Translation, cross-cultural adaptation, and psychometric properties of the Thai version of the Identification of Functional Ankle Instability (IdFAI-THAI) questionnaire.

BACKGROUND: This study developed a Thai version of the Identification of Functional Ankle Instability (IdFAI-THAI) questionnaire. METHODS: To determine construct validity, 200 participants with a history of lateral ankle sprain completed the IdFAI-THAI, the Modified Thai Lower Extremity Functional Scale (LEFS), the Visual Analog Scale of Instability (VAS-I), and the Thai Foot and Ankle Ability Measure (FAAM). Eight days later, 100 randomly selected participants refilled the IdFAI-THAI to assess test-retest reliability and internal consistency. RESULTS: The IdFAI-THAI moderate correlated with the LEFS (rs = -0.62), the VAS-I (rs = 0.62), and the FAAM (rs = -0.63 and -0.69 for the activities of daily living and sports subscales, respectively). The IdFAI-THAI had good test-retest reliability (ICC2,1 = 0.89) and excellent internal consistency (Cronbach's alpha = 0.94). Ceiling and floor effects were absent. CONCLUSION: The valid and reliable IdFAI-THAI can identify chronic ankle instability among Thai speakers in clinical and research settings.

A 6-Week Nine-Square Exercise Programme for Collegiate Athletes with Chronic Ankle Instability: A Randomised Controlled Trial.

Background: Individuals with chronic ankle instability (CAI) have poor postural stability, functional limitations and low quality of life. Although nine-square exercise can improve postural control, there is limited evidence demonstrating whether it can function as an alternative CAI rehabilitation programme. This study aimed to determine the effects of nine-square exercise on postural stability and self-reported outcomes in individuals with CAI. Methods: Eighteen male collegiate athletes with CAI participated in either a 6-week nine-square exercise or a control group (n = 9 per group). At baseline and post-intervention, the participants undertook clinical tests to measures dynamic and static postural control, and self-reported outcomes regarding ankle stability and function. Results: Within-group differences, the nine-square exercise group experienced improved dynamic postural control (P = 0.004), static postural control (P = 0.001) and self-reported outcomes (P < 0.05). For the control group, only static postural control improved (P = 0.018). Post-intervention, the nine-square exercise group experienced significant improvements in dynamic postural control (P < 0.001), ankle stability (P = 0.002) and functional ability (P < 0.05) relative to the control group. Conclusion: These findings suggest that the nine-square exercise can offer an alternative rehabilitation programme for improving postural control, self-perceived ankle stability and functional ability in CAI.

A Screening Tool for Patients With Lumbar Instability: A Content Validity and Rater Reliability of Thai Version.

OBJECTIVE: Lumbar instability is a condition that has been extensively reported in its prevalence and its effect on patients. To date, however, a clinical screening tool for this condition has not been developed for use in Thailand. The objectives of this study were to translate and test the content validity and rater reliability of a screening tool for evaluating Thai patients with lumbar instability. METHODS: The investigators selected the lumbar instability questionnaire from an original English version. Elements of the tool comprised the dominant subjective findings reported by this clinical population. The screening tool was translated into the Thai language following a process of cross-cultural adaptation. The index of item-objective congruence (IOC) was checked for content validity by 5 independent experts. Seventy-five Thai patients with chronic nonspecific low back pain were asked to report their symptoms. The interview procedure using the tool was conducted by expert and novice physical therapists, which informed the intraclass correlation coefficient (ICC) for inter- and intrarater reliability. RESULTS: The IOC was 0.95. The interrater ICC between expert and novice physical therapists was 0.92 (95% CI = 0.88-0.95). The intrarater ICC of novice physical therapist was 0.91 (95% CI = 0.86-0.94). CONCLUSION: The Thai version of the screening tool for patients with lumbar instability achieved excellent content validity and interrater and intrarater reliability. This screening tool is recommended for use with Thai patients with low back pain to identify the subpopulation with lumbar instability.

The Gross Motor Function Classification System Family Report Questionnaire: reliability between special-education teachers and caregivers.

AIM: The aim of this study was to investigate the reliability of the Thai Gross Motor Function Classification System Family Report Questionnaire (GMFCS-FR) and the possibility of special-education teachers and caregivers in the community using this system in children with cerebral palsy (CP). METHOD: The reliability was examined by two teachers and two caregivers who classified 21 children with CP aged 2 to 12 years. A GMFCS-FR workshop was organized for raters. The teachers and caregivers classified the mobility of 362 children. The rater reliability was analysed using the weighted kappa coefficient. The possibility of using the GMFCS-FR is reported. The reliability of using the GMFCS-FR in the community was analysed by the intraclass correlation coefficient. RESULTS: The intrarater reliability ranged from 0.91 to 1.00. The interrater reliability between teachers was 0.85 (95% confidence interval [CI] 0.69-0.97) and between caregivers was 0.84 (95% CI 0.70-0.97). Ninety-seven percent of raters used the Thai GMFCS-FR correctly. The overall intraclass correlation coefficient between raters was 0.90 (95% CI 0.88-0.92). INTERPRETATION: The Thai GMFCS-FR is a reliable system for classifying the motor function of young children with CP by teachers and caregivers in the community.

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.

Derivation of an Ambulatory Prognostic Score Chart for Thai Children with Cerebral Palsy Aged 2 to 18.

Background: Most parents want to know that their children with cerebral palsy will be able to walk. A simple tool to predict ambulatory status and one uses The Gross Motor Function Classification System is still lacking. Objective: To develop a simple prognostic score chart for predicting ambulatory status in Thai children with cerebral palsy. Material and Method: Four hundred seventy one children with cerebral palsy aged 2 to 18 registered and treated at six special schools or hospitals for children with physical disability between 2008 and 2013 were recruited. Baseline characteristics and clinical histories of children with cerebral palsy were collected from medical and physical therapy records. Ambulatory status was classified as three ordinal scales by The Gross Motor Function Classification System - Expanded and Revised version. Results: Multivariable ordinal continuation ratio logistic regression analysis identified age, type of cerebral palsy, sitting independently at the age of two, and eating independently as significant predictors of ambulation. These items were combined into a clinical prediction score: non-ambulation (scores <7), assisted ambulation (scores 7 to 8), and independent ambulation (scores >8). Conclusion: The prognostic tool has high discriminative values of ambulatory status among children with cerebral palsy. However, the validation of this tool needs to be tested in other subjects before clinical practice application.

Reduction of spasticity in cerebral palsy by anodal transcranial direct current stimulation.

OBJECTIVE: To evaluate the anti-spasticity effects of anodal transcranial direct current stimulation (tDCS) in individuals with spastic cerebral palsy (CP). MATERIAL AND METHOD: Forty-six children and adolescents with cerebral palsy were randomly assigned to either active (1 mA anodal) or sham (placebo) tDCS over the left primary motor cortex (Ml) on five consecutive days. Both group also received routine physical therapy. Measures of spasticity and passive range of motion (PROM) were administered before treatment, immediately after treatment, and at 24- and 48-hours follow-up. RESULTS: Participants assigned to active tDCS treatment evidenced significantly more pre- to immediately post-treatment reductions in spasticity than participants assigned to the sham (p = 0.004, p

External cues benefit walking ability of ambulatory patients with spinal cord injury.

BACKGROUND/OBJECTIVES: Sensorimotor dysfunction following spinal cord injury (SCI) reduces ability of the patients to perceive information and control movements. They may need alternative sources of input to optimize their walking ability. This study investigated effects of external cues on walking ability in 33 independent ambulatory participants with SCI. METHODS: Participants' walking ability was cross-sectionally assessed under three conditions including self-determined fastest walking speed (uncued condition), and fastest walking speed with the use of external cues (visual cue and visuotemporal cue conditions). Walking ability was measured in terms of walking speed, stride length, cadence, and percent step symmetry. Findings of the three conditions were compared using the one-way analysis of variance with repeated measures. RESULTS: When using external cues particularly the visuotemporal cue, participants showed a significant increase in walking speed, stride length, and cadence as compared with those of the uncued condition (P < 0.005). The increment of walking speed was demonstrated even in participants at a chronic stage of injury (post-injury time ≥ 12 months), with severe SCI (American Spinal Injury Association Impairment Scale C), or who required a walking device. CONCLUSION: The results suggested the benefit of external cues, particularly the visuotemporal cues, as a potential rehabilitation tool to improve walking speed of individuals with SCI.

Performance of motor imitation in children with and without dyspraxia.

BACKGROUND: Motor imitation is truly essential for young children to learn new motor skills, social behavior and skilled acts or praxis. The present study aimed to investigate motor imitation ability between typically-developing children and dyspraxic children and to examine the development trends in both children groups. MATERIAL AND METHOD: The comparison ofmotor imitation was studied in 55 typically-developing children and 59 dyspraxic children aged 5 to 8 years. The Motor Imitation subtest consisted of two sections, imitation of postures and imitation of verbal instructions. Typically-developing children and dyspraxic children were examined for developmental trends. The independent samples t-test was used to analyze the differences between both groups. Two-way analysis of variance (ANOVA) was used to analyze inter-age differences for each age group. RESULTS: The results revealed significant differences between dyspraxic and typically-developing children. Both typically-developing and dyspraxic children demonstrated age trends. The older children scored higher than younger children. CONCLUSION: Imitation is a primary learning strategy of young children. It is essential that children with dyspraxia receive early detection and need effective intervention. Typically-developing children and dyspraxic children showed higher mean score on the Imitation of Posture section than the Verbal Instructions section. Motor imitation competency, therefore, changes and improves with age.

The usage of a hand-made chair at home for children with moderate to severe cerebral palsy: preliminary study.

BACKGROUND: Specially designed chairs are expensive. A hand-made chair easily constructed from recycled material can be an alternative option. However data on the feasibility of hand-made chair use at home is limited. The present study aimed to explore the usage of a hand-made chair at home in children with moderate to severe motor disabilities. MATERIAL AND METHOD: Seventeen children with cerebral palsy were recruited. Main caregivers were interviewed regarding the possibility of using the chair at home. Home visits and observations were also performed to explain how the chair had been used at home. RESULTS: Nine children (52.9%) used the chair everyday. Seven of these nine children were seated at least 30 minutes each time and two to three times per day. The total time that children spent on the hand-made chair each day ranged from 10 to 90 minutes. CONCLUSION: The severity of disability and main caregivers' workload may explain an inadequate usage of the hand-made chair. A few modifications may help to improve the applicability of the hand-made chair.

Intra-Individual Variability in Gross Motor Development in Healthy Full-Term Infants Aged 0-13 Months and Associated Factors during Child Rearing.

The gross motor development of a typically developing infant is a dynamic process, the intra-individual variability of which can be investigated through longitudinal assessments. Changes in gross motor development vary, according to the interaction of multiple sub-systems within the child, environment, task setting, and experience or practice of movement. At present, studies on environmental factors that influence gross motor development in full-term infants over time are limited. The main aim of this study was to investigate environmental factors affecting intra-individual variability from birth to 13 months. The gross motor development of 41 full-term infants was longitudinally assessed every month from the age of 15 days using the Alberta Infant Motor Scale. Parents were interviewed monthly about environmental factors during childcare. Infants showed fluctuations in the percentile of gross motor development, and no systematic pattern was detected. The total mean range of gross motor percentile was 65.95 (SD = 15.74; SEM = 2.28). The percentiles of gross motor skills over the 14 assessments ranged from 36 to 93 percentile points. Factors that were significantly associated with the gross motor development percentile were the use of a baby walker (Coef. = -8.83, p ≤ 0.0001) and a baby hammock (Coef. = 7.33, p = 0.04). The use of baby hammocks could increase the gross motor percentile by 7.33 points. Although the usage of a baby walker is common practice in childcare, it may cause a decrease in the gross motor percentile by 8.83 points according to this study. In conclusion, healthy full-term infants exhibited a natural variability in gross motor development. Placing infants in a baby walker during the first year of age should be approached with caution due to the risk of delayed gross motor development.

Prevalence of Thai People with Lumbar Instability and Associated Factors: A Cross-Sectional Study.

Background: Lumbar instability has been extensively reported; however, the risk factors for lumbar instability remain poorly defined, and understanding this condition better would help health professionals and their patients. Proposal: To determine the prevalence of lumbar instability in Thai people with chronic low back pain (CLBP) and explore the factors associated with lumbar instability in these patients. Patients and Methods: Using multistage random sampling methods, 1762 participants with CLBP were enrolled in the study from six regions of Thailand. Data were collected using a paper-based questionnaire. Participants were interviewed by physical therapists in the hospital they attended. They were classified as having lumbar instability when they attained ≥7/14 items on the lumbar instability screening tool. Univariate and multivariate regression analysese were used to determine the possible factors associated with lumbar instability. Results: There were 961 (54.54%) participants with lumbar instability and 801 (45.46%) participants without. The eight factors associated with lumbar instability were: (i) age ≥40 years (AOR: 1.36; 95% CI: 1.09-1.69); (ii) body mass index ≥25 kg/m2 (AOR: 1.42; 95% CI: 1.16-1.74); (iii) having an underlying disease (AOR: 1.32; 95% CI: 1.06-1.65); (iv) frequent lifting ≥5 kg in occupational habits (AOR: 1.69; 95% CI: 1.36-2.09); (v) prolonged walking ≥4 hours per day (AOR: 1.31; 95% CI: 1.04-1.64); (vi) gardening in leisure time (AOR: 1.37; 95% CI: 1.10-1.71); (vii) other area of pain (AOR: 1.24; 95% CI: 1.01-2.52): and (viii) other area of numbness (AOR: 1.85; 95% CI: 1.50-2.27). When considering only women, prior pregnancy was associated with lumbar instability with OR of 1.76 (95% CI: 1.36-2.22), p-value <0.0001. Conclusion: When treating patients with CLBP who are suspected to have lumbar instability, healthcare professionals should consider associated factors that might be modifiable targets for interventions to improve outcomes.

Effects of Play in an Upright Position on Intra-Individual Variability of Gross Motor and Language Development in Institutionalized Infants.

(1) Objective: To investigate the effects of play in an upright position on intra-individual variability and to examine the relationship between the variability of gross motor and language development in institutionalized infants aged six to ten months. (2) Methods: Thirty infants were conveniently enrolled in either the experimental or control groups. The Alberta Infant Motor Scale (AIMS) and the Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP) Infant/Toddler Checklist were tested pre and post each monthly intervention for three months. Sixteen infants in the experimental group received an additional program of 45 min play in an upright position three times a week for a 3-month period. (3) Results: There were significant between-group differences in intra-individual variability of the AIMS percentiles (p-value = 0.042). In addition, there was a significant difference in the intra-individual variability of the language percentile between groups (p-value = 0.009). The intra-individual variability of gross motor development was significantly correlated (rs = 0.541; p = 0.03) with language development. (4) Conclusions: Play in an upright position could be applied to improve intra-individual variability in gross motor and language development percentiles in institutionalized infants.

Factors Associating with the Segmental Postural Control during Sitting in Moderate-to-Late Preterm Infants via Longitudinal Study.

(1) Background: biological variables and particular child rearing practices could be linked to postural control and rates of sitting onset. The segmental Assessment of Trunk Control (SATCo) is currently used as an assessment of postural control with a specific segment on premature infants. However, the association between related factors and segmental trunk control during sitting development in preterm infants via longitudinal assessments is still limited. Objective: to investigate the associations between biological and child rearing factors and segmental trunk control during sitting in moderate to late premature birth from the age of 4 months to age of independent sitting attainment. (2) Methods: forty-two infants born between 32 and 36 weeks of gestation were recruited. Their segmental trunk control was assessed using the SATCo. Their related factors were recorded from the age of 4 months to early onset of independent sitting attainment. The generalised estimating equation (GEE) model was used to identify the association between related factors and the SATCo with a linear distribution. (3) Results: cause of prematurity, baby rocking recliner and baby walker usage were negative factors, while play in a sitting position, opportunity to move on a traditional mat and sleep mattress were positive factors contributing to the segmental control of the trunk. (4) Conclusions: the experience of sitting on different surfaces and an opportunity to sit without support during the child rearing period from age of 4 months corrected could be positive factors associating with the segmental trunk control in moderate-to-late premature infants.

Segmental Assessment of Trunk Control in Moderate-to-Late Preterm Infants Related to Sitting Development.

(1) Background: The assessment of postural segment control in premature infants seems to be critical during the onset of upright gross motor development, especially sitting. Identifying correlations between postural segment control and the development of sitting milestones could help with promoting optimal gross motor movement. However, data on this topic in home-raised premature infants via longitudinal design are still limited. The purpose of this study was to examine relationships between postural segment control and sitting development through series assessments from the corrected age of 4 months until the early onset of independent sitting attainment. (2) Methods: 33 moderate-to-late premature infants were recruited. Their trunk segment control was assessed using the Segmental Assessment of Trunk Control (SATCo), and sitting development was examined by the Alberta Infant Motor Scale (AIMS). Relationships between SATCo and sitting scores were analysed using Spearman's rank correlation (rs). (3) Results: significant fair-to-good correlations between segmental trunk control and sitting scales were found from 4 months (rs = 0.370-0.420, p < 0.05) to the age of independent sitting attainment (rs = 0.561-0.602, p < 0.01). (4) Conclusion: relationships between the trunk segment control and sitting ability of moderate-to-late preterm infants were increased in accordance with age.

Effectiveness of the manual diaphragmatic stretching technique on respiratory function in cerebral palsy: A randomised controlled trial.

BACKGROUND: Respiratory failure resulting from diaphragmatic muscle weakness is a major cause of long-term hospitalization in children with cerebral palsy (CP). Manual diaphragmatic stretching technique (MDST) can be directly applied to stretch diaphragmatic muscle and has been reported to improve respiratory function in patients with asthma and COPD. However, there have been no studies among CP. This study aimed to examine the effects of a six-week MDST course on respiratory function among CP. METHODS: Fifty-three children with spastic CP were randomly assigned to experimental (n = 27) and control (n = 26) groups. The experimental group received MDST on non-consecutive days, three days per week for six weeks alongside standard physiotherapy (SDPT), while the control group received only SDPT. The outcome variables were diaphragmatic mobility, pulmonary function and chest wall expansion. RESULTS: MDST significantly improved diaphragmatic mobility on both sides of the body, with a between-group difference of 0.97 cm (95% CI 0.55-1.39 cm, p < 0.001) for the right side and 0.82 cm (95% CI 0.35-1.29 cm, p = 0.001) for the left side. MDST significantly improved chest wall expansion at the xiphoid process and umbilical levels, with between-group differences of 0.57 cm (95% CI 0.12-1.20 cm, p = 0.013) and 0.87 cm (95% CI 0.31-1.43 cm, p = 0.003), respectively. There was no significant difference in pulmonary function testing between the groups. CONCLUSION: MDST could significantly improve diaphragmatic mobility, and lower and abdominal chest wall expansion, among children with CP. Therefore, MDST could be considered as an additional technique for physiotherapy programmes, to improve diaphragmatic function in spastic CP.

Factors related to obstacle crossing in independent ambulatory patients with spinal cord injury.

BACKGROUND/OBJECTIVES: To evaluate factors related to the ability of ambulatory patients with spinal cord injury (SCI) to walk over small obstacles. STUDY DESIGN: Cross-sectional study. METHODS: Thirty-four patients with SCI (ASIA impairment scale [AIS] D) who were able to walk independently at least 10 m with or without walking devices were recruited for the study. Participants were required to walk over small obstacles (1, 4, and 8 cm in height or width; total of 6 conditions). A "fail" was recorded when either the lower limbs or the walking device contacted the obstacle. Multiple logistic regression models were applied to determine the effects of walking devices (presence or absence), SCI levels (tetraparesis or paraparesis), and SCI stages (acute or chronic) on the ability of obstacle crossing. RESULTS: Fifteen participants (44%) failed to adequately clear the foot or walking device over obstacles in at least one condition (range 1-3 conditions). After adjusting for covariates, the chance of failure on obstacle crossing was greatly increased with the use of walking devices (odds ratio = 8.50; 95% CI = 0.85-75.03) CONCLUSIONS: Gait safety in independent ambulatory participants with SCI remains threatened. Participants who walked with walking devices encountered a greater chance of failing to walk over obstacles as a result of inefficiently moving the foot or walking device over small obstacles. Thus, instead of training in an empty/ quiet room, rehabilitation procedures should incorporate contextual conditions that patients encounter at home and in the community in order to minimize risk of injury and prepare patients to be more independent after discharge.

Gross motor development of Thai healthy full-term infants aged from birth to 14 months using the Alberta Infant Motor Scale: Inter individual variability.

BACKGROUND: The gross motor percentiles of the Alberta Infants Motor Scale (AIMS) have been commonly referenced in research. Cross-cultural assessment of gross motor development during the first year of life is suggested as diverse child-rearing practices can cause inter-variability. The main aim of this study was to develop an AIMS percentile curve for typically developing home-raised infants in the northeastern part of Thailand. The AIMS scores of these infants were also compared with the standard Canadian norms. METHODS: The gross motor development of 574 full-term infants aged 15 days to 14 months was assessed using the Thai version of the AIMS. Percentile curves of their gross motor ability were developed. The Thai infants' mean AIMS scores were compared with the Canadian norm using the one-sample t-test. RESULTS: The percentile curve of gross motor development of healthy Thai infants showed that mean AIMS scores increased with age. Large inter-variability was present from the 7th to 10th months. The mean AIMS scores of Thai infants were significantly lower than the standard Canadian means during the first three months (P < 0.05), but significantly higher in three age groups: 7-<8 months, 11-<12 months, and 13-14 months. CONCLUSION: The developed percentile curve of gross motor development is applicable for infants from the same demographic and environmental context. According to the study, infants from diverse cultures display a natural inter-variability in gross motor development between the 7th and 10th months.

Cultural translation and adaptation of the Alberta Infant Motor Scale Thai version.

BACKGROUND: The Alberta Infant Motor Scale (AIMS) is a widely used screening tool used to measure gross-motor maturation for clinical and research usage in various countries. A cross-cultural translation and adaptation process is essential to produce reliable and applicable translated assessment tools. AIMS: The purposes of this cross-sectional study were to obtain the Alberta Infant Motor Scale Thai version and to determine its reliability, validity, and applicability. METHODS: The process of translation and cultural adaptation of the AIMS Thai version was performed. The conceptual, semantic, and idiomatic equivalences of the language of the AIMS Thai version were strictly reviewed by committee. The intra-rater/inter-rater reliabilities and concurrent validity with the Bayley III were examined in 30 full-term typically developing infants. Then, 19 infants from an orphanage and 23 typically developing infants were assessed using the final translated version of the AIMS. RESULTS: The AIMS Thai version was generated systematically. Two therapists showed high intra-rater reliability using the Thai AIMS with an ICC of 0.995 (95% CI 0.989-0.998) and 0.979 (95%CI 0.919-0.992), and the inter-rater reliability was 0.988 (95%CI 0.976-0.994). The concurrent validity of the AIMS Thai version and the Bayley III was 0.969 (p < 0.01). The AIMS percentile of gross-motor development of orphaned infants (94.7%) were equal or lower than the 5th percentile, while the AIMS percentile of home-raised infants ranged from the 5th to the 90th percentile. CONCLUSION: The translated and adapted AIMS Thai version is reliable and valid to use in Thai infants.

Diaphragmatic mobility in children with spastic cerebral palsy and differing motor performance levels.

The aim of this study was to compare diaphragmatic mobility (DM) and respiratory function between children with cerebral palsy (CP) and healthy controls (HC). CP was divided into non-ambulatory CP (NACP) and ambulatory CP (ACP). Eighteen children with NACP, 18 with ACP and 18 HC age between 8 and 18 years were recruited. Ultrasound was used to measure DM on both sides. Respiratory muscle strength (RMS), pulmonary function (PF) and chest expansion (CE) were also measured. The results showed that there was significantly lower right DM in CP than HC group. The NACP group had significantly lower DM than the ACP group. There were also significantly lower values of RMS, PF and CE in CP, compared to the HC group. There are significant impairments of diaphragmatic and respiratory function in CP, relative to HC. Thus, appropriate interventions to improve diaphragmatic muscle strength are necessary for children with CP, especially in the NACP.