. J Pediatr. 2002;141[5]:644-651) revealed a large and significant effect on BMD in 1 of 3 sites in the distal femur (SMD: 1.88 [95% confidence interval (CI): 0.52-3.24]). There were 3 trials of weight-bearing through varying approaches, one of which (Caulton JM, Ward KA, Alsop CW, Dunn G, Adams JE, Mughal MZ. Arch Dis Child. 2004;89[2]:131-135) showed a large and significant effect on the lumbar spine when increasing static standing time (SMD: 1.03 [95% CI: 0.21-1.85]). The administration of vitamin D and calcium produced a large, nonsignificant effect on BMD in the lumbar spine (Jekovec-Vrhovsek M, Kocijancic A, Prezelj J. Dev Med Child Neurol. 2000;42[6]:403-405) (SMD: 0.88 [95% CI: -0.07 to 1.84). Growth hormone combined with vitamin D and/or calcium resulted in effects comparable with vitamin D and/or calcium on BMD in the lumbar spine (Ali O, Shim M, Fowler E, et al. J Clin Endocrinol Metab. 2007;92[3]:932-937) (SMD 0 [95% CI: -1.24 to 1.24]).

CONCLUSIONS

Important effects on LBMD have been observed in small and diverse cohorts of children with CP. It is unclear whether small sample sizes or variable treatment responses account for nonsignificant findings. Additional large RCTs are needed of both physical and medical approaches.

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.

The pathophysiological basis of weakness in children with cerebral palsy

PURPOSE

To examine the evidence concerning the neurologic and muscular pathophysiology that contributes to clinically observed weakness in children and young people with cerebral palsy (CP).

METHOD

Literature concerning the neural or muscular changes in subjects with CP was found by searching 6 databases plus supplementary searching.

RESULTS

A final set of 51 articles was identified by 2 independent reviewers.

SUMMARY OF KEY POINTS

Muscle weakness is due to reduced central drive, possible abnormal neural maturation, insufficient and disorganized motor recruitment, impaired voluntary control, impaired reciprocal inhibition, altered setting of muscle spindles, and reinforcement of abnormal neural circuits. Muscle tissue is altered, with selective atrophy of fast fibers and altered myosin expression, changes in fiber length and cross-sectional area, changes in the length-tension curve, reduced elasticity, and impoverished muscle tissue development.

CONCLUSION

Children with CP are weak because of both neurologic and muscular changes.