Functional electrical stimulation cycling, goal-directed training, and adapted cycling for children with cerebral palsy: a randomized controlled trial

AIM

To test the efficacy of functional electrical stimulation (FES) cycling, goal-directed training, and adapted cycling, compared with usual care, to improve function in children with cerebral palsy (CP).

METHOD

The intervention was delivered between 2017 and 2019 and included three sessions per week for 8 weeks (2×1h sessions at a children's hospital, and 1h home programme/week). Hospital sessions included 30 minutes of FES cycling and 30 minutes of goal-directed training. Home programmes included goal-directed training and adapted cycling. The comparison group continued usual care. Primary outcomes were gross motor function assessed by the Gross Motor Function Measure (GMFM) and goal performance/satisfaction assessed using the Canadian Occupational Performance Measure (COPM). Secondary outcomes were sit-to-stand and activity capacity, participation in home, school, and community activities, and power output. Linear regression was used to determine the between-group mean difference immediately post-training completion after adjusting for baseline scores.

RESULTS

This randomized controlled trial included 21 participants (mean age=10y 3mo, standard deviation [SD]=3y; Gross Motor Function Classification System level: II=7, III=6, IV=8) who were randomized to the intervention (n=11) or usual care group (n=10). Between-group differences at T2 favoured the intervention group for GMFM-88 (mean difference=7.4; 95% confidence interval [CI]: 2.3-12.6; p=0.007), GMFM-66 (mean difference=5.9; 95% CI: 3.1-8.8; p<0.001), COPM performance (mean difference=4.4; 95% CI: 3.9-5.3; p<0.001) and satisfaction (mean difference=5.2; 95% CI: 4.0-6.4; p<0.001).

INTERPRETATION

Children with CP achieved meaningful functional improvements after FES cycling, goal-directed training, and adapted cycling training. Cycling programmes for children with CP should be individualized and goal directed.

A qualitative analysis of the experiences of children with cerebral palsy and their caregivers in a goal-directed cycling programme

PURPOSE

This qualitative thematic analysis aimed to capture the experiences of children with cerebral palsy (CP) and caregivers who completed an 8-week goal-directed cycling programme, to provide insights on engagement and programme feasibility.

METHODS

Children with CP (6-18 years, Gross Motor Function Classification Scale (GMFCS) levels II-IV) and caregivers completed semi-structured interviews at the end of the training programme. Interview transcripts were coded by two investigators and systematically organised into themes. A third investigator reviewed the final thematic map.

RESULTS

17 interviews were conducted with 29 participants (11 children: 7-14 years). Four themes emerged: facilitators and challenges to programme engagement; perceived outcomes; the functional-electrical stimulation (FES) cycling experience; and previous cycling participation. Engagement was facilitated by the "therapist's connection," "cycling is fun" and "participant driven goal setting," while "getting there" and "time off school" were identified as challenges. Participants positively linked improved physical function to greater independence. The FES-experience was "fun and challenging," and participants had mixed feelings about electrode "stickiness." Previous cycling participation was limited by access to adapted bikes.

CONCLUSIONS

Children with CP enjoy riding bikes. Facilitators and challenges to engagement were identified that hold practical relevance for clinicians. Environmental and personal factors should be carefully considered when developing future programs, to maximise opportunities for success.

CLINICAL TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry - ACTRN12617000644369pIMPLICATIONS FOR REHABILITATIONAdapted cycling is a fun and engaging activity for young people with cerebral palsy.Environmental and personal factors should be carefully considered when prescribing adapted or FES cycling programs to this group.Engagement in adapted and FES-cycling programs can be facilitated by access to loan equipment, a goal-directed focus, and positive therapist-child relationship.Participation in adapted cycling is limited by access to adapted cycling equipment.

Machine learning to quantify habitual physical activity in children with cerebral palsy

AIM

To investigate whether activity-monitors and machine learning models could provide accurate information about physical activity performed by children and adolescents with cerebral palsy (CP) who use mobility aids for ambulation.

METHOD

Eleven participants (mean age 11y [SD 3y]; six females, five males) classified in Gross Motor Function Classification System (GMFCS) levels III and IV, completed six physical activity trials wearing a tri-axial accelerometer on the wrist, hip, and thigh. Trials included supine rest, upper-limb task, walking, wheelchair propulsion, and cycling. Three supervised learning algorithms (decision tree, support vector machine [SVM], random forest) were trained on features in the raw-acceleration signal. Model-performance was evaluated using leave-one-subject-out cross-validation accuracy.

RESULTS

Cross-validation accuracy for the single-placement models ranged from 59% to 79%, with the best performance achieved by the random forest wrist model (79%). Combining features from two or more accelerometer placements significantly improved classification accuracy. The random forest wrist and hip model achieved an overall accuracy of 92%, while the SVM wrist, hip, and thigh model achieved an overall accuracy of 90%.

INTERPRETATION

Models trained on features in the raw-acceleration signal may provide accurate recognition of clinically relevant physical activity behaviours in children and adolescents with CP who use mobility aids for ambulation in a controlled setting.

WHAT THIS PAPER ADDS

Machine learning may assist clinicians in evaluating the efficacy of surgical and therapy-based interventions. Machine learning may help researchers better understand the short- and long-term benefits of physical activity for children with more severe motor impairments.

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.

Potential precision of the δ15N natural abundance method in field estimates of nitrogen fixation by crop and pasture legumes in south-west Australia

Precision of estimation of the proportion of legume N derived from N2 fixation (%Ndfa) was assessed in relation to subterranean clover (Trifolium subterraneum L.) pastures and crops of pea (Pisum sativum L.) and lupin (Lupinus angustifolius L.) under south-west Australian conditions. By using a standardized 10-point sampling procedure of paired sampling of legume and reference plant and reference plant 15N natural abundance (S15N) values in the range from +2.9 to +4. 0%o, %Ndfa of sample crops of lupin and field pea and a clover pasture were assessed with respective precisions of 93� O.6%, 76� 2.4% and 91�1.3% (� s.e., n = 10). Effects on S15N due to isotope discrimination during fixation and subsequent distribution of N by the three study legumes were studied using sand-cultured, fully symbiotic plant material. The resulting S15N data (B values) showed consistently more negative values for shoots than roots (all species), no significant effects of cultivar on B values (all species), a marked effect of rhizobial strain on B value (subclover) and a tendency for B values to fall with plant age (pea and lupin). The likely magnitude of errors in %Ndfa estimates due to incorrect choice of B value was indicated. By using data for reference plant S15N values from field surveys and previously assessed error factors in mass spectrometric measurement of S15N, precision of estimation of %Ndfa by using bulked material from the 10-point field sampling procedure was predicted for situations ranging from where a legume was obtaining only minimal amounts (10%) through to the bulk (90%) of its N by atmospheric fixation.

The field pea crop in S.W. Australia. II. Effects of contrasting morphology and environment on reproductive performance

Reproductive performance of six field pea genotypes was assessed at three contrasting field sites in Western Australia and under optimal conditions in a glasshouse using comparative data on phenology, branching pattern, green area indices, number distribution and fruiting success of reproductive nodes and final seed yields per plant or unit crop area. Two genotypes (Dundale and Wirrega) were tall, indeterminate and conventionally leaved, the other four semi-dwarf and more erect. Three of the latter were semi-leafless (Dinkurn, L82 and L80) and the other tare-leaved (Progreta). Seed yields at the field sites increased generally in relation to rainfall during the growing season (May-October), viz. Avondale (267 mm), Wongan Hills (350 mm), Mt Barker (421 mm). Superior performance at Mt Barker was related to greater biomass and green area index and higher number of reproductive nodes and pods per plant, but not to increased branches per plant, pods per node, seeds per pod or seed size. Improved harvest index, larger seeds and greater reproductive yield from basal and aerial branches were responsible for the trellised well-watered and fertilized glasshouse plants mostly outyielding those at the field sites. Field-site specific superiority of certain genotypes over others was evident, e.g. the top ranking performance of the deeper-rooted, late maturing Wirrega at the drier sites of Avondale or Wongan Hills and the much improved performance of the semi-leafless types in the extended cool and moist season of Mt Barker. Poor seed yields of tall types relative to their vegetative biomass were pronounced at Mt Barker due to poor fruit set and seed filling in the severely lodged and self-shaded canopies. Data are discussed in relation to previous cultivar evaluations and ideotype prescriptions by other workers in Australia or overseas.

Selection of reference plants for 15N natural abundance assessment of N2 fixation by crop and pasture legumes in south-west Australia

The 15N natural abundance (S15N) of the shoot total N of a range of non-N2 fixing potential reference species was compared with that of nodulated field pea (Pisum sativum L.), narrow leafed lupin (Lupinus angustijolius L.) or subterranean clover (Trijolium subterraneum L.) across a range of field sites, to which N fertilizers had not been applied in the season of study. Shoot S15N values of reference species lay mostly within the range from +3 to +5%o and there was some evidence of lower S15N values in gramineaceous than dicotyledonous non-legume species. Continuous sampling within crops of each legume showed S15N values to differ consistently between and within potential reference species through the season. The S15N values of seedlings of four non legume species in a lupin crop were closer to that of soil N03-N (S15N = 4.2%o) than soil NH4-N (S15N = 7.9%0). Shoot S15N values of non-nodulated pea, lupin and subterranean clover, and a range of possible reference species all sand-cultured on a defined nitrate source (S15N = 7.5%), suggested little or no discrimination during utilization of nitrate. However, when four candidate reference species were sand cultured with nodulated actively fixing subterranean clover on the same nitrate source, the S15N of the ryegrass was lowered significantly below that of the NO3. Field plot comparisons of nine potential reference species with nodulated field pea showed certain species to resemble field pea more closely than others in terms of the S15N value of their shoots. Reference plants sampled within or well outside the rooting zone of an actively fixing legume (subterranean clover, field pea or lupin) showed significantly lower shoot S15N of mixed grass components when harvested in root contact with, as opposed to well distant from, subterranean clover. A similar effect was observed for barley within v. outside the rooting zone of pea, but no such effects were observed between capeweed and subterranean clover, pea and radish, or for any of five reference plants matched with lupin. The data are utilized to select appropriate reference plants for field assessments of N2 fixation under south-west Australian conditions.

The field pea crop in S.W. Australia. I. Patterns of growth, biomass production and photosynthetic performance in genotypes of contrasting morphology

Biological yield and photosynthetic performance of six field pea genotypes of contrasting foliar morphology and growth habit were studied in a water-limited field environment at Wongan Hills, Western Australia. Dundale and Wirrega were tall, indeterminate, scrambling and conventionally leaved; Dinkum, L82 and L80 (semi-leafless) and Progreta (tare-leaved) were semi-dwarf and more erect. Green area index (green leaf area per unit of ground area), green area duration (time integral of green area), crop growth rate (rate of dry matter accumulation per unit ground area) during early spring, net photosynthetic rate (CO2 exchange rate per unit green area or unit green weight) and net assimilation rate (rate of dry matter accumulation per unit green area) all influenced crop productivity. Shoot and root biomass was highest in Wirrega, due mainly to superior green area index, extended green area duration and maintenance of high growth rate during pod fill. Inverse relationships amongst genotypes were evident between green area index and net assimilation rate, and between green area index and CO2 exchange rate of green area. Total net photosynthesis of the tendrils of semi-leafless types was similar to that of leaflets of conventional types, due mainly to larger biomass of tendrils compensating for poor photosynthetic rates. The poor growth of semi-leafless and tare-leaved types was attributed to lower vigour, green area, ground cover and photosynthate production. Future selection of such types for water-limited environments should concentrate on increasing shoot height, node number per plant, stipule and tendril size and photosynthetic efficiency of green area.

Wheat response after temperate crop legumes in south-eastern Australia

At 15 sites in the cereal belt of New South Wales and Victoria, wheat after lupin or pea produced more biomass and had a greater nitrogen (N) content than wheat after wheat or barley; on average these crops assimilated 36 kg N/ha more. The improved wheat yield after lupin averaged 0 . 9 t/ha and after pea 0.7 t/ha, increases of 44 and 32% respectively. The responses were variable with site, year and legume. Soil available N was increased by both lupin and pea and the levels of surface inorganic N measured at the maturity of first year crops was often related to N in wheat grown in the following year. Of two possible sources of additional N for wheat after legumes, namely mineral N conserved in soil by lupin or pea (up to 60 kg N/ha) and the total N added in the residues of these legumes (up to 152 kg N/ha), both were considered significant to the growth of a following wheat crop. Their relative contribution to explaining variance in wheat N is analysed, and it is suggested wheat may acquire up to 40 kg N/ha from legume stubbles. Non-legume break crops also increased subsequent wheat yield but this effect was not as great as the combined effect of added N and disease break attained with crop legumes.

Reducing height and lodging in rapeseed with growth regulators

The plant growth regulators (PGRs) ethrel (20% a.i. 2-chloroethane phosphonic acid), PP 333 (25% w/v a.i. paclobutrazol), cycocel (50% w/v a.i. chlormequat chloride), pix (5% w/v a.i. mepiquat chloride) and EL 500 (50% w/w a.i. flurprimidol) were applied to bulky crops of Jumbuck, Marnoo and RU 14 rapeseed at Cowra and Woodstock in central-western New South Wales, in an effort to reduce their height and lodging. The most effective growth retardants under evaluation were PP 333 and EL 500, and this was achieved without apparent phytotoxicity. Height reductions were enhanced as rates were increased from 0 to 2 Lha, and the heights of Jumbuck, Mamoo and RU 14 were reduced on average by 22% (from 159 to 124 cm), 26% (from 136 to 100 cm) and 14% (from 150 to 129 cm), respectively. Significant reductions in lodging accompanied these changes. Ethrel resulted in some phytotoxicity, while pix and cycocel had little or no measured effect on any plant characters. Jumbuck was the tallest variety and the most severely lodged, and under these conditions, yield responses to PGR were large (900 kg/ha or 54%). Shorter, erect plants produced an even, compact pod canopy, and as a result, ripening was more uniform, pod shattering reduced and harvesting more efficient. In situations where seed yields were increased, these practical considerations, rather than physiological responses (e.g. pod and seed set), were largely responsible. These findings support further research and commercial development of PGRs for use in canola production in the more favoured areas and support the inclusion of reduced plant height and increased stem strength as integral components of the overall breeding objectives for canola in Australia.

N2 fixation and its value to soil N increase in lupin, field pea and other legumes in south-eastern Australia

N2 fixation and its potential contribution to increasing soil total N were estimated in field-grown crops of lupin and pea in 21 trials at 10 locations in New South Wales and Victoria, during 1984 to 1987. Chickpea, faba bean and annual medic were included at some sites. Across experiments there were differences in annual rainfall (267 to 646 mm), soil N (0.02 to 0.20%), soil pH (CaCl2,4.3 to 8.0) and sowing date (24 April to 16 June). Most experiments were conducted on acidic (pH < 4.8) red-earth, the others on grey-cracking clay or sandy soil, both of higher pH The differing sites, seasons, and sowing time contributed to variation in legume biomass (2.02 to 14.33 t/ha) and total N (45 to 297 kg N/ha), and the amount of N harvested with grain (8 to 153 kg N/ha), which were related.Lupin fixed an average of 65% of total crop N, and pea 61%, but there was considerable variation about these averages (20 to 97%). Significant differences in % N2 fixation between legumes within sites were few. The amount of N2 fixed averaged 98.5 kg N/ha by lupin and 80.5 kg N/ha by pea, varying 26 to 288 kg N/ha and 16 to 177 kg N/ha, respectively. Variation in proportional and total N2 fixation was associated with biomass, soil mineral N, and sowing date. N2 fixation increased with more biomass and declined with higher soil mineral N, and later sowing (lupin). Each additional tonne of dry matter increased fixed N by c. 20 kg N/ha. Differences in amounts of fixed N between legumes within sites were due primarily to biomass differences.N2fixed by lupin contributed an average of 38.2 kg N/ha to soil N, and by pea, 17.9 kg N/ha. The contribution was variable, -41 to 135 kg N/ha (lupin) and -32 to 96 kg N/ha (pea), and correlated with proportional and total N2 fixation. Positive increase to soil total N occurred when lupin fixed at least 50% of its crop N, and pea 65%. This occurred in most crops. Legumes frequently used less of the available soil N than cereals.

Dissociation of effects of xanthine analogs on renal prostaglandins and renal excretory function in the awake rat

In awake, male rats, oral theophylline (TH) or enprofylline (EN; 3-propyl xanthine), 10 to 50 mg/kg b.wt., similarly increased urinary prostaglandin (PG)E2 excretion, by 2- to 3-fold; urinary PGF2 alpha excretion was increased to a lesser extent (50%), while excretion of a PGI2 metabolite, 6-keto-PGF1 alpha, was not altered. In rat renal high-speed supernatant, neither TH nor EN inhibited activity of 15-hydroxyprostaglandin dehydrogenase, an intrarenal PG catabolizing enzyme, suggesting that the increased urinary PG excretion was due to increased synthesis. TH, at all doses that increased urinary PGE2 excretion, also caused dose-related 2-to 4-fold increases in urine volume and urinary excretion of sodium and potassium. In contrast, at low doses EN increased urinary PGE2 excretion without altering urine volume or electrolyte excretion; at the highest dose tested, EN produced a modest diuresis and natriuresis. Pretreatment of rats with indomethacin or meclofenamate (10 mg/kg b.wt., p.o.), chemically dissimilar PG synthesis inhibitors, prevented effects of TH and EN on urinary PG excretion, and also blocked their diuretic and natriuretic effects. Thus, increased renal PGs may be permissive and requisite for the diuretic and natriuretic effects of xanthines, but not sufficient to cause those effects. Enprofylline has been reported (Persson et al., Life Sci. 30: 2181, 1982) to be more active than theophylline as a phosphodiesterase inhibitor, but inactive as an adenosine antagonist, suggesting that the latter action is not required for xanthine stimulation of urinary PG excretion but may be a factor in the diuretic and natriuretic effects.

Effects of ethambutol on phospholipid metabolism in Mycobacterium smegmatis

Soon after Mycobacterium smegmatis was exposed to ethambutol, the synthesis of cardiolipin and phosphatidylinositol dimannoside declined. The synthesis of phosphatidylethanolamine continued, but the drug caused this phospholipid to leak out of the cells.

Inhibition by ethambutol of mycolic acid transfer into the cell wall of Mycobacterium smegmatis

Ethambutol simultaneously inhibited the transfer (presumably via mycolyl acetyl trehalose) of mycolic acids into the cell wall and stimulated the synthesis of trehalose dimycolates of Mycobacterium smegmatis. Structural similarities of the drug and mycolyl acetyl trehalose suggested that competitive inhibition was involved.

Metabolic role of free mycolic acids in Mycobacterium tuberculosis

Small amounts of free mycolic acids and trehalose dimycolate that are rapidly formed by Mycobacterium tuberculosis H37Ra are probably derived from mycolyl acetyl trehalose and transferred to the cell wall. However, the transfer of mycolic acids from mycolyl acetyl trehalose to the cell wall still appears to be the more prominent route.

Isolation, characterization, and function of 6-mycolyl-6'-acetyltrehalose in the H37Ra strain of Myocobacterium tuberculosis

The major mycolic acid containing extractable lipid of the H37Ra strain of Mycobacterium tuberculosis was established to be 6-mycolyl-6'-acetyltrehalose (MAT). This new glycolipid was extracted from harvested cells with chloroform-methanol (2:1, v/v) and initially precipitated out in acetone. A series of column (DEAE-cellulose, silicic acid, and Sephadex LH-20) and preparative thin-layer chromatography steps yielded a homogeneous preparation. A single sugar was released by saponification and it was identified to be trehalose by paper chromatography and gas-liquid chromatography of the trimethylsilyl derivative. The lipid moiety was determined to be exclusively mycolic acids. The major mycolic acid component of this glycolipid was isolated, purified as the methyl ester, and characterized to be methyl alpha-mycolate by nuclear magnetic resonance spectroscopy and mass spectrometry. The molar ratio of trehalose to mycolic acids was determined to be 1:1. The other acyl group in MAT was established to be acetate by gas-liquid chromatography. Methylation analysis showed the mycolate and acetate ester linkages to the 6 and 6' positions of trehalose. The time course of incorporation of 14C-labeled acetate into the mycolates of both MAT and total cellular fatty acids was followed. These results showed that the synthesis of MAT is rapid and linear for the initial 20 min of incubation whereas the curve for the total cellular mycolates minus MAT (an estimate of the cell wall mycolates) had a 25-30-min lag period. When the label in the lipids was chased out with an excess of unlabeled acetate, relatively rapid decline in the labeled MAT resulted with a corresponding rise in the level of radioactivity in the mycolates of the nonextractable cellular fraction (assumed to be the cell wall fraction). Thus mycolic acids are rapidly transferred from MAT to the cell wall of M. tuberculosis.

Site of inhibitory action of isoniazid in the synthesis of mycolic acids in Mycobacterium tuberculosis

The cellular mycolate synthetase activity of Mycobacterium tuberculosis H37Ra was previously shown to be very sensitive to isoniazid (Wang, L., and K. Takayama. 1972. Antimicrob. Agents Chemother. 2: 438-441). We have now examined the question of how isoniazid inhibits the synthesis of mycolic acids. The saponifiable 14-C-labeled lipids of control and isoniazid-treated cells (1.0 mug/ml, 60 min) were compared on a Sephadex LH-20 column, and it appeared that the synthesis of the intermediate-sized fatty acids was partially inhibited. These fatty acids were fractionated as their methyl esters by Sephadex LH-20 column chromatograp-y and gas-liquid (6% Dexsil) chromatography. Mass sectral analysis of the fractionated lipids revealed several series of fatty acids: fraction II, C39-C56; fraction III, C27-C40. The long-chain fatty acids in three kinds of isoniazid-treated cells were examined: (a) long-term exposure (48 hr, 0.5 mug/ml), (b) short-term exposure (60 min, 1.0 mug/ml), and (c) variable exposure at low concentration (0-90 min, 0.2 mug/ml). Both long- and short-term exposure experiments showed that isoniazid inhibited the synthesis of saturated fatty acids greater than C26 and of unsaturated fatty acids greater than C24. The variable-exposure experiment at low isoniazid concentration showed that the syntheses of mycolic acids and long-chain fatty acid fractions II and III were inhibited to the same extent. These fatty acids may thus be precursors of mycolic acids.