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

Effect of Neurodevelopmental Treatment on fall risk and balance in children with spastic cerebral palsy: randomized controlled trial

AIM

Investigating the effect of Neurodevelopmental Treatment (NDT) on the risk of falling and balance in children diagnosed with Cerebral Palsy (CP).

METHODS

Participants were randomly assigned to experimental and control groups. At baseline, the balancing skills of all participants was assessed using the Pediatric Balance Scale, and the gait parameters and fall risk was measured using the LEGSys. The experimental group underwent an 8-week, case-specific, NDT program with intensive gait and balance training for 45-minute sessions, twice a week. The control group received only conventional physiotherapy for the duration of the study. Balancing, gait, and fall risk evaluations repeated after treatment was completed.

RESULTS

A total of 44 cases (Experimental: 22, Control: 22) were analyzed. Pre- and post-treatment comparisons were made within groups and change rates for both groups were compared. The differences in the change rates of specific fall risk parameters between groups was significant.

CONCLUSION

The eight-week NDT and conventional physiotherapy combined program effectively reduced the risk of falling in children with spastic CP.

Effects of various exercise interventions on motor function in cerebral palsy patients: a systematic review and network meta-analysis

PURPOSE

A network meta-analysis was utilized to compare the rehabilitative effectiveness of different exercise interventions on motor function in cerebral palsy(CP) patients.

METHODS

Computer searches were conducted across 9 databases, including PubMed, Cochrane Library, Scopus, Web of Science, Embase, and others, to identify randomized controlled trials focusing on different exercise interventions aimed at enhancing motor function in CP patients. The search spanned from the inception of the databases to January 31, 2024.

RESULTS

20 articles, encompassing 570 patients and evaluating three types of exercise interventions, were included in the analysis. Results showed that aerobic training, resistance training, and mixed training exhibited superior outcomes compared to the control group, as evidenced by improvements in Gross Motor Function Measure scores, muscle strength, gait speed, and 10-Meter Walk Test scores (P < 0.05). Furthermore, the network meta-analysis revealed that resistance training ranked highest in enhancing gross motor function and gait speed among CP patients, while mixed training was deemed most effective in improving muscle strength and 10-Meter Walk Test scores.

CONCLUSION

Exercise interventions have been shown to significantly improve motor function in CP patients. Among these, resistance training and mixed training stand out for their effectiveness in enhancing walking capabilities. Resistance training is specifically aimed at improving gross motor function, while mixed training focuses on increasing muscle strength.

Efficacy and threshold dose of intensive training targeting mobility for children with cerebral palsy: A systematic review and meta-analysis

AIM

To systematically review the evidence for intensive mobility training in cerebral palsy (CP) and to determine the minimum effective dose to improve mobility.

METHOD

Randomized controlled trials (RCTs) or quasi-RCTs that included participants with CP, and which used intensive task-oriented training (TOT) mobility interventions and reported mobility outcomes, were included. Five databases were searched; two independent reviewers selected studies and extracted data. The Grading of Recommendations Assessment, Development, and Evaluation system and the Cochrane Risk of Bias 2 tool were used to rate the certainty of evidence at the outcomes level and to determine the risk of bias respectively. Meta-analyses were conducted with clinically homogeneous studies. Threshold dose was analysed through meta-regression.

RESULTS

Forty-six RCTs with 1449 participants (mean age range 1 year 2 months to 16 years 4 months) were included. TOT had statistically and clinically significant effects on walking speed (p = 0.001), cadence (p = 0.02), gross motor function (p = 0.03), and functional mobility (p = 0.009) compared with control interventions. The threshold dose was undeterminable owing to the high heterogeneity of studies.

INTERPRETATION

TOT may improve walking speed, walking endurance, and balance. Studies with homogeneous samples and outcomes are needed to support clinical recommendations for intensive mobility interventions.

Group-based progressive functional, high-intensity training in adolescents and young adults with unilateral cerebral palsy - a tool to improve gross motor function, endurance and gait? - a pilot study

PURPOSE

This pilot study assessed the safety and effects of progressive functional high-intensity training in a group setting for adolescents with unilateral cerebral palsy (CP) on daily function indicators.

METHODS

Nine adolescents (mean age 16.9 years, GMFCS levels I-II) participated in 12 weeks of training (2x/week). Evaluations included 3D gait analysis, the 6-min walking test (6MWT), clinical exams, and the Gross Motor Function Measure-66 (GMFM-66).

RESULTS

No adverse events occurred, and GMFM-66 scores significantly improved (p = .031, Δ = 2.19%). Although increases in 6MWT (p = .09, Δ = 29.8 m) performance and propulsion ratio (p = .067, Δ = 5.4%) for the affected leg were observed, they were not statistically significant.

DISCUSSION

The study suggests that this training is safe and may enhance gross motor function, endurance, and gait asymmetry in unilateral CP. Future research should include upper limb evaluations and out-of-clinic motion analysis with wearable inertial measurement units (IMUs) to provide a more comprehensive assessment of functional movements.

Sit-to-stand performance in children with cerebral palsy: a population-based cross-sectional study

BACKGROUND

Sit-to-stand (STS) is one of the most commonly performed functional movements in a child's daily life that enables the child to perform functional activities such as independent transfer and to initiate walking and self-care. Children with cerebral palsy (CP) often have reduced STS ability. The aim of this study was to describe STS performance in a national based total population of children with CP and its association with age, sex, Gross Motor Function Classification System (GMFCS) level, and CP subtype.

METHODS

This cross-sectional study included 4,250 children (2,503 boys, 1,747 girls) aged 1-18 years from the Swedish Cerebral Palsy Follow-Up Program (CPUP). STS performance was classified depending on the independence or need for support into "without support," "with support," or "unable." "With support" included external support from, e.g., walls and furniture. Physical assistance from another person was classified as "unable" (dependent). Ordinal and binary logistic regression analyses were used to identify associations between STS and age, GMFCS level, and CP subtype.

RESULTS

60% of the children performed STS without support, 14% performed STS with support, and 26% were unable or needed assistance from another person. STS performance was strongly associated with GMFCS level and differed with age and subtype (p < 0.001). For all GMFCS levels, STS performance was lowest at age 1-3 years. Most children with GMFCS level I (99%) or II (88%) performed STS without support at the age of 4-6 years. In children with GMFCS level III or IV, the prevalence of independent STS performance improved throughout childhood. CP subtype was not associated with STS performance across all GMFCS levels when adjusted for age.

CONCLUSIONS

Independent STS performance in children with CP is associated with GMFCS level and age. Children with CP acquire STS ability later than their peers normally do. The proportion of children with independent STS performance increased throughout childhood, also for children with GMFCS level III or IV. These findings suggest the importance of maintaining a focus on STS performance within physiotherapy strategies and interventions for children with CP, including those with higher GMFCS level.

Reporting of Adverse Events in Muscle Strengthening Interventions in Youth: A Systematic Review

Clear definition, identification, and reporting of adverse event (AE) monitoring during training interventions are essential for decision making regarding the safety of training and testing in youths.

PURPOSE

To document the extent to which AEs, resulting from intervention studies targeting muscle strengthening training (MST) in youth, are reported by researchers.

METHODS

Electronic databases (CINAHL, PubMed, SPORTDiscus, and Web of Science) were searched for English peer-reviewed articles published before April 2018. Inclusion criteria were: (1) average age <16 years, (2) use of MST, (3) statement(s) linked to the presence/absence of AEs, and (4) randomized controlled trials or quasi-experimental designs. Risk of reporting bias for AEs followed recommendations by the Cochrane Collaboration group.

RESULTS

One hundred and ninety-one full-text articles were screened. One hundred and thirty met all MST criteria, out of which only 44 (33.8%; n = 1278, age = 12.1 [1.1] y) included a statement as to the presence/absence of adverse events. The 86 other studies (66.2%) included no such statement. Of the reporting 44 studies, 18 (40.1%) indicated one or more adverse events. Of the 93 reported adverse events, 55 (59.1%) were linked to training or testing.

CONCLUSIONS

Most MST studies in youth do not report presence/absence of adverse events, and when reported, adverse events are not well defined.

Physiotherapy strategies for functional improvement in a child with complicated hereditary spastic paraplegia: 1-year follow-up of a case report using a changing criterion design

BACKGROUND

and Purpose: Hereditary spastic paraplegias (HSP) are a group of clinically diverse genetic disorders that share the neurologic symptom of difficulty in walking due to progressive serious muscle weakness and spasticity in the legs. This study describes a physiotherapy program for improving the functional ability of a child diagnosed with complicated HSP and reports the treatment results.

METHODS

A 10-year-old boy with complicated HSP received a physiotherapy intervention that included strengthening of the leg muscles and treadmill training for 1 h per session, three to four times a week for 6 weeks. Outcome measures included sit-to-stand, 10-m walk, 1-min walk tests, and gross motor function measures (dimensions D and E).

RESULTS

After the intervention, the sit-to-stand, 1-min walk, and 10-m walk test scores improved by 6.75 times, 2.57 m, and 0.05 m/s, respectively. Furthermore, the gross motor function measure dimensions D and E scores improved by 8% (46%-54%) and 5% (22%-27%), respectively. The gains in each parameter were maintained at the 3- and 6-month and 1-year follow-ups.

CONCLUSION

These results suggest that structured physiotherapy programs can benefit the functional rehabilitation of children with complicated HSP.

What are the optimum training parameters of progressive resistance exercise for changes in muscle function, activity and participation in people with cerebral palsy? A systematic review and meta-regression

OBJECTIVES

To explore the effect of progressive resistance exercise (PRE) on impairment, activity and participation of people with cerebral palsy (CP). Also, to determine which programme parameters provide the most beneficial effects.

DATA SOURCES

Electronic databases searched from the earliest available time.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) implementing PRE as an intervention in people with cerebral palsy were included.

STUDIES APPRAISAL & SYNTHESIS METHODS

Methodological quality of trials was assessed with the PEDro scale. Meta-analysis and meta-regression were completed.

RESULTS

We included 20 reports of 16 RCTs (n = 504 participants). Results demonstrated low certainty evidence that PRE improved muscle strength (pooled standardised mean difference (SMD)= 0.59 (95%CI: 0.16-1.01; I²=70%). This increase in muscle strength was maintained an average of 11 weeks after training stopped. Τhere was also moderate certainty evidence that it is inconclusive whether PRE has a small effect on gross motor function (SMD= 0.14 (95%CI: -0.09 to 0.36; I²=0%) or participation (SMD= 0.26 (95%CIs: -0.02 to 0.54; I²=0%). When PRE was compared with other therapy there were no between-group differences. Meta-regression demonstrated no effect of PRE intensity or training volume (frequency x total duration) on muscle strength (p > 0.5). No serious adverse events were reported. There is lack of evidence of the effectiveness of PRE in adults and non-ambulatory people with CP.

CONCLUSIONS

PRE is safe and increases muscle strength in young people with CP, which is maintained after training stops. The increase in muscle strength is unrelated to the PRE intensity or dose. CONTRIBUTION OF THE PAPER.

Loaded Functional Strength Training versus Traditional Physical Therapy on Hip and Knee Extensors Strength and Function Walking Capacity in Children with Hemiplegic Cerebral Palsy: Randomized Comparative Study

Objective: This study’s objective was to see how loaded functional strengthening exercises using a plantigrade foot position and a shoe supporter affected muscle strength and walking ability in spastic hemiplegic children. Methods: Seventy-two children with spastic hemiplegic cerebral palsy, both sexes, aged ten to twelve years, were randomly assigned into two groups equal in number (control and intervention groups). The control group received a specially designed physical therapy program, whereas the intervention group received a loaded functional strengthening exercises program using a shoe supporter to maintain a plantigrade foot position. The training program was carried out for 60 min, three times per week for three consecutive months. All participants were evaluated both before and after the therapy program by using a Medical Commander Echo Manual Muscle Tester dynamometer to assess isometric muscle power of hip and knee extensors on the affected side. To assess functional walking capacity, a 6 min walking (6MWT) test was used. Results: Study groups were comparable with respect to all outcome measures at entry (p > 0.05). Within-group comparison showed significant improvements in all measured variables. Furthermore, between-group comparison revealed significantly greater improvements (p < 0.05) in hip and knee extensors strength as well as the functional walking capacity in favor of the intervention group. Conclusions: In all the analyzed variables, loaded functional strength exercises from the plantigrade foot position were found to be considerably more effective in the intervention group than in the control group.

Effect of Pilates Exercises on Standing, Walking, and Balance in Children With Diplegic Cerebral Palsy

Objective

To analyze how Pilates exercises affect standing, walking, and balance in children with diplegic cerebral palsy throughout a 10-week program.

Methods

We included 40 children aged 7–9 years with diplegic cerebral palsy, and randomly allocated them into two groups of the same size: conventional therapy group (group A) and conventional therapy+Pilates group (group B). We administered the same conventional physical therapy program to both groups for 45 minutes, with group B receiving additional Pilates exercises for 45 minutes. Both groups attended the intervention program three times/week for 10 weeks. We used the Growth Motor Function Measure Scale (GMFM-88) to evaluate standing and walking (Dimensions D and E), and the Pediatric Balance Scale to evaluate balance function before and after treatment.

Results

Comparison of the average values of all measured variables before and after therapy showed a statistically significant difference (p<0.05) between the two groups. All measured variables showed a significant difference between groups A and B, in favor of group B (p<0.05).

Conclusion

Pilates exercise in addition to conventional therapy is more effective in improving balance and gross motor function in children with diplegic cerebral palsy than the conventional therapy alone.

Koumantakis G, Theotokatos G, Skordilis E. The effects of a strengthening program on walking and stair-climbing ability of adolescents and young adults with cerebral palsy: a randomized controlled trial

Purpose

The study aim was to examine the effects of a 10-week school-based strengthening program on walking and stair-climbing ability of adolescents and young adults with cerebral palsy.

Methods

Overall, 35 participants, aged 12–19 years, were classified in 3 levels in accordance with the Gross Motor Function Classification System and randomly assigned to the experimental and control group. The experimental group participated in a 10-week progressive resistance exercise program during the adapted physical education class and performed functional strength exercises (sit-to-stand, lateral and front step-up), with a frequency of 3 times per week. The experimental and control groups continued their usual care at school regarding physical therapy and/or occupational therapy. Stair-climbing ability was assessed with the Timed Up and Down Stairs test and walking ability was evaluated with the 10-m walk test and the 1-minute walk test.

Results

There was a significant between-group improvement for stair-climbing ability favouring the intervention group (F = 6.519, p = 0.016, ƞ2 = 0.169), whereas walking ability as assessed with the 10-m walk test and the 1-minute walk test remained unchanged.

Conclusions

A functional strengthening program administered in adolescents and young adults with cerebral palsy may positively influence their stair-climbing ability, without any adverse effects.

Sit-to-stand training for self-care and mobility in children with cerebral palsy: a randomized controlled trial

AIM

To investigate if a sit-to-stand exercise programme for children with cerebral palsy (CP) would improve self-care and mobility.

METHOD

Thirty-eight children with CP (19 males, 19 females; mean age 8y 0mo, SD 2y 4mo, age range 4y 0mo-12y 4mo) classified in Gross Motor Function Classification System (GMFCS) levels III and IV and their caregivers were randomly allocated to sit-to-stand training plus routine physiotherapy (balance and gait training) or routine physiotherapy only (controls). Task-specific sit-to-stand training was completed five times a week for 6 weeks under physiotherapist (twice weekly) and caregiver (three times weekly) supervision. Blinded outcome assessments at week 7 were the self-care and mobility domains of the Functional Independence Measure for Children, Five Times Sit-to-Stand Test (FTSST), and Modified Caregiver Strain Index (MCSI).

RESULTS

The sit-to-stand group self-care increased by 2.2 units (95% confidence interval [CI] 1.3-3.1) and mobility increased by 2.2 units (95% CI 1.4-3.0) compared to the control group. In the sit-to-stand group, the FTSST was reduced by 4.0 seconds (95% CI -4.7 to -3.2) and the MCSI was reduced by 0.8 units (95% CI -1.2 to -0.4) compared to the control group.

INTERPRETATION

A sit-to-stand exercise programme for children with CP classified in GMFCS levels III and IV improved sit-to-stand performance and resulted in small improvements in self-care and mobility, while reducing caregiver strain. What this paper adds Sit-to-stand training improved independence in self-care and mobility for children with cerebral palsy (CP). Home-based sit-to-stand training programmes for children with CP can reduce the burden on supervising caregivers.

Aerobic Responses to FES-Assisted and Volitional Cycling in Children with Cerebral Palsy

Recumbent stationary cycling is a potential exercise modality for individuals with cerebral palsy (CP) that lack the postural control needed for upright exercises. Functional electrical stimulation (FES) of lower extremity muscles can help such individuals reach the cycling intensities that are required for aerobic benefits. The aim of this study was to examine the effect of cycling with and without FES assistance to that of a no-intervention control group on the cardiorespiratory fitness of children with CP. Thirty-nine participants were randomized to a FES group that underwent an 8-week FES-assisted cycling program, the volitional group (VOL), who cycled without FES, or a no-intervention control group (CON) (15 FES, 11 VOL, 13 CON). Cadence, peak VO₂, and net rise in heart rate were assessed at baseline, end of training, and washout (8-weeks after cessation of training). Latent growth curve modeling was used for analysis. The FES group showed significantly higher cycling cadences than the VOL and CON groups at POST and WO. There were no differences in improvements in the peak VO₂ and peak net HR between groups. FES-assisted cycling may help children with CP attain higher cycling cadences and to retain these gains after training cessation. Higher training intensities may be necessary to obtain improvements in peak VO₂ and heart rate.

Effect of muscle strength training in children and adolescents with spastic cerebral palsy: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis investigates the effects of strength training program in children and adolescents with cerebral palsy to improve function, activity, and participation.

DATA SOURCES

Five electronic databases (MEDLINE-Pubmed, Cochrane Library, PEDro, CINAHL, and SPORTDiscus) were systematically searched for full-text articles published from inception to 30 June 2021.

REVIEW METHODS

Randomized controlled trials were included, who compared: (i) child population with spastic cerebral palsy population between 0 and 22 years; (ii) studies in which a muscle strength training program was performed and included dosing information; (iii) studies comparing strength training with other physical therapy technique(s) or untreated control group. Studies with similar outcomes were pooled by calculating standardized mean differences. Risk of bias was assessed with Cochrane Collaboration's tool for assessing the risk of bias and PROSPERO's registration number ID: CRD42020193535.

RESULTS

Twenty-seven studies, comprising 847 participants with spastic cerebral palsy. The meta-analyses demonstrated significant standardized mean differences in favor of strength training program compared to other physical therapy technique(s) or untreated control group(s) for muscle strength at the knee flexors, at the knee extensor, at the plantarflexors, maximum resistance, balance, gait speed, GMFM (global, D and E dimension) and spasticity.

CONCLUSION

A strength training program has positive functional and activity effects on muscle strength, balance, gait speed, or gross motor function without increasing spasticity for children and adolescents with cerebral palsy in Gross Motor Function Classification System levels I, II, and III when adequate dosage and specific principles are utilized.

Cerebral Palsy: Sport and Exercise Considerations

ABSTRACT

Cerebral palsy (CP) is a group of debilitating motor disorders that carries a wide array of clinical presentations ranging from isolated physical or cognitive impairment to global loss of function. Despite the prevalence of CP, recommendations and benefits of physical activity/exercise have historically not been clearly defined. The research on the subject has several limitations, including small sample size, power, standardized measures/outcomes, and poor classification regarding severity of the disease. Nonetheless, the general consensus and new research shows that individuals with CP who participate in sports and exercise regimens, even at reduced frequency and intensity, exhibit improvements in health care benefits, including cardiorespiratory endurance, gross motor function, gait stability, and reduction in pain. These regimens can be prescribed safely and individualized by health care providers to improve morbidity and mortality in patients suffering from CP.

Six Months Guided Exercise Therapy Improves Motor Abilities and White Matter Connectivity in Children with Cerebral Palsy

Background

Diffusion magnetic resonance imaging (dMRI) provides the state of putative connectivity from lesioned areas to other brain areas and is potentially beneficial to monitor intervention outcomes. This study assessed the effect of a 6 months guided exercise therapy on motor abilities and white matter diffusivity in the brains of cerebral palsy (CP) children.

Methods

This is a single arm pre-and post-test research design involving 10 spastic CP children, aged 8–18 years and whose Gross Motor Function Classification System Expanded and Revised (GMFCS-E & R) at least Level 21 with the ability to ambulate independently. They were recruited from Paediatric Neurology Clinic, Hospital Universiti Sains Malaysia (HUSM) from December 2015–December 2016. All participants underwent 6 months of therapist-guided exercise session comprising progressive strength training at a frequency of twice a week, 1 h duration per session. The effect of exercise on motor abilities was assessed using the Gross Motor Function Measures (GMFM)-88. Six out of the 10 children consented for dMRI. Probabilistic tractography of the corticospinal tract (CST) was performed to determine the connectivity index of the tracts pre-and post-intervention.

Results

All the participants displayed statistically significant increment in GMFM-88 scores pre-to post-exercise intervention. This improvement was concurrent with increased connectivity index in the CST of upper limbs and lower limbs in the brain of these children.

Conclusion

Our findings demonstrated that 6 months guided exercise therapy improves motor abilities of CP children concurrent with strengthening the connectivities of the motor pathways in the brain.

Effect of Functional Progressive Resistance Exercise on Lower Extremity Structure, Muscle Tone, Dynamic Balance and Functional Ability in Children with Spastic Cerebral Palsy

The purpose of this study was to investigate the effects of functional progressive resistance exercise (FPRE) on muscle tone, dynamic balance and functional ability in children with spastic cerebral palsy. Twenty-five subjects were randomized into two groups: the FPRE group (n = 13) and the control group (n = 12). The experimental group participated in an FPRE program for 30 min per day, three times per week for six weeks. Knee extensor strength, rehabilitative ultrasound imaging (RUSI), muscle tone, dynamic balance, and functional ability was evaluated. The results showed statistically significant time × group interaction effects on the dominant side for knee extensor strength and cross-sectional area (CSA) in RUSI (p < 0.05). On both sides for thickness of the quadriceps (TQ) in RUSI, muscle tone and dynamic balance were statistically significant time × group interaction effects (p < 0.05). Additionally, knee extensor strength, CSA, TQ in RUS, muscle tone, dynamic balance and gross motor function measure (GMFM) in functional ability were significantly increased between pre- and post-intervention within the FPRE group (p < 0.05). The results suggest that FPRE is both feasible and beneficial for improving muscle tone, dynamic balance and functional ability in children with spastic cerebral palsy.

Effects of whole-body vibration combined with action observation on gross motor function, balance, and gait in children with spastic cerebral palsy: a preliminary study

This study evaluated the effects of whole-body vibration (WBV) com-bined with action observation on gross motor function, balance, and gait in children with spastic cerebral palsy. The participants were randomized into the WBV combined with action observation (WBVAO) group (n=7) and the WBV group (n=7). The WBVAO group received WBV combined with action observation training, and the WBV group received WBV training for 4 weeks. Both groups received 30 min of training a day, 3 times a week. All participants completed the 5 times sit to stand (FTSTS) test, Timed Up and Go (TUG) test, pediatric reach test, 10-m walk test, 6-min walk test (6MWT), and timed up and down stair (TUDS) test before and after the training intervention. Moreover, the participant’s Gross Motor Function Measure (GMFM) and Pediatric Balance Scale (PBS) scores were assessed. Both the WBVAO and WBV groups demonstrated significant increases in the scores of FTSTS test, GMFM (D and E dimensions), PBS, TUG test, 6MWT, and TUDS test. The WBVAO group improved more significantly compared to the WBV group based on the scores of the FTSTS test, GMFM (D dimension), PBS, 6MWT, and TUDS test. WBV combined with action observation improved lower extremity functional strength, gross motor function, and balance and gait in children with cerebral palsy. These results suggest that WBV combined with action observation is both feasible and suitable for individuals with cerebral palsy.

Defining Functional Therapy in Research Involving Children with Cerebral Palsy: A Systematic Review

Aim: To review definitions and elements of interventions in studies, which used the word "functional" to describe their intervention for children with cerebral palsy (CP), and to determine whether definitions and elements are similar to criteria of functional therapy described in the Dutch Guidelines.Methods: Systematic review of intervention studies, which used the word "functional" to describe interventions for children with CP. We described criteria of functional therapy that were used to describe the intervention, and whether criteria were described similarly to the descriptions used in the Dutch Guidelines.Results: Of the 27 included studies, criteria "based on the activities/participation level of the ICF-CY", "goal-directed" and "context-specific" were referred to the most (40-59.3%). Descriptions of these criteria were less comparable to the suggested definition (43.8-69.2%). The remaining three criteria ("active involvement", "task-specific", and "focused on functionality instead of normality") were referred to less frequently (18.5-33.3%). The descriptions reported for these criteria were, however, the most comparable with the suggested definitions (80-100%).Conclusions: The included studies, in general have not used criteria of functional therapy. Future studies have to describe the elements of interventions in detail. Moreover, it is important to reach consensus on the definition and elements of functional therapy.

Effect of task-oriented training on balance and motor function of ambulant children with cerebral palsy

INTRODUCTION AND OBJECTIVES

The study evaluated the effect of task-oriented training (TOT) on the motor function (MF) and balance of ambulant children with cerebral palsy (CP).

MATERIALS AND METHODS

A total of 46 children were randomised into TOT group (n=23) and Control Group (CG [n=23]), but 39 children complete the study. Balance and MF were assessed at baseline, 6th and 12th weeks and 6 weeks post-intervention. Data were analysed with repeated measures ANOVA, Friedman's, Mann-Whitney U, Student's-t and post hoc tests at α≤0.05.

RESULTS

The two groups were comparable in all baseline scores (P>0.05). At the 6th week, significant between-group difference was observed in MF only [TOT=81.9 (18.5); CG=72.8 (19.4)] (P<0.05). There were significant between-group differences in MF [TOT=88.8 (9.4); CG=75.5 (18.5); P<0.05] and balance (TOT=9.4±4.5; CG=13.6±6.9; P<0.05) at the 12th week (P<0.05) and 6 weeks post-intervention (P<0.05).

CONCLUSION

TOT improved the balance and MF of ambulant children with CP.

Impact of Resistance Therapy on Motor Function in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

Cerebral palsy is one of the main causes of disability in childhood. Resistance therapy shows benefits in increasing strength and gait in these patients, but its impact on motor function is not yet clear. The objective was to analyze the impact of resistance therapy on the improvement in the motor function using a review and meta-analysis. A comprehensive literature research was conducted in Medline (PubMed), Institute for Scientific Information (ISI) Web of Knowledge, and Physiotherapy Evidence Database (PEDro) in relation to clinical trials in which resistance therapy was used and motor function was assessed. Twelve controlled clinical trials and three non-controlled clinical trials (only one intervention arm) studies were identified. In terms of pre-post difference, the overall intra-group effect was in favor of resistance therapy intervention: standardized mean difference (SMD) = 0.37, 95% confidence interval (CI) = 0.21 to 0.52, p < 0.001 (random-effects model), with moderate heterogeneity (I2 = 59.82%). SMDs were also positive by restricting to each of the analyzed scales: SMD = 0.37, 1.33, 0.10, and 0.36 for Gross Motor Function Measure (GMFM), Lateral Step Up (LSU), Time Up and Go (TUG), and Mobility Questionnaire (MobQue) scales, respectively. Regarding the difference between groups, the results showed a high heterogeneity (I2 < 99%), with the mean difference (MD) also favorable for the GMFM scale: MD = 1.73, 95% CI = 0.81 to 2.64, p < 0.001 (random-effects model). Our results support a positive impact of resistance therapy on motor function. Further studies should delve into the clinical relevance of these results.

Effect of physical therapy interventions on spatiotemporal gait parameters in children with cerebral palsy: a systematic review

AIM

To investigate the effect of physical therapy interventions on spatiotemporal gait parameters in children with cerebral palsy.

METHODS

Six databases were searched: PubMed, Embase, Web of Science, Science Direct, Lilacs, and Scopus. Two independent reviewers worked on primary study selection based on titles, abstracts, and full text reading. We included randomized controlled trials investigating the role of therapeutic interventions on gait kinematics in children with cerebral palsy. The independent reviewers extracted information about study population, intervention type, main outcomes, and methodological quality according to PEDro Scale. The body of evidence was synthesized through GRADE.

RESULTS

Twenty-six studies were found addressing the following treatment categories: functional electrical stimulation, transcranial stimulation, gait training, muscular strengthening, vibratory platform training, and serial casting. A moderate level of evidence was identified for vibratory platform training, gait training, transcranial stimulation (positive effect), and isolated muscle strengthening (negative effect) in relation to gait velocity. Electrical stimulation showed a moderate level of evidence regarding stride length. The evidence for other outcomes was of low or very low quality.

CONCLUSION

Vibratory platform, gait training, electrical stimulation, and transcranial stimulation were effective to improve spatiotemporal gait parameters, especially velocity in children with cerebral palsy.Implication for rehabilitationImprovement and maintenance of gait of children with cerebral palsy is a great challenge to rehabilitation professionalsVibratory platform, gait training, electrical stimulation, and transcranial stimulation improve gait parameters.Isolated strength training was not effective to improve gait parameters in Cerebral Palsy.Long-term effect of most techniques on gait parameters until unclear.

Results From a Randomized Controlled Trial to Address Balance Deficits After Traumatic Brain Injury

OBJECTIVE

To evaluate the efficacy of an in-home 12-week physical therapy (PT) intervention that utilized a virtual reality (VR) gaming system to improve balance in individuals with traumatic brain injury (TBI).

SETTING

Home-based exercise program (HEP).

PARTICIPANTS

Individuals (N=63; traditional HEP n=32; VR n=31) at least 1 year post-TBI, ambulating independently within the home, not currently receiving PT services.

MAIN OUTCOME MEASURES

Primary: Community Balance and Mobility Scale (CB&M); Secondary: Balance Evaluation Systems Test (BESTest), Activities-Specific Balance Confidence Scale (ABC), Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

No significant between-group differences were observed in the CB&M over the study duration (P=.9983) for individuals who received VR compared to those who received a HEP to address balance deficits after chronic TBI nor in any of the secondary outcomes: BESTest (P=.8822); ABC (P=.4343) and PART-O (P=.8822). However, both groups demonstrated significant improvements in CB&M and BESTest from baseline to 6, 12, and at 12 weeks follow-up (all P's <.001). Regardless of treatment group, 52% of participants met or exceeded the minimal detectable change of 8 points on the CB&M at 24 weeks and 38% met or exceeded the minimal detectable change of 7.81 points on the BESTest.

CONCLUSION

This study did not find that VR training was more beneficial than a traditional HEP for improving balance. However, individuals with chronic TBI in both treatment groups demonstrated improvements in balance in response to these interventions which were completed independently in the home environment.

Effects of a training programme of functional electrical stimulation (FES) powered cycling, recreational cycling and goal-directed exercise training on children with cerebral palsy: a randomised controlled trial protocol

INTRODUCTION

Children with cerebral palsy (CP) experience declines in gross motor ability as they transition from childhood to adolescence, which can result in the loss of ability to perform sit-to-stand transfers, ambulate or participate in leisure activities such as cycling. Functional electrical stimulation (FES) cycling is a novel technology that may provide opportunities for children with CP to strengthen their lower limbs, improve functional independence and increase physical activity participation. The proposed randomised controlled trial will test the efficacy of a training package of FES cycling, adapted cycling and goal-directed functional training to usual care in children with CP who are susceptible to functional declines.

METHODS AND ANALYSIS

Forty children with CP (20 per group), aged 6-8 years and classified as Gross Motor Function Classification System (GMFCS) levels II-IV will be recruited across South East Queensland. Participants will be randomised to either an immediate intervention group, who will undertake 8 weeks of training, or a waitlist control group. The training group will attend two 1 hour sessions per week with a physiotherapist, consisting of FES cycling and goal-directed, functional exercises and a 1 hour home exercise programme per week, consisting of recreational cycling. Primary outcomes will be the gross motor function measure and Canadian occupational performance measure, and secondary outcomes will include the five times sit-to-stand test, habitual physical activity (accelerometry), power output during cycling and Participation and Environment Measure-Children and Youth. Outcomes will be assessed at baseline, postintervention (8 weeks) and 8 weeks following the intervention (retention).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Griffith University (2018/037) and the Children's Health Queensland Hospital and Health Service (CHQHHS) Human Research Ethics Committee (HREC/17/QRCH/88). Site-specific approval was obtained from CHQHHS research governance (SSA/17/QRCH/145). Results from this trial will be disseminated via publication in relevant peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000644369p.

Relationship between walking efficiency and muscular strength of the lower limbs in children with cerebral palsy

[Purpose] In children with cerebral palsy, despite increases in muscle strength after strengthening, improvements in walking efficiency are inconsistent in previous studies. The purpose of this study was to analyze the relationship between walking efficiency and muscle strength in children with cerebral palsy. [Participants and Methods] Twenty-six children with cerebral palsy participated in this study. Isometric muscle strength in the lower extremities and the Total Heart Beat Index were measured. Participants were divided into the high and low walking efficiency groups based on the median Total Heart Beat Index value (2.06 beats/m). [Results] For all participants, all isometric muscle strength values were significantly correlated with the Total Heart Beat Index. In the high walking efficiency group, there was no significant correlation. All isometric muscle strength values in the low walking efficiency group were significantly correlated with the Total Heart Beat Index, except for that of the hip extensors. [Conclusion] The influence of muscular strength on walking efficiency in children with cerebral palsy varied. Significant correlations were observed only for those in the low walking efficiency group. The walking efficiency level should be confirmed before planning muscle strength training to improve walking efficiency.

Effects of task-specific movement patterns during resistance exercise on the respiratory functions and thickness of abdominal muscles of children with cerebral palsy: randomized placebo-controlled double-blinded clinical trial

[Purpose] This study was conducted to examine the effects of task-specific movement patterns during resistance exercise program, which are applied to children with cerebral palsy, on respiratory functions and thickness of abdominal muscles. [Participants and Methods] This study was conducted with randomized double-blinded controlled research was pursued since it is a clinical trial with minors with disabilities as the participants. Seventeen children with cerebral palsy were randomly allocated to both experimental group and placebo group by means of simple randomized sampling. The experimental group wore weighted vest to which loaded-resistance was applied by means of sand bag while the placebo group wore weighted vest without loaded-resistance. Task-specific movement patterns during resistance exercise were performed for 40 minutes 2 times a week over a period of 12 weeks for the participants in both groups. Differences in respiratory functions and thickness of abdominal muscles measured prior to and after 12 weeks of the experiment were compared. [Results] All the measurement values for the respiratory functions and abdominal muscle thickness displayed statistically significant changes between those prior to and after the exercise in both of the experimental group and the placebo group. There were statistically significant differences in the changes prior to and following the exercise between the two groups. [Conclusion] Therefore, task-specific movement patterns in anatomical plane, diagonal patterns and combined forms during resistance exercise program on for children with cerebral palsy can be considered as an efficient intervention method in improving respiratory capacity.

Caregiver-Provided Physical Therapy Home Programs for Children with Motor Delay: A Scoping Review

Background

Caregiver-provided physical therapy home programs (PTHP) play an important role in enhancing motor outcomes in pediatric patient populations.

Purpose

This scoping review systematically mapped clinical trials of caregiver-provided PTHP that were aimed at enhancing motor outcomes in children who have or who are at risk for motor delay, with the purpose of (1) describing trial characteristics; (2) assessing methodologic quality; and (3) examining the reporting of caregiver-related components.

Data Sources

Physiotherapy Evidence Database (PEDro), Cochrane CENTRAL, PubMed, Scopus, ScienceDirect, ProQuest Central, CINAHL, LILACS, and OTseeker were searched up to July 31, 2017.

Study Selection

Two reviewers independently assessed study eligibility. Randomized or quasi-randomized controlled trials on PTHP administered by parents, other family members, friends, or informal caregivers to children who had or who were at risk for motor delay were included.

Data Extraction

Two reviewers independently appraised trial quality on the PEDro scale and extracted data.

Data Synthesis

Twenty-four articles representing 17 individual trials were identified. Populations and interventions investigated were heterogeneous. Most of the trials had important research design limitations and methodological issues that could limit usefulness in ascertaining the effectiveness of caregiver-provided PTHP. Few (4 of 17) trials indicated involvement of caregivers in the PTHP planning, assessed how the caregivers learned from the training or instructions provided, or carried out both.

Limitations

Included studies were heterogeneous, and unpublished data were excluded.

Conclusions

Although caregiver-provided PTHP are important in addressing motor outcomes in this population, there is a lack of evidence at the level of clinical trials to guide practice. More research is urgently needed to determine the effectiveness of care-giver-provided PTHP. Future studies should address the many important issues identified in this scoping review to improve the usefulness of the trial results.

Active exercise interventions improve gross motor function of ambulant/semi-ambulant children with cerebral palsy: a systematic review

PURPOSE

Evaluate effectiveness of active exercise interventions for improving gross motor activity/participation of school-aged, ambulant/semi-ambulant children with cerebral palsy (CP).

METHOD

A systematic review was conducted following PRISMA guidelines. Five databases were searched for papers including school-aged children with CP, participating in active, exercise interventions with gross motor outcomes measured at the Activity/Participation level. Interventions with previous systematic reviews were excluded (e.g. hippotherapy). Evidence Level and conduct were examined by two raters.

RESULTS

Seven interventions (34 studies) met criteria. All studies reported on gross motor function, however, a limited number investigated participation outcomes. Strong positive evidence was available for Gross Motor Activity Training (n= 6, Evidence Level II-IV), and Gross Motor Activity Training with progressive resistance exercise plus additional physiotherapy (n = 3, all Evidence Level II). Moderate positive evidence exists for Gross Motor Activity Training plus additional physiotherapy (n = 2, all Evidence Level II) and Physical Fitness Training (n = 4, Evidence Level II-V). Weak positive evidence was available for Modified Sport (n = 3, Evidence Level IV-V) and Non-Immersive Virtual Reality (n = 12, Evidence Level II-V). There was strong evidence against Gross Motor Activity Training plus progressive resistance exercise without additional physiotherapy (n = 4, all Evidence Level II).

INTERPRETATION

Active, performance-focused exercise with variable practice opportunities improves gross motor function in ambulant/semi-ambulant children with CP. Implications for rehabilitation Active exercise interventions improve gross motor function of ambulant/semi-ambulant children with cerebral palsy. Gross Motor Activity Training is the most common and effective intervention. Practice variability is essential to improve gross motor function. Participation was rarely measured and requires further research, particularly in interventions that embed real-world participation opportunities like Modified Sport.

The relationship between the physical cost index and knee extensor strength in children with hemiplegic cerebral palsy

[Purpose] Lower extremity strength is a contributing factor to energy efficiency of gait. However, this contribution has not previously been evaluated in children with hemiplegic cerebral palsy (CP). The aim of this study was to evaluate the association between energy consumption, measured by the physical cost index (PCI), and strength of lower extremity, measured by the maximum knee extensor strength (MKES), in children with hemiplegic CP. [Subjects and Methods] Subjects were 10 children (4 males and 6 females; age, 7–17 years) with hemiplegic CP, but no history of orthopedic intervention or botulinum toxin treatment over the 1 year prior to the assessment. The PCI was measured during a 6-min walk test, and MKES using hand-held dynamometry, with the highest of two measures used for analysis. [Results] A negative correlation was identified between the PCI and MKES (R-value, −0.81 (affected) and −0.83 (unaffected) lower limb). [Conclusion] Higher lower extremity strength was associated with lower fatigability during a 6-min walk test in children with hemiplegic CP, providing evidence for the inclusion of strengthening exercises for both the affected and unaffected extremities in the rehabilitation of these children.

Biodex balance training versus conventional balance training for children with spastic diplegia

Objective

The purpose of this study was to compare the effectiveness of balance training using the Biodex balance system and a conventional balance training programme on balance score and on gross motor skills of children with spastic diplegia.

Methods

A randomized controlled study was conducted on 48 spastic diplegic children with cerebral palsy (26 boys and 22 girls) in the age range of 5-8 years. The children were randomly allocated to two equal groups. The investigators performed balance and gross motor function assessments for every child using the paediatric Berg balance scale and the gross motor function measure -88 scale (dimensions D and E) before and after the treatment programme. Passive repositioning sense was measured by a Biodex III isokinetic dynamometer. The study group received Biodex balance training and traditional physical therapy programme training, whereas the control group received conventional balance training in addition to the traditional physical therapy programme training, 3 times per week for 12 weeks.

Results

Significant improvement was observed in all outcome measures of the two groups, comparing their pre- and post-treatment mean values. Furthermore, the results revealed a significant (P < 0.05) improvement in mean post-treatment values for the Biodex balance training group.

Conclusion

Balance training using the Biodex balance system is superior to conventional balance training for improving the balance abilities and gross motor functions of children with cerebral palsy and spastic diplegia.

Hands Support and Postural Oscillation During Sit-to-Stand Movement in Children With Cerebral Palsy and Typical Children

The authors aimed to compare the weight bearing on hands during sit-to-stand (STS) movement in children with cerebral palsy (CP) and typical children (TC), verify its effect on postural oscillation, and analyze the relationship between weight bearing on hands and postural oscillation. Twenty children with CP (Gross Motor Function Classification System levels I and II) and 35 TC performed STS with and without anterior hands support. Mann-Whitney test compared weight bearing between groups. Wilcoxon test investigated differences in postural oscillation between the conditions with and without anterior hand support for both groups. The Spearman correlation tested the relationship between weight-bearing and postural oscillation during the hand support condition. Children with CP bore more weight on hands than TC to perform STS. The hand support reduced postural oscillation during the second phase of STS in both groups. In the CP group, greater weight bearing was related with lower postural oscillation in the beginning of STS. Although children with CP were able to perform STS without support, they bore more weight on their hands to perform the task than TC. Moreover, children with CP and TC use mechanical and somatosensory information to modulate their postural control during STS in different ways.

The association between the maximum step length test and the walking efficiency in children with cerebral palsy

[Purpose] To improve walking efficiency could be useful for reducing fatigue and extending possible period of walking in children with cerebral palsy (CP). For this purpose, current study compared conventional parameters of gross motor performance, step length, and cadence in the evaluation of walking efficiency in children with CP. [Subjects and Methods] Thirty-one children with CP (21 boys, 10 girls; mean age, 12.3 ± 2.7 years) participated. Parameters of gross motor performance, including the maximum step length (MSL), maximum side step length, step number, lateral step up number, and single leg standing time, were measured in both dominant and non-dominant sides. Spatio-temporal parameters of walking, including speed, step length, and cadence, were calculated. Total heart beat index (THBI), a parameter of walking efficiency, was also calculated from heartbeats and walking distance in 10 minutes of walking. To analyze the relationships between these parameters and the THBI, the coefficients of determination were calculated using stepwise analysis. [Results] The MSL of the dominant side best accounted for the THBI (R²=0.759). [Conclusion] The MSL of the dominant side was the best explanatory parameter for walking efficiency in children with CP.

Exercise interventions for cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder resulting from an injury to the developing brain. It is the most common form of childhood disability with prevalence rates of between 1.5 and 3.8 per 1000 births reported worldwide. The primary impairments associated with CP include reduced muscle strength and reduced cardiorespiratory fitness, resulting in difficulties performing activities such as dressing, walking and negotiating stairs.Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness, and it is a commonly used intervention for people with CP. Aerobic and resistance training may improve activity (i.e. the ability to execute a task) and participation (i.e. involvement in a life situation) through their impact on the primary impairments of CP. However, to date, there has been no comprehensive review of exercise interventions for people with CP.

OBJECTIVES

To assess the effects of exercise interventions in people with CP, primarily in terms of activity, participation and quality of life. Secondary outcomes assessed body functions and body structures. Comparators of interest were no treatment, usual care or an alternative type of exercise intervention.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, nine other databases and four trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of children, adolescents and adults with CP. We included studies of aerobic exercise, resistance training, and 'mixed training' (a combination of at least two of aerobic exercise, resistance training and anaerobic training).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and potentially relevant full-text reports for eligibility; extracted all relevant data and conducted 'Risk of bias' and GRADE assessments.

MAIN RESULTS

We included 29 trials (926 participants); 27 included children and adolescents up to the age of 19 years, three included adolescents and young adults (10 to 22 years), and one included adults over 20 years. Males constituted 53% of the sample. Five trials were conducted in the USA; four in Australia; two in Egypt, Korea, Saudi Arabia, Taiwan, the Netherlands, and the UK; three in Greece; and one apiece in India, Italy, Norway, and South Africa.Twenty-six trials included people with spastic CP only; three trials included children and adolescents with spastic and other types of CP. Twenty-one trials included people who were able to walk with or without assistive devices, four trials also included people who used wheeled mobility devices in most settings, and one trial included people who used wheeled mobility devices only. Three trials did not report the functional ability of participants. Only two trials reported participants' manual ability. Eight studies compared aerobic exercise to usual care, while 15 compared resistance training and 4 compared mixed training to usual care or no treatment. Two trials compared aerobic exercise to resistance training. We judged all trials to be at high risk of bias overall.We found low-quality evidence that aerobic exercise improves gross motor function in the short term (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.02 to 1.04, N = 65, 3 studies) and intermediate term (mean difference (MD) 12.96%, 95% CI 0.52% to 25.40%, N = 12, 1 study). Aerobic exercise does not improve gait speed in the short term (MD 0.09 m/s, 95% CI -0.11 m/s to 0.28 m/s, N = 82, 4 studies, very low-quality evidence) or intermediate term (MD -0.17 m/s, 95% CI -0.59 m/s to 0.24 m/s, N = 12, 1 study, low-quality evidence). No trial assessed participation or quality of life following aerobic exercise.We found low-quality evidence that resistance training does not improve gross motor function (SMD 0.12, 95% CI -0.19 to 0.43, N = 164, 7 studies), gait speed (MD 0.03 m/s, 95% CI -0.02 m/s to 0.07 m/s, N = 185, 8 studies), participation (SMD 0.34, 95% CI -0.01 to 0.70, N = 127, 2 studies) or parent-reported quality of life (MD 12.70, 95% CI -5.63 to 31.03, n = 12, 1 study) in the short term. There is also low-quality evidence that resistance training does not improve gait speed (MD -0.03 m/s, 95% CI -0.17 m/s to 0.11 m/s, N = 84, 3 studies), gross motor function (SMD 0.13, 95% CI -0.30 to 0.55, N = 85, 3 studies) or participation (MD 0.37, 95% CI -6.61 to 7.35, N = 36, 1 study) in the intermediate term.We found low-quality evidence that mixed training does not improve gross motor function (SMD 0.02, 95% CI -0.29 to 0.33, N = 163, 4 studies) or gait speed (MD 0.10 m/s, -0.07 m/s to 0.27 m/s, N = 58, 1 study) but does improve participation (MD 0.40, 95% CI 0.13 to 0.67, N = 65, 1 study) in the short-term.There is no difference between resistance training and aerobic exercise in terms of the effect on gross motor function in the short term (SMD 0.02, 95% CI -0.50 to 0.55, N = 56, 2 studies, low-quality evidence).Thirteen trials did not report adverse events, seven reported no adverse events, and nine reported non-serious adverse events.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions is low to very low. As included trials have small sample sizes, heterogeneity may be underestimated, resulting in considerable uncertainty relating to effect estimates. For children with CP, there is evidence that aerobic exercise may result in a small improvement in gross motor function, though it does not improve gait speed. There is evidence that resistance training does not improve gait speed, gross motor function, participation or quality of life among children with CP.Based on the evidence available, exercise appears to be safe for people with CP; only 55% of trials, however, reported adverse events or stated that they monitored adverse events. There is a need for large, high-quality, well-reported RCTs that assess the effectiveness of exercise in terms of activity and participation, before drawing any firm conclusions on the effectiveness of exercise for people with CP. Research is also required to determine if current exercise guidelines for the general population are effective and feasible for people with CP.

Effects of Combined Exercise Training on Functional Performance in Children With Cerebral Palsy: A Randomized-Controlled Study

PURPOSE

The purpose of this study was to investigate the effects of combined exercise training on functional performance in participants with cerebral palsy.

METHODS

Fifteen participants with spastic cerebral palsy were randomly allocated into either exercise or control groups. Participants in the exercise group participated in a combined strength and endurance training program for 70 minutes per day, 3 days per week, for 8 weeks, whereas those in the control group did not participate in an exercise program. Study participants in both groups continued with their regular physical therapy during the study.

RESULTS

After the 8-week training, a 6-minute walk, 30-second sit-to-stand, 10-m walk, and Functional Reach Tests, participants in the exercise group had significant improvement over their baseline values and were significantly higher than those in the control group.

CONCLUSIONS

Combined exercise training improved walking ability, functional lower limb strength, and balance in participants with cerebral palsy.

Effectiveness of Rehabilitation Interventions to Improve Gait Speed in Children With Cerebral Palsy: Systematic Review and Meta-analysis

BACKGROUND

Children with cerebral palsy (CP) have decreased gait speeds, which can negatively affect their community participation and quality of life. However, evidence for effective rehabilitation interventions to improve gait speed remains unclear.

PURPOSE

The purpose of this study was to determine the effectiveness of interventions for improving gait speed in ambulatory children with CP.

DATA SOURCES

MEDLINE/PubMed, CINAHL, ERIC, and PEDro were searched from inception through April 2014.

STUDY SELECTION

The selected studies were randomized controlled trials or had experimental designs with a comparison group, included a physical therapy or rehabilitation intervention for children with CP, and reported gait speed as an outcome measure.

DATA EXTRACTION

Methodological quality was assessed by PEDro scores. Means, standard deviations, and change scores for gait speed were extracted. General study information and dosing parameters (frequency, duration, intensity, and volume) of the intervention were recorded.

DATA SYNTHESIS

Twenty-four studies were included. Three categories of interventions were identified: gait training (n=8), resistance training (n=9), and miscellaneous (n=7). Meta-analysis showed that gait training was effective in increasing gait speed, with a standardized effect size of 0.92 (95% confidence interval=0.19, 1.66; P=.01), whereas resistance training was shown to have a negligible effect (effect size=0.06; 95% confidence interval=-0.12, 0.25; P=.51). Effect sizes from negative to large were reported for studies in the miscellaneous category.

LIMITATIONS

Gait speed was the only outcome measure analyzed.

CONCLUSIONS

Gait training was the most effective intervention in improving gait speed for ambulatory children with CP. Strength training, even if properly dosed, was not shown to be effective in improving gait speed. Velocity training, electromyographic biofeedback training, and whole-body vibration were effective in improving gait speed in individual studies and warrant further investigation.

Impact of loaded sit-to-stand exercises at different speeds on the physiological cost of walking in children with spastic diplegia: A single-blind randomized clinical trial

PURPOSE

In the present study, we aimed to determine whether similarly loaded sit-to-stand exercises at different speeds improve the physiological cost of walking in children with spastic diplegia.

METHODS

This design was a single-blind randomized clinical trial. Sixteen children with cerebral palsy (CP), aged 12-18 years, with a diagnosis of spastic diplegia, were randomly allocated to a slow loaded sit-to-stand exercise group (n=8) and a self-paced loaded sit-to-stand exercise group (n=8). Loaded sit-to-stand exercise was conducted at home for 15min, 4 sets per day, 3-4days per week, for 6 weeks. The patients were evaluated immediately before the intervention and after the training. Lower limb muscle strength using a hand-held dynamometer, selective voluntary motor control using SCALE, 6-min walk distance (6MWD), and Physiological Cost Index (PCI) were measured.

RESULTS

The 6MWD showed a significant difference before and after intervention. PCI showed a significant difference between the two groups and the two time points. 6MWD and the PCI improved after intervention in the slow sit-to-stand exercise group.

CONCLUSIONS

Compared to loaded sit-to-stand exercise at a regular speed, slow low-loaded sit-to-stand exercise improved the 6MWD and PCI in children with CP, suggesting that this decrease in speed during exercise improves the physiological cost of walking in these children.

The impact of strength training on skeletal muscle morphology and architecture in children and adolescents with spastic cerebral palsy: A systematic review

AIM

The aim of this study was to systematically review the current literature to determine the impact of strength training on skeletal muscle morphology and architecture in individuals aged 4-20 years with spastic type cerebral palsy.

METHODS

A comprehensive search for randomised and non-randomised controlled trials, cohort studies and cross-comparison trials was performed on five electronic databases. Included studies were graded according to level of evidence and assessed for methodological quality using the Downs and Black scale. Quantitative data was analysed using effect sizes.

RESULTS

Six of 304 articles met the inclusion criteria. Methodological quality of the included papers ranged from 14 to 19 (out of 32). A large effect was found on muscle cross-sectional area following strength training, with small to moderate effects on muscle volume and thickness.

CONCLUSION AND IMPLICATIONS

There is preliminary evidence that strength training leads to hypertrophy in children and adolescents with CP. A paucity of studies exist measuring morphological and architectural parameters following strength training in these individuals. Overall low study methodological quality along with heterogeneous study design, dissimilar outcome measures, and lack of adequate control groups, indicated that care is needed when interpreting the results of these studies in isolation.

Exercise and physical activity recommendations for people with cerebral palsy

Physical activity and its promotion, as well as the avoidance of sedentary behaviour, play important roles in health promotion and prevention of lifestyle-related diseases. Guidelines for young people and adults with typical development are available from the World Health Organisation and American College of Sports Medicine. However, detailed recommendations for physical activity and sedentary behaviour have not been established for children, adolescents, and adults with cerebral palsy (CP). This paper presents the first CP-specific physical activity and exercise recommendations. The recommendations are based on (1) a comprehensive review and analysis of the literature, (2) expert opinion, and (3) extensive clinical experience. The evidence supporting these recommendations is based on randomized controlled trials and observational studies involving children, adolescents, and adults with CP, and buttressed by the previous guidelines for the general population. These recommendations may be used to guide healthcare providers on exercise and daily physical activity prescription for individuals with CP.

Postural stability with exhaustive repetitive sit-to-stand exercise in young adults

Previous research has indicated that muscle fatigue due to repeated bouts of physical activity can have negative residual effects on balance; however investigations using multi-joint forms of exercise involved in everyday settings and determination of how control of posture is altered during the physical activity itself are limited. The purpose of this investigation was to evaluate alterations in postural stability before, during, and after prolonged multi-joint STS exercise in healthy young adults. Center of pressure (COP) acquisitions were collected during repetitive STS exercise, while voluntary limits of stability (LOS) testing was performed before, immediately after, and 10min after STS exercise. By 50% total STS exercise time, fatigue resulted in increased anterio-posterior (y) and medio-lateral (x) COP path lengths (p=0.003 and p=0.018 respectively) and an anterior shift of COP at seat-off towards the mid-foot (p=0.010). No significant change in LOS mean amplitude was found after STS exercise; however a significant fatigue effect resulted in increased COPy sway velocity at maximal lean positions (p=0.006), but returned to PRE values after 10min of rest. Declines in postural stability during repetitive STS exercise was associated with reduced control of COP, as well as a reduced ability to stably control COP at extreme postural limits; however, 10min was adequate in young adults for recovery. These results may have important implications for monitoring fall risk due to acute bouts of exercise induced muscle fatigue from repetitive multi-joint activities such as the STS.

Metabolic, cardiorespiratory, and neuromuscular fitness performance in children with cerebral palsy: A comparison with healthy youth

The aim of this study was to assess metabolic, cardiorespiratory, and neuromuscular fitness parameters in children with spastic cerebral palsy (CP) and to compare these findings with typically developing children. 40 children with CP (21 males, 19 females; mean age, 11.0±3.3 yr; range, 6.5–17.1 yr; Gross Motor Function Classification System levels 1 or 2) and 40 healthy, age- and sex-matched children completed a test battery that consisted of 8 tests and 28 measures that assessed cardio-respiratory fitness, energy expenditure, anaerobic endurance, muscle strength, agility, stability and flexibility. Children with CP had significantly lower performance (P<0.05) on most cardiorespiratory and metabolic tests than those of healthy children, Differences in neuromuscular measures of muscular strength, speed, agility, anaerobic endurance, and flexibility between groups were most apparent. Grouped differences in cardiorespiratory variables revealed a 25% difference in performance, whereas grouped differences in metabolic and neuromuscular measures were 43% and 60%, respectively. The physical fitness of contemporary children with CP is significantly less than healthy, age-matched children. Significant differences in neuromuscular measures between groups can aid in the identification of specific fitness abilities in need of improvement in this population.

Predictors of Independent Walking in Young Children With Cerebral Palsy

BACKGROUND

The attainment of walking is a focus of physical therapy intervention in children with cerebral palsy (CP) and may affect their independence in mobility and participation in daily activities. However, knowledge of determinants of independent walking to guide physical therapists' decision making is lacking.

OBJECTIVE

The aim of this study was to identify child factors (postural control, reciprocal lower limb movement, functional strength, and motivation) and family factors (family support to child and support to family) that predict independent walking 1 year later in young children with CP at Gross Motor Function Classification System (GMFCS) levels II and III.

DESIGN

A secondary data analysis of an observational cohort study was performed.

METHODS

Participants were 80 children with CP, 2 through 6 years of age. Child factors were measured 1 year prior to the walking outcome. Parent-reported items representing family factors were collected 7 months after study onset. The predictive model was analyzed using backward stepwise logistic regression.

RESULTS

A measure of functional strength and dynamic postural control in a sit-to-stand activity was the only significant predictor of taking ≥3 steps independently. The positive likelihood ratio for predicting a "walker" was 3.26, and the negative likelihood ratio was 0.74. The model correctly identified a walker or "nonwalker" 75% of the time.

LIMITATIONS

Prediction of walking ability was limited by the lack of specificity of child and family characteristics not prospectively selected and measurement of postural control, reciprocal lower limb movement, and functional strength 1 year prior to the walking outcome.

CONCLUSIONS

The ability to transfer from sitting to standing and from standing to sitting predicted independent walking in young children with CP. Prospective longitudinal studies are recommended to determine indicators of readiness for independent walking.

Lower Extremity Handheld Dynamometry Strength Measurement in Children With Cerebral Palsy

PURPOSE

The purpose of this study was to evaluate the evidence on reliability of handheld dynamometry protocols to quantify maximal isometric strength of the muscles of the lower extremities of children with cerebral palsy.

METHODS

A systematic search of Cochrane, MEDLINE, CINAHL, and PubMed up to December 2013 and best-evidence synthesis were performed.

RESULTS

Seven eligible studies were identified. Best-evidence synthesis revealed "unknown" to "moderate" evidence. Intraclass correlation coefficient values were "positive" for most muscle groups for intrarater reliability and showed mixed results for interrater reliability.

CONCLUSIONS

Because of small sample sizes (10-25) in all included studies, the final level of evidence remains "unknown." Reliability data obtained in the included studies of handheld dynamometry in children with cerebral palsy are promising, despite low levels of evidence. When these protocols are applied very carefully, they may prove relevant to different clinical settings.

Effects of combined Adeli suit and neurodevelopmental treatment in children with spastic cerebral palsy with gross motor function classification system levels I and II

Background:

Children with cerebral palsy (CP) exhibit diverse gait patterns depending on their neurological deficits and musculoskeletal problems. The Adeli suit treatment (AST) has been proposed as an intensive exercise protocol in the management of CP.

Objectives:

The aim of this study was to compare the effects of a 6-week programme of combined AST and neurodevelopment treatment (NDT) with those of NDT alone on Gross Motor Function Measure (GMFM), balance, and gait in children with CP.

Methods:

Twenty children with CP of Gross Motor Function Classification System levels I and II were randomly assigned to one of the following two groups: (1) NDT or (2) AST/NDT. The participants were assessed using the GMFM, Pediatric Balance Scale (PBS), Timed Up and Go (TUG) test, and spatiotemporal gait parameters.

Results:

The GMFM, PBS, and TUG test for both groups showed a statistically significant increase (p < 0.05). Three children were excluded. Compared to the NDT group (n = 9), the AST/NDT group (n = 8) demonstrated a significant increase in spatiotemporal gait parameters (p < 0.05).

Conclusion:

These results provide evidence for the greater effectiveness of combined AST/NDT than NDT alone in improving spatiotemporal gait parameters but not GMFM, PBS, and TUG test.

Whole-body vibration training improves the walking ability of a moderately impaired child with cerebral palsy: a case study

[Purpose] Strength training is recommended for children with cerebral palsy. However, it is difficult for moderately impaired children with cerebral palsy, who require crutches for ambulation, to participate in this type of training. The purpose of this study was to investigate whether whole-body vibration training is an effective method of strengthening in a moderately impaired child with cerebral palsy. [Subject and Methods] This report describes an 8-year-old Japanese boy with cerebral palsy, who was ambulatory with crutches. The subject participated in physical therapy twice a week for 5 weeks. Whole-body vibration training was selected to complement the standing practice. The patient's crutch-walking ability, gross motor function, and spasticity were evaluated. [Results] The number of steps and walking duration were reduced in a 5-m walk test with crutches and gross motor function was improved. Further, the spasticity was reduced. [Conclusion] Whole-body vibration training is an effective physical therapy intervention in moderately impaired children with cerebral palsy, who are unable to walk without crutches.