Strength Training for Adolescents with cerebral palsy (STAR): study protocol of a randomised controlled trial to determine the feasibility, acceptability and efficacy of resistance training for adolescents with cerebral palsy

Acceptability of a progressive resistance training programme for ambulatory adolescents with spastic cerebral palsy in England: a qualitative study

PURPOSE

The aim of this study was to explore the acceptability of a 10-week progressive resistance training programme from the perspective of ambulatory adolescents with CP and physiotherapists.

MATERIAL AND METHODS

Semi-structured interviews were conducted with 32 adolescents with spastic CP, aged 10-19 years in Gross Motor Function Classification System (GMFCS) levels I-III, and 13 physiotherapists. Adolescents had completed a 10-week progressive resistance training programme and physiotherapists had delivered the programme. The Framework Method was used to analyse data.

RESULTS

The analysis identified four themes. "It's do-able" described the acceptability of the programme structure, including the frequency of sessions and the duration of the programme. "They were difficult but I did it" described the acceptability of the exercises. "It is completely different," explored the experience of using equipment to progress the programme and "I wish I could do it on a permanent basis" discussed continuing to participate in resistance training.

CONCLUSIONS

Findings suggest that resistance training is largely acceptable to adolescents and physiotherapists. Acceptability was enhanced by having a weekly supervised session and being able to adapt and progress the exercises to meet the individual's ability. However, there are challenges to implementing progressive resistance training as part of routine practice.Clinical trial registration number: ISRCTN90378161.

Combining intensive rehabilitation with a non-functional isokinetic strengthening program in adolescents with cerebral palsy: a study protocol for a randomized controlled trial

BACKGROUND

Cerebral palsy (CP) is the most common brain injury in the pediatric population. CP patients present different affectations such as decreased muscle strength, gait deviations, impaired proprioception, and spasticity. Isokinetic strengthening programs combined with an intensive rehabilitation may improve muscle strength and therefore gait efficiency. Clinical Trials: The protocol has been accepted by the French National Ethics Committee (IDRCB: 2022-A00431-42).

OBJECTIVE

The primary aim of this randomized controlled trial is to compare the effect of an intensive rehabilitation combined with a non-functional isokinetic progressive strengthening program to an intensive rehabilitation alone on gait parameters and muscle strength in CP patients. Another goal of the current study is to determine whether adding an isokinetic program to an intensive rehabilitation is more effective than an intensive reha-bilitation alone on decreasing spasticity and improving joint position sense in CP patients.

METHODS

Thirty adolescents with spastic diplegia CP (GMFCS level I to III) will be randomized, by an independent researcher, into a 3-week intensive rehabilitation and isokinetic pro-gressive strengthening group or an intensive rehabilitation control group. Gait param-eters, muscle strength, spasticity and knee joint position sense will be assessed. These variables will be evaluated at baseline (T0) and at the end of the intervention (T1). The intensive rehabilitation will consist of physiotherapy sessions twice a day and hydro-therapy and virtual reality gait training once a day. The isokinetic training group will have a total of 9 supervised isokinetic strength training focusing on knee flexors and extensors with different execution speeds.

RESULTS

The protocol has been accepted by the French National Ethics Committee in October 2022. Inclusion of patients will start in November 2022.

CONCLUSIONS

The combination of an intensive rehabilitation with an isokinetic program on knee flexors and extensors have not been studied yet. The findings of this study may determine if an isokinetic strength training program of knee flexors and extensors is benefic to improve gait parameters, muscle strength, spasticity, and joint position sense in adolescents with spastic diplegia.

CLINICALTRIAL

The protocol has been accepted by the French National Ethics Committee (IDRCB: 2022-A00431-42).

Co-designing resources to support the transition from child to adult health services for young people with cerebral palsy: A design thinking approach

Introduction

Design thinking is a human-centred process that aims to identify the needs of end-users and iteratively develop solutions. Involving end-users in the development and design of solutions may enhance effectiveness by increasing focus on the needs of the target population. This paper describes the process of co-designing resources to support the transition from child-centred to adult-orientated health services using a design thinking approach.

Methods

Five co-design workshops were conducted remotely with a young person advisory group and parent advisory group. A design thinking process guided by the Stanford D.School approach was used to understand the transition needs of young people and their parents and iteratively develop solutions to improve end-user experience.

Results

Eight resource prototypes were generated: (1) designated transition coordinator, (2) digital stories of transition experience (3) written informational support (4) transition website, (5) transition checklists and worksheets (6) transition app, (7) transition programme or course and (8) educational programme for health professionals.

Conclusion

Design thinking is a feasible approach to identify, characterise and prioritise resources collaboratively with end-user partners.

Safety and Feasibility of 1-Repetition Maximum (1-RM) Testing in Children and Adolescents With Bilateral Spastic Cerebral Palsy

PURPOSE

The purpose of this study was to standardize 1-repetition maximum (1-RM) testing procedures and evaluate the safety and feasibility of these procedures in youth with cerebral palsy (CP).

METHODS

Youth with CP completed 1-RM testing on a leg press.

RESULTS

Mean absolute, adjusted, and normalized 1-RM loads were 262.4 ± 161.3 lb, 127.0 ± 80.2 lb, and 1.28 ± 0.51, respectively, and 67% were able to successfully lift the same or heavier load after a single failure. Cessation of testing after 1 failed attempt resulted in a 19.0% underestimation of the 1-RM.

CONCLUSIONS

1-RM testing in youth with CP is safe and feasible. Multiple attempts at a failed load should be provided to prevent underestimation in strength. The 1-RM test provides a more accurate strength assessment, which will improve the dosing for resistance training in youth with CP.

Influence of Personalized Health Management Model Based on Internet Mode on Self-Management Ability and Life Quality of Patients with Chronic Diseases Undergoing Physical Examination

Objective

To explore the influence of personalized health management model based on the Internet mode on self-management ability and life quality of patients with chronic diseases of physical examination.

Methods

Sixty patients with chronic diseases who went through physical examination from February 2019 to April 2021 were enrolled in our hospital. The patients were arbitrarily assigned into control and research group. The former group received routine nursing, and the latter group received personalized health management mode based on the Internet mode. The nursing satisfaction, self-management behavior ability, blood pressure level, physiological index, mastery of health knowledge, and life quality scores were compared.

Results

In terms of nursing satisfaction, the research group was very satisfied in 20 cases, satisfactory in 9 cases, and general in 1 case, with a satisfaction rate of 100.00%; In the control group, 15 cases were very satisfied, 9 cases were satisfied, 1 case was general, 5 cases were not satisfied, and the satisfaction rate was 83.33%; The nursing satisfaction of the research group was higher (P < 0.05). Compared with the self-management behavior ability, the scores of diet control, regular medication, correct medication, and smoking cessation in the research group were remarkably higher (P < 0.05). There exhibited no significant difference in blood pressure level before intervention (P > 0.05); after intervention, the blood pressure levels lessened. Compared with the control group, the systolic blood pressure and diastolic blood pressure of the research group were lower (P < 0.05). The levels of triglyceride, total cholesterol, low-density lipoprotein, and fasting blood glucose in the research group were remarkably lower (P < 0.05). Compared with the control group, the scores of health knowledge in the research group were remarkably higher, including the harm of smoking, the use of drugs, the importance of persisting in taking drugs, the pathogenesis of chronic diseases, the effect of emotional management on the disease, and the dietary awareness in the research group (P < 0.05). There exhibited no significant difference in the score of life quality before nursing (P > 0.05); after nursing, the score of life quality lessened, and the scores of physiological function, psychological function, social function, and health self-cognition in the research group were lower (P < 0.05).

Conclusion

The personalized health management model based on the Internet mode can effectively enhance the chronic disease physiological indexes such as blood pressure, blood lipids, and blood sugar and improve the self-management ability of the patients with chronic disease, which is worth further popularizing and applying in the clinical physical examination in clinic.

Effects of voluntary exercise on muscle structure and function in cerebral palsy

Skeletal muscles are required for functional movement and force production. While it is clear that cerebral palsy (CP) results in loss of muscle strength and bodily function, and that much of this loss is caused by injury to the central nervous system, muscle is a very plastic tissue that is also dramatically affected. In many studies, it is assumed that voluntary exercise will cause the muscle to respond in the same way that typically developing muscle does, but there are scarce data demonstrating that this is true. The purpose of this review is to briefly describe muscle architectural adaptation to various forms of exercise with specific reference to voluntary exercise performed in children with CP. Exercise itself is not generic but can vary by intensity, duration, and the exact nature of the muscle length change and velocity imposed during the exercise. Our goal is to stimulate discussion in this area by pointing out salient experimental variables and, ultimately, to improve activity and participation in children with CP.

Predictors of Treatment Response to Progressive Resistance Training for Adolescents With Cerebral Palsy

OBJECTIVE

The aim of the study was to examine the variability in plantar-flexor muscle strength changes after progressive resistance training for adolescents with cerebral palsy (CP) and to identify baseline variables associated with change in muscle strength.

METHODS

Thirty-three adolescents with CP were randomized to a 10-week progressive resistance training program as part of a randomized controlled trial (STAR trial). The associations between muscle strength at 10 weeks (n = 30 adolescents) and 22 weeks (n = 28 adolescents) and biomechanical and neuromuscular baseline characteristics, motor function, and fidelity to the program were examined with multivariable linear regression.

RESULTS

Changes in plantar-flexor muscle strength from baseline ranged from -47.7% to 192.3% at 10 weeks and -54.3% to 198.4% at 22 weeks. Muscle activation was the only variable associated with change in strength at 10 weeks and 22 weeks. A model containing peak muscle activity and baseline muscle strength explained 49.1% of the variation in change in muscle strength (R2 = 0.491) at 10 weeks and 49.2% of the variation in change muscle strength at 22 weeks (R2 = 0.492).

CONCLUSION

Assessing levels of muscle activation may be able to identify responders to a progressive resistance training program for adolescents with CP. These findings are a first step toward developing tools that can inform decision making in the clinical setting.

IMPACT

Due to the heterogenous nature of CP, it is challenging to assess the efficacy of strength training programs in individuals with CP and to understand the variability in outcomes among participants. This study provides a better understanding of the factors that predict response to an exercise program so that resistance training can be directed to those who will potentially benefit from it.

LAY SUMMARY

There is wide variability in how well young people with CP respond to resistance training. If you are a young person with CP, your physical therapist can measure the amount of gastrocnemius muscle activity you have, so as to get an indication of how well you will respond.

A Study on Physical Exercise and General Mobility in People with Cerebral Palsy: Health through Costless Routines

Sedentary behavior (SB) is a common problem that may produce health issues in people with cerebral palsy (CP). When added to a progressive reduction in motor functions over time, SB can lead to higher percentages of body fat, muscle stiffness and associated health issues in this population. Regular physical activity (RPA) may prevent the loss of motor skills and reduce health risks. In this work, we analyzed data collected from 40 people (20 children and teenagers, and 20 adults) who attend two specialist centers in Seville to obtain an up-to-date picture regarding the practice of RPA in people with CP. Roughly 60% of the participants showed mostly mid/severe mobility difficulties, while 38% also had communicative issues. Most of the participants performed light-intensity physical activity (PA) at least once or twice a week and, in the majority of cases, had a neutral or positive attitude to exercising. In the Asociación Sevillana de Parálisis Cerebral (ASPACE) sample test, the higher the International Classification of Functioning, Disability and Health (ICF), the higher the percentage of negative responses to doing exercise. Conversely, in the Centro Específico de Educación Especial Mercedes Sanromá (CEEEMS), people likes PA but slightly higher ratios of positive responses were found at Gross Motor Function Classification System (GMFCS) levels V and II, agreeing with the higher personal engagement of people at those levels. We have also performed a literature review regarding RPA in CP and the use of low-cost equipment. As a conclusion, we found that RPA produces enormous benefits for health and motor functions, whatever its intensity and duration. Costless activities such as walking, running or playing sports; exercises requiring low-cost equipment such as elastic bands, certain smartwatches or video-games; or therapies with animals, among many others, have all demonstrated their suitability for such a purpose.

Standardized Outcomes Measures in Physical Therapy Practice for Treatment and Rehabilitation of Cerebral PALSY: A Systematic Review

Cerebral palsy (CP) treatment includes physical therapy and various complementary therapies to the standard clinical treatment. However, there are not many reviews that focus on the methods used and evaluation procedures. This study aims to analyze which tools are most suitable for the evaluation and methodology of patients with CP treated with physical therapy. Following the PRISMA statement, through a PICOS strategy, PubMed/MEDLINE, Web of Science (WOS), Scopus, Science Direct, and Scielo were searched with the following terms: cerebral palsy AND (physical therapy modalities OR therapeutics) AND outcome assessment. The methodological quality of the RCTs was assessed with the Evidence Project risk of bias tool. Thirty-seven RCTs and six RCT protocols, comprising 1359 participants with different types of CP: spastic hemiplegia/paresis, spastic diplegia/paresis, and spastic CP, met the inclusion criteria, uncovering 21 variables measured through 77 different instruments and several interventions. The therapies most widely used in CP are gaming or technology-assisted therapies, aerobic training, hippotherapy, music therapy, gait training, and aquatic exercises. This study provides an overview of what the authors used in the neurorehabilitation field through procedure evaluation and checking the technological advance that began to be used.

Effects of whole-body vibration on quadriceps and hamstring muscle strength, endurance, and power in children with hemiparetic cerebral palsy: a randomized controlled study

Background

Hemiplegic cerebral palsy (CP) enormously affects the quadriceps and hamstring muscles. It causes weakness in the affected lower-extremity muscles in addition to muscle imbalance and inadequate power production, especially in the ankle plantar-flexor and knee extensor muscles. It also causes anomalous delayed myoelectrical action of the medial hamstring. A whole-body vibration (WBV) exercise can diminish muscle spasticity and improve walking speed, muscle strength, and gross motor function without causing unfavorable impacts in adults suffering from CP. Thus, the aim of this study is to investigate the impacts of WBV training associated with conventional physical therapy on the quadriceps and hamstring muscle strength, endurance, and power in children with hemiparetic CP.

Results

The post-intervention values of the quadriceps and hamstring muscle force, endurance, and power were significantly higher than the pre-intervention values for both groups (p = 0.001). The post-intervention values of the study group were significantly higher than the control group (quadriceps force, p = 0.015; hamstring force, p = 0.030; endurance, p = 0.025; power, p = 0.014).

Conclusion

The 8 weeks of WBV training that was added to traditional physical therapy was more successful in improving the quadriceps and hamstring muscle strength, endurance, and power in children with hemiparetic CP when compared to traditional physical therapy alone.

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.

Progressive resistance training for adolescents with cerebral palsy: the STAR randomized controlled trial

AIM

To evaluate the effect of progressive resistance training of the ankle plantarflexors on gait efficiency, activity, and participation in adolescents with cerebral palsy (CP).

METHOD

Sixty-four adolescents (10-19y; 27 females, 37 males; Gross Motor Function Classification System [GMFCS] levels I-III) were randomized to 30 sessions of resistance training (10 supervised and 20 unsupervised home sessions) over 10 weeks or usual care. The primary outcome was gait efficiency indicated by net nondimensional oxygen cost (NNcost). Secondary outcomes included physical activity, gross motor function, participation, muscle strength, muscle and tendon size, and muscle and tendon stiffness. Analysis was intention-to-treat.

RESULTS

Median attendance at the 10 supervised sessions was 80% (range 40-100%). There was no between-group difference in NNcost at 10 (mean difference: 0.02, 95% confidence interval [CI] -0.07 to 0.11, p=0.696) or 22 weeks (mean difference: -0.08, 95% CI -0.18 to 0.03, p=0.158). There was also no evidence of between-group differences in secondary outcomes at 10 or 22 weeks. There were 123 adverse events reported by 27 participants in the resistance training group.

INTERPRETATION

We found that 10 supervised sessions and 20 home sessions of progressive resistance training of the ankle plantarflexors did not improve gait efficiency, muscle strength, activity, participation, or any biomechanical outcome among adolescents with CP.

WHAT THIS PAPER ADDS

Thirty sessions of progressive resistance training of the ankle plantarflexors over 10 weeks did not improve gait efficiency among ambulatory adolescents with cerebral palsy. Resistance training did not improve muscle strength, activity, or participation. Ninety percent of participants experienced an adverse event. Most adverse events were expected and no serious adverse events were reported.

Comparison of the CHU-9D and the EQ-5D-Y instruments in children and young people with cerebral palsy: a cross-sectional study

OBJECTIVE

To compare the performance of the EuroQol 5D youth (EQ-5D-Y) and child health utility 9D (CHU-9D) for assessing health-related quality of life (HRQoL) in children and young people (CYP) with cerebral palsy (CP).

DESIGN

Cross-sectional study.

SETTING

England.

PARTICIPANTS

Sixty-four CYP with CP aged 10-19 years in Gross Motor Function Classification System (GMFCS) levels I-III.

MAIN OUTCOME MEASURES

Missing data were examined to assess feasibility. Associations between utility values and individual dimensions on each instrument were examined to assess convergent validity. Associations between utility values and GMFCS level were examined to assess known-group differences.

RESULTS

Missing data were <5% for both instruments. Twenty participants (32.3%) and 11 participants (18.0%) reported full health for the EQ-5D-Y and CHU-9D, respectively. There was poor agreement between utilities from the two instruments (intraclass correlation coefficient=0.62; 95% limits of agreement -0.58 to 0.29). Correlations between EQ-5D-Y and CHU-9D dimensions were weak to moderate (r=0.25 to 0.59). GMFCS level was associated with EQ-5D-Y utility values but not CHU-9D utility values.

CONCLUSION

The EQ-5D-Y and CHU-9D are feasible measures of HRQoL in CYP with CP. However, the two instruments demonstrate poor agreement and should not be used to measure and value HRQoL in CYP with CP interchangeably. We propose that the CHU-9D may be preferable to use in this population as it assesses concepts that influence HRQoL among CYP with CP and provides less extreme utility values than the EQ-5D-Y.

Movement Competency Training Delivery: At School or Online? A Pilot Study of High-School Athletes

Movement competency (MC) development of high-school athletes can prepare them for the requirements of physical preparation training and the demands of sport. The aim of this study was to explore the physical effects of and athlete compliance to coach-led versus self-directed training approaches in this population. Thirty-nine high-school athletes (19 male, 14.5 ± 0.3 years old; 20 female, 14.6 ± 0.3 years) were allocated into two groups for a physical preparation program to improve MC. Groups were prescribed either (i) one face-to-face and one online (F2F, n = 18), or (ii) two online (OL, n = 21) sessions per week for 16-weeks. Before and after the intervention, the Athlete Introductory Movement Screen (AIMS) was used to assess MC alongside common physical capacity measures (triple-hop, star-excursion balance, medicine ball throw, 40m sprint and countermovement jump). Dropout left 22 participants with pre-post physical scores. Compliance with online training was low and F2F session attendance moderate. Semi-structured interviews were conducted to assess participant perceptions following the intervention. Assessing individual responses, the F2F group had a higher proportion of positive responders to AIMS scores, yet capacity measures were inconclusive across groups. Face-to-face coaching when acquiring MCs as part of physical preparation, may provide greater positive perceptions towards training compared to self-directed online prescriptions, and thereby greater compliance.

Validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF) as a measure of physical activity (PA) in young people with cerebral palsy: A cross-sectional study

OBJECTIVES

The aim of this study was to examine the validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF) as a measure of physical activity (PA) in young people with cerebral palsy (CP).

DESIGN

Cross-sectional.

SETTING

Participants were recruited through 8 National Health Service (NHS) trusts, one school, one university and through organisations that provide services for people with disabilities in England.

PARTICIPANTS

Sixty-four, ambulatory young people aged 10-19 years with CP [Gross Motor Function Classification System (GMFCS) levels I-III] participated in this study.

MAIN OUTCOME MEASURE

The IPAQ-SF was administered to participants. Participants were then asked to wear a wGT3X-BT triaxial accelerometer (ActiGraph, Pensacola, FL) for 7 days to objectively assess PA. Time spent in sedentary behaviour, in moderate to vigorous PA (MVPA) and in total PA (TPA) was compared between measures.

RESULTS

Young people with CP self-reported less time in sedentary behaviour and underestimated the time spent in TPA, when compared to accelerometer measurements. Bland-Altman plots demonstrated poor agreement between the measures for MVPA, with upper and lower 95% limits of agreement of -147 to 148.9minute. After adjusting for gender and GMFCS level, age was a predictor of the difference between measures for MVPA (P<0.001) and TPA (P<0.001).

CONCLUSIONS

These findings suggest that the IPAQ-SF is not a valid method of measuring TPA or sedentary behaviour in young people with CP and it is not appropriate for use when assessing an individual's time in MVPA. Therefore, where feasible, an objective measure of PA should be used.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN90378161.

Predictors of Walking Efficiency in Children With Cerebral Palsy: Lower-Body Joint Angles, Moments, and Power

BACKGROUND

People with cerebral palsy (CP) experience increased muscle stiffness, muscle weakness, and reduced joint range of motion. This can lead to an abnormal pattern of gait, which can increase the energy cost of walking and contribute to reduced participation in physical activity.

OBJECTIVE

The aim of the study was to examine associations between lower-body joint angles, moments, power, and walking efficiency in adolescents with CP.

DESIGN

This was a cross-sectional study.

METHODS

Sixty-four adolescents aged 10 to 19 years with CP were recruited. Walking efficiency was measured as the net nondimensional oxygen cost (NNcost) during 6 minutes of overground walking at self-selected speed. Lower-body kinematics and kinetics during walking were collected with 3-dimensional motion analysis, synchronized with a treadmill with integrated force plates. The associations between the kinematics, kinetics, and NNcost were examined with multivariable linear regression.

RESULTS

After adjusting for age, sex, and Gross Motor Function Classification System level, maximum knee extension angle (β = -0.006), hip angle at midstance (β = -0.007), and maximum hip extension (β = -0.008) were associated with NNcost. Age was a significant modifier of the association between the NNcost and a number of kinematic variables.

LIMITATIONS

This study examined kinetic and kinematic variables in the sagittal plane only. A high interindividual variation in gait pattern could have influenced the results.

CONCLUSIONS

Reduced knee and hip joint extension are associated with gait inefficiency in adolescents with CP. Age is a significant factor influencing associations between ankle, knee, and hip joint kinematics and gait efficiency. Therapeutic interventions should investigate ways to increase knee and hip joint extension in adolescents with CP.