Physiological Response to the 6-Minute Frame Running Test in Children and Adults With Cerebral Palsy.

PURPOSE: To determine the physiological response and association to peak oxygen uptake of the 6-minute Frame Running test (6-MFRT) in persons with cerebral palsy (CP). METHODS: Twenty-four participants with CP, Gross Motor Function Classification System II/III/IV, performed the 6-MFRT. Distance, peak heart rate (HR peak ), peak respiratory exchange ratio (RER peak ), and peak oxygen uptake ( O 2peak ) were measured. RESULTS: HR peak ranged from 146 to 201 beats per minute, RER peak from 0.94 to 1.49, 6-MFRT distance from 179 to 1220 m and O 2peak from 0.62 to 2.18 L/min. HR peak was achieved in 63%, RER peak in 71%. A strong correlation was observed between 6-MFRT and O 2peak . CONCLUSIONS: The 6-MFRT represented a (near) maximum effort for 75% of the participants and the 6-MFRT can be used to estimate oxygen consumption on an individual basis.

Pain, fatigue, depressive symptoms and sleep disturbance in young adults with cerebral palsy.

PURPOSE: Investigate pain, fatigue, depressive symptoms and sleep disturbance in young adults with cerebral palsy compared to references. MATERIALS AND METHODS: Young adults with cerebral palsy (n = 97, aged 21-34 years) and age-matched references from the general population (n = 190) rated pain using a numeric rating scale and fatigue, depressive symptoms, sleep disturbance and global health using Patient-Reported Outcomes Measurement Information System® short forms. Scores were compared between cerebral palsy subgroups and the reference population. Correlation coefficients and linear regression analyses assessed interrelationships of health issues and associations with global health. RESULTS: Individuals with Gross Motor Function Classification System level I had less pain, fatigue and depressive symptoms, while individuals with levels II and III-V had more pain (53% and 56%, p < 0.001) and those with levels III-V more fatigue (39%, p = 0.035) than references (pain: 26%, fatigue: 14%). Pain and fatigue were more interrelated (correlation coefficients: 0.71 vs. 0.41) and stronger associated with global mental health in individuals with cerebral palsy. CONCLUSIONS: Young adults with Gross Motor Function Classification System levels II-V report more pain and those with levels III-V report more fatigue than references. Pain and fatigue are highly interrelated and specifically relate to mental health in individuals with cerebral palsy.Implications for rehabilitationExcept for those in the highest level of motor function, young adults with cerebral palsy report higher levels of pain and fatigue compared to the general population of the same age.Pain and fatigue are strongly interrelated and associated with mental health in young adults with cerebral palsy.The present study recommends to monitor pain and fatigue in young adults with cerebral palsy with low levels of gross motor function.We advise rehabilitation professionals to consider combined treatment for both pain and fatigue.

Improvements in Muscle Strength Are Associated With Improvements in Walking Capacity in Young Children With Cerebral Palsy: A Secondary Analysis.

PURPOSE: To evaluate whether changes in lower-limb muscle strength explain changes in walking capacity during 14-week periods of usual care, power training and follow-up for children with spastic cerebral palsy. METHODS: Secondary analysis of a previously conducted double-baseline controlled trial of 22 children with spastic cerebral palsy. Generalized estimating equations were used to evaluate the relationships between within-subject changes in isometric muscle strength and walking capacity over 3 periods. RESULTS: Changes in hip abductor strength were associated with changes in the Muscle Power Sprint Test, changes in gastrocnemius and hip abductor strength were associated with changes in the Shuttle Run Test, and changes in gastrocnemius strength were associated with changes in the 1-minute walk test. All associations supported better walking capacity with increased strength. CONCLUSION: Walking capacity, especially sprint capacity, can be improved by increasing strength by functional power training in this population.

Intraobserver Reliability and Construct Validity of the Squat Test in Children With Cerebral Palsy.

PURPOSE: This study evaluated intraobserver reliability and construct validity of the squat test to assess lower extremity strength in children with cerebral palsy (CP) and spastic diplegia. METHODS: Children with CP performed 2 trials of the squat test and calculated the intraclass correlation coefficient to evaluate intraobserver reliability. Correlations between outcomes of hand-held dynamometry (HHD) of knee extensor strength and an 8-repetition maximum (8RM) leg press test and the squat test were calculated to evaluate construct validity. RESULTS: Excellent intraobserver reliability was observed for the squat test. Correlations between squat test performance and HHD knee extension and 8RM leg press test demonstrated good construct validity. CONCLUSIONS: The squat test is a reliable and valid tool to assess lower extremity strength in children with CP and spastic diplegia. The squat test is inexpensive and less time-consuming, and therefore particularly suitable for clinicians.

Fatigue in Children and Young Adults With Physical Disabilities: Relation With Energy Demands of Walking and Physical Fitness.

PURPOSE: To examine whether general fatigue and fatigue during or after walking are related to energy demands during walking and physical fitness in children and young adults with physical disabilities. METHODS: Sixty-eight individuals with physical disabilities participated. General fatigue (Checklist Individual Strength [CIS8R] questionnaire), walking-induced fatigue (OMNI [OMNIwalk] scale after walking for 6 min), gross and net energy costs (ECs) of walking, physical strain of walking, and aerobic and anaerobic fitness were measured. RESULTS: Regression analyses showed no relations with the CIS8R. For all participants, a higher net EC was weakly related to an increased OMNIwalk. For teenagers only, low anaerobic fitness and high physical strain of walking values were moderately related to high OMNIwalk scores. CONCLUSION: Low anaerobic fitness and high physical strain values partly explain fatigue after walking in teenagers with cerebral palsy, but not in younger children. General fatigue was not explained by low fitness levels or high energy demands of walking.

Development curves of communication and social interaction in individuals with cerebral palsy.

AIM: To determine development curves of communication and social interaction from childhood into adulthood for individuals with cerebral palsy (CP). METHOD: This Pediatric Rehabilitation Research in the Netherlands (PERRIN)-DECADE study longitudinally assessed 421 individuals with CP, aged from 1 to 20 years at baseline, after 13 years (n=121 at follow-up). Communication and social interactions were assessed using the Vineland Adaptive Behavior Scales. We estimated the average maximum performance limit (level) and age at which 90% of the limit was reached (age90 ) using nonlinear mixed-effects modeling. RESULTS: One-hundred individuals without intellectual disability were aged 21 to 34 years at follow-up (39 females, 61 males) (mean age [SD] 28y 5mo [3y 11mo]). Limits of individuals without intellectual disability, regardless of Gross Motor Function Classification System (GMFCS) level, approached the maximum score and were significantly higher than those of individuals with intellectual disability. Ages90 ranged between 3 and 4 years for receptive communication, 6 and 7 years for expressive communication and interrelationships, 12 and 16 years for written communication, 13 and 16 years for play and leisure, and 14 and 16 years for coping. Twenty-one individuals with intellectual disability were between 21 and 27 years at follow-up (8 females, 13 males) (mean age [SD] 24y 7mo [1y 8mo]). Individuals with intellectual disability in GMFCS level V showed the least favourable development, but variation between individuals with intellectual disability was large. INTERPRETATION: Individuals with CP and without intellectual disability show developmental curves of communication and social interactions similar to typically developing individuals, regardless of their level of motor function. Those with intellectual disability reach lower performance levels and vary largely in individual development. WHAT THIS PAPER ADDS: Communication and social interactions in individuals with cerebral palsy without intellectual disability develop similarly to typically developing individuals. Communication and social interactions of individuals with intellectual disability develop less favourably and show large variation.

CURVAS DE DESARROLLO DE COMUNICACIÓN E INTERACCIÓN SOCIAL EN NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Determinar las curvas de desarrollo de la comunicación y la interacción social desde la infancia hasta la edad adulta para las personas con parálisis cerebral (PC). MÉTODO: Esta Investigación de Rehabilitación Pediátrica en el Estudio de los Países Bajos (PERRIN)-DECADE evaluó longitudinalmente 421 individuos con PC, de 1 a 20 años en el inicio, después de 13 años (n=121 en el seguimiento). La comunicación y las interacciones sociales se evaluaron utilizando la Escala de comportamiento adaptativo de Vineland. Estimamos el límite promedio de rendimiento máximo (nivel) y la edad a la que se alcanzó el 90% del límite (edad90 ) utilizando un modelo no lineal de efectos mixtos. RESULTADOS: Cien individuos sin discapacidad intelectual tenían entre 21 y 34 años en el seguimiento (39 mujeres, 61 varones; edad media [DS] 28 y 5 meses [3 años y 11meses]). Los límites de las personas sin discapacidad intelectual, independientemente del nivel del Sistema de Clasificación de la Función Motora Gruesa (GMFCS), se acercaron a la puntuación máxima y fueron significativamente superiores a los de personas con discapacidad intelectual. Edad 90s entre 3 y 4 años para la comunicación receptiva, 6 y 7 años para la comunicación expresiva y las interrelaciones, 12 y 16 años para la comunicación escrita, 13 y 16 años por juego y ocio, y 14 y 16 años por sobrellevarlo. Veintiún individuos con discapacidad intelectual tenían entre 21 y 27 años en seguimiento (8 mujeres, 13 hombres; edad media [DS] 24 años y 7 meses [1 año y 8 meses]). Las personas con discapacidad intelectual en el nivel V de GMFCS mostraron el desarrollo menos favorable, pero la variación entre las personas con discapacidad intelectual fue grande. INTERPRETACIÓN: Las personas con PC sin discapacidad intelectual muestran curvas de desarrollo de comunicación e interacciones sociales similares a las personas con desarrollo típico, no considerando su nivel de función motora. Las personas con PC y discapacidad intelectual alcanzan niveles de rendimiento más bajos y varían en gran medida en el desarrollo individual.

CURVAS DE DESENVOLVIMENTO DA COMUNICAÇÃO E INTERAÇÃO SOCIAL EM CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Determinar as curvas de desenvolvimento e interação social da infância para a adolescência para indivíduos com paralisia cerebral (PC). MÉTODO: Este estudo Europeu de Reabilitação Pediátrica na Holanda (PERRIN)-DECADE avaliou longitudinalmente 421 indivíduos com PC, com idades de 1 a 20 anos na linha de base, após 13 anos, (n=121 no acompanhamento). A comunicação e interação social foram avaliadas usando as Escalas Vineland de Compartamento Adaptativo. Estimamos o limite máximo de desempenho médio (nível) e idade em que 90% do limite foi atingido (idade90 ) usando modelos não-lineares de efeitos mistos. RESULTADOS: Cem indivíduos sem deficiência intelectual com idades entre 21 e 34 anos no acompanhamento (39 do sexo feminino, 61 do sexo masculino; média de idade [DP] 28a 5m [3a 11m]). Os limites de indivíuduos sem deficiência intelectual, independente do nível do Sistema de Classificação da Função Motora Grossa (GMFCS), se aproximou da pontuação maxima e foram significativamente maiores do que os valores de indivíduos com deficiência intelectual. A idade 90s variou entre 3 e 4 anos para comunicação receptiva, 6 e 7 anos para comunicação expressiva e intercomunicações, 12 e 16 anos para comunicação escrita, 12 e 16 years para brincadeiras e lazer, e 14 e 16 anos para adaptabilidade. Vinte e um indivíduos com deficiência intelectual estavam entre 21 e 27 anos no acompanhamento (8 do sexo feminino, 13 do sexo masculino; média de idade [DP] 24a 7m [1a 8m]). Indivíduos com deficiência intelectual no nível GMFCS V mostraram o desenvolvimento menos favorável, mas a variação entre indivíduos com deficiência intelectual foi grande. INTERPRETAÇÃO: Indivíduos com PC com e sem deficiência intelectual mostram curvas desenvolvimentais de comunicação e interação social similares a indivíduos com desempenho típico, independente do nível de função motora. Aqueles com deficiência intelectual tiveram menores níveis de performance e variaram amplamente no desenvolvimento individual.

Teenage predictors of participation of adults with cerebral palsy in domestic life and interpersonal relationships: A 13-year follow-up study.

BACKGROUND: Adults with cerebral palsy (CP) may experience problems with participation in domestic life and interpersonal relationships. AIMS: To identify teenage predictors of adult participation in domestic life and interpersonal relationships. METHODS AND PROCEDURES: This 13-year follow-up of the PERRIN 16-24 cohort included 53 adults with CP without intellectual disability [current age 31.7 (SD = 1.4) years]. Participation performance was assessed as attendance (Vineland Adaptive Behavior Scales), and difficulty/assistance with participation (Life Habits questionnaire). 56 teenage factors were categorized in ICF components. Stepwise multiple linear regression analyses explored predictors of participation. OUTCOMES AND RESULTS: Lower gross motor capacity, following special education, having protective parents and a rigid personality predicted less participation in domestic life. Having rejective parents, receiving little daily support, having a socially avoidant personality or coping style and the male gender predicted less participation in interpersonal relationships. Lower activity and participation levels as a teenager predicted less participation in both domestic life and interpersonal relationships of adults with CP. CONCLUSIONS AND IMPLICATIONS: Environmental and personal factors, gross motor capacity and teenage participation were predictors of participation of adults with CP. These factors help identify subgroups at risk for suboptimal adult participation and provide targets for rehabilitation.

Effects of functional power training on gait kinematics in children with cerebral palsy.

BACKGROUND: Muscle weakness is one of the most prevalent symptoms in children with cerebral palsy (CP). Although recent studies show that functional power training can improve strength and functional capacity in young children with CP, effects on specific gait parameters have not previously been reported. RESEARCH QUESTION: What are the effects of functional power training on gait in children with CP? Specifically, we investigated effects of training on gait kinematics and spatiotemporal parameters, and whether these were dependent on walking speed. METHODS: Ten children with CP (age 5-10 years, GMFCS I-II) participated in a functional power training program. At the start and end of the program, children underwent 3D gait analysis on a treadmill at a gradual range of walking speeds (70-175% of their comfortable walking speed). Multilevel (linear mixed model) analysis was used to evaluate effects pre-post training at different walking velocities. RESULTS: Although children's self-chosen comfortable walking speed improved (0.71 ±â€¯0.25 to 0.85 ±â€¯0.25 m/s, p < .05), effects on gait kinematics at similar speed were limited and only exceeded statistical and clinically meaningful thresholds when children walked at higher walking speed. At fast speeds, improvements up to 5° were found in knee and hip extension during stance (p < .01). SIGNIFICANCE: This study demonstrates that gait kinematics can improve after functional power training, but the magnitude of effects is dependent on walking speed. In this light, improvements are underestimated when evaluating gait at pre-training comfortable walking speed only.

Lower limb muscle fatigue during walking in children with cerebral palsy.

AIM: To investigate whether more prominent signs of muscle fatigue occur during self-paced walking in children with cerebral palsy (CP) compared to typically developing peers. METHOD: In this case-control study, 13 children with CP (four males, nine females; mean age [SD] 11y 4mo [3y 8mo]; nine in Gross Motor Function Classification System [GMFCS] level I, three in GMFCS level II, and one in GMFCS level III) and 14 typically developing peers (nine males, five females; mean age [SD] 9y 10mo [1y 10mo]) walked 5 minutes overground at a self-selected walking speed. Electromyography (EMG) median frequency and root mean square (RMS) were identified per gait cycle from EMG recordings of the tibialis anterior, gastrocnemius medialis, soleus, rectus femoris, and semitendinosus. Rate of change in those variables was analysed using mixed linear model analyses. RESULTS: The decrease in EMG median frequency of gastrocnemius medialis and soleus and increase in EMG-RMS of tibialis anterior, gastrocnemius medialis, and soleus were significantly larger in the most affected leg of children with CP compared with typically developing peers. INTERPRETATION: Increased selective muscle fatigue of the lower leg muscles was observed during self-paced walking in children with mild-to-moderate severe CP. This could contribute to and account for limited walking capacity. WHAT THIS PAPER ADDS: Children with cerebral palsy (CP) show more signs of lower leg muscle fatigue than typically developing peers. No signs of muscle fatigue were observed in upper leg muscles of children with CP.

Long-term course of difficulty in participation of individuals with cerebral palsy aged 16 to 34 years: a prospective cohort study.

AIM: To determine the long-term course of difficulty in participation of individuals with cerebral palsy (CP) without intellectual disability between 16 years and 34 years of age. METHOD: One hundred and fifty-one individuals with CP aged 16 to 20 years were included (63% male, 37% female; Gross Motor Function Classification System [GMFCS] levels I-IV; without intellectual disability). The Assessment of Life Habits questionnaire 3.0 general short form was used up to three times biennially and at 13-year follow-up (13-year follow-up: n=98). Scores (range 0-10) reflect difficulty and assistance in participation in housing, education and employment, interpersonal relationships, recreation, community life, and responsibilities. Multilevel models were used to determine the course of difficulty in participation by GMFCS level. RESULTS: Despite high average participation levels, 41% to 95% of adolescents and young adults with CP experienced difficulty. Difficulty in participation in housing and interpersonal relationships increased from age 16 years onwards and in most other life areas in the mid- and late 20s. In adolescents in GMFCS levels III and IV, participation in recreation and community life improved up to age 23 years. INTERPRETATION: Individuals with CP experience increasing difficulties in participation in their mid- and late 20s. Clinicians should systematically check for participation difficulties in young adults with CP and offer timely personalized treatment. WHAT THIS PAPER ADDS: Many individuals with cerebral palsy (CP) aged 16 to 34 years experience difficulty in participation. Difficulty in participation increases in the mid- and late 20s for individuals with CP. Participation in recreation/community life improves before age 23 years for those in Gross Motor Function Classification System levels III and IV.

Activity Performance Curves of Individuals With Cerebral Palsy.

: media-1vid110.1542/5804911840001PEDS-VA_2017-3723Video Abstract OBJECTIVES: Describe development curves of motor and daily activity performance in individuals with cerebral palsy (CP). METHODS: Participants with CP aged 1 to 20 years at baseline (n = 421) and Gross Motor Functioning Classification System (GMFCS) levels I to V (27% of participants with intellectual disability [ID]) were longitudinally assessed up to a 13-year follow-up period. Motor and daily activity performance were assessed using the relevant subdomains of the Vineland Adaptive Behavior Scales survey. Nonlinear mixed effects analyses were used, estimating the limit (average maximal performance level) and the age by which individuals reached 90% of the limit (age90). RESULTS: Limits of motor performance decreased with each lower functional level. Age90 for motor performance was reached at ∼6 to 8 years of age in children with GMFCS levels I to III, and at younger ages in those with lower functional levels. Limits of daily activity performance did not differ between individuals without ID with GMFCS levels I to III. The age90s of daily activities were reached between 11 and 14 (personal), 26 and 32 (domestic), and 22 and 26 years of age (community). Individuals with ID reached lower daily activity performance limits earlier. CONCLUSIONS: Individuals with CP continue to develop motor performance after gross motor capacity limits are reached. For those without ID, daily activities continue to develop into their 20s. Individuals who are severely affected functionally have the least favorable development of motor performance, and those with ID have the least favorable development of daily activity performance.

Intramuscular botulinum toxin prior to comprehensive rehabilitation has no added value for improving motor impairments, gait kinematics and goal attainment in walking children with spastic cerebral palsy.

OBJECTIVE: Botulinum toxin (BoNT-A) is widely used in combined treatment for spastic cerebral palsy, but its added value preceding comprehensive rehabilitation for motor impairments, gait, and goal attainment has not been studied. DESIGN: A comparative multi-centre trial, in which two groups underwent comprehensive rehabilitation (i.e. high-intensive functional physiotherapy, and indicated casting/orthoses). One group received intramuscular BoNT-A prior to rehabilitation, and the other group did not receive BoNT-A. SUBJECTS/PATIENTS: Children with spastic cerebral palsy, Gross Motor Function Classification System (GMFCS) levels I-III, age range 4-12 years, indicated for BoNT-A treatment regarding mobility problems. METHODS: Sixty-five children participated (37 boys), mean age 7.3 years (standard deviation (SD) 2.3, range 4-12 years), equally distributed across GMFCS levels. Forty-one children received BoNT-A+ comprehensive rehabilitation and 24 received comprehensive rehabilitation only. Functional leg muscle strength, passive range of motion, angle of catch, cerebral palsy-related pain, walking speed, kinematic gait parameters, goal attainment, and proxy-reported general functioning were assessed at baseline, primary end-point (12 weeks) and 24-week follow-up. Statistical analyses were performed with linear mixed models. RESULTS: At the primary end-point there were no statistically significant differences in treatment effects between the groups, except for the angle-of-catch of the rectus femoris, which was in favour of comprehensive rehabilitation without BoNT-A (12° difference, 95% confidence interval (95% CI) 2:23, p = 0.025). Results at follow-up were similar. CONCLUSION: At the group level, treating with BoNT-A prior to comprehensive rehabilitation did not add to the clinical effectiveness of rehabilitation. Thus, BoNT-A prescription and use should be critically reconsidered in this cerebral palsy age- and GMFCS-subgroup.

Improved parent-reported mobility and achievement of individual goals on activity and participation level after functional power-training in young children with cerebral palsy: a double-baseline controlled trial.

BACKGROUND: In children with cerebral palsy (CP), strength training programs to improve walking capacity and participation in activities of daily living are commonly used in clinical practice, despite lacking evidence of its effectiveness. It has been suggested that strength training with high movement velocity could be more effective than traditional resistance training to improve functional abilities such as walking. In a recently published study, we have demonstrated the positive effects of functional high-velocity resistance (power) training on muscle strength and walking capacity in young children with CP. Whether this type of training is also effective in achieving individual predefined goals in daily activities and self-reported mobility limitations, has not yet been described however. AIM: To evaluate the effect of functional power-training on parent-reported mobility and achievement of individual goals on activity and participation level in young children with CP. DESIGN: A double-baseline design was used to compare a 14-week period usual care with a 14-week period of functional power-training (3 times a week) and a follow-up period of 14 weeks. SETTING: A rehabilitation center, two special needs schools for children with physical disabilities, and a university medical center outpatient clinic. POPULATION: Twenty-two children with spastic CP (13 bilateral, GMFCS level I [N.=10] and level II [N.=12], mean age 7.5 years [SD 1.8, range 4-10 years]) and their parents participated. METHODS: Outcome measures were goal attainment scaling (GAS) of individual daily activity related treatment goals, mobility performance as measured using the Functional Mobility Scale (FMS-5 m, 50 m and 500 m), and the parent-reported Mobility Questionnaire (MobQues). RESULTS: After power-training, 86% of children achieved or exceeded their goal, compared with 14% in the usual care period (P<.001). The probability of improvement by one point or more on the FMS-500 meter after functional power-training was 10 times higher, compared with the usual care period (Relative Risk=10.0 with 95% CI 1.4 - 71.3). No changes were found in the FMS-5m and FMS-50m categories. Improvement on the MobQues was significantly greater after power-training compared with usual care (7.9% (95% CI 2.7 - 13.0, P=.005)). The improvement in performance in the activities defined in the treatment goals continued during the follow-up period. CONCLUSIONS AND CLINICAL REHABILITATION IMPACT: The results indicated that functional power-training is an effective training to achieve personalized treatment goals for activities in daily life and parent-reported mobility performance in young children with cerebral palsy.

Measuring wearing time of knee-ankle-foot orthoses in children with cerebral palsy: comparison of parent-report and objective measurement.

Purpose state: Orthotic wearing time may be an important confounder in efficacy studies of treatment in children with spastic cerebral palsy (SCP). Most studies measure parent-reported wearing time (WTparent) with questionnaires, but it is questionable whether this yields valid results. This study aims to compare WTparent with objectively measured wearing time (WTobj) in children with SCP receiving orthotic treatment. METHOD: Eight children with SCP participated in this observational study. For one year, they received knee-ankle-foot orthosis (KAFO) treatment. WTparent was measured using questionnaires. WTobj was measured using temperature sensor-data-loggers that were attached to the KAFOs. The 2.5th and 97.5th percentiles and median of differences between methods (per participant) were used to calculate limits of agreement and systematic differences. RESULTS: There was no systematic difference between WTparent and WTobj (0.1 h per week), but high inter-individual variation of the difference was found, as reflected by large limits of agreement (lower limit/2.5th percentile: -1.7 h/week; upper limit/97.5th percentile: 11.1 h/week). CONCLUSIONS: Parent-reported wearing time (WTparent) of a KAFO differs largely from objectively measured wearing time (WTobj) using temperature sensors. Therefore, parent-reported wearing time (WTparent) of KAFOs should be interpreted with utmost care. Implications for Rehabilitation Low wearing time of orthoses may be a cause of inefficacy of orthotic treatment and incorrect reported wearing time may bias results of efficacy studies. Results of this study show that parent-reported wearing time is not in agreement with objectively measured wearing time. Parent-reported wearing time of KAFOs should be interpreted with utmost care. Objective methods are recommended for measuring orthotic wearing time.

Improved Walking Capacity and Muscle Strength After Functional Power-Training in Young Children With Cerebral Palsy.

BACKGROUND: Strength training programs for children with cerebral palsy (CP) showed inconclusive evidence for improving walking, despite improvements in strength. Recent studies have suggested that strength training with high movement velocity is more effective for improving walking than traditional resistance training. OBJECTIVE: The purpose of this study was to evaluate the effect of functional high-velocity resistance training (power-training) to improve muscle strength and walking capacity of children with CP. METHOD: Twenty-two children with spastic CP participated (13 bilateral, Gross Motor Function Classification System [GMFCS] level I [n = 10] and II [n = 12], 7.5 years [SD 1.8, range 4-10 years]). Within-subjects changes in a 14-weeks usual care period were compared with changes in a 14-week functional power-training period (in groups, 3×/wk). Outcome measures were the muscle power sprint test (MPST), 1-minute walk test (1MWT), 10-m shuttle run test (SRT), gross motor function (GMFM-66), isometric strength of lower-limb muscles and dynamic ankle plantar flexor strength. RESULTS: Changes during the training period were significantly larger than changes in the usual care period for all outcome measures ( P < .05). Large improvements were found during the training period for walking capacity (ΔMPST [mean]: 27.6 W [95%CI 15.84-39.46, 83% increase], Δ1MWT: 9.4 m [95% CI 4.17-14.68, 13%], ΔSRT: 4.2 [95%CI 2.57-5.83, 56%], ΔGMFM-66: 5.5 [95% CI 3.33-7.74, 7%]) and muscle strength (18%-128%), while outcomes remained stable in the usual care period. CONCLUSIONS: The results indicate that functional power-training is an effective training for improving walking capacity in young children with cerebral palsy.

Effectiveness of Functional Power Training on Walking Ability in Young Children With Cerebral Palsy: Study Protocol of a Double-Baseline Trial.

PURPOSE: To evaluate the effect of functional high-velocity resistance (power) training to improve walking ability of young children with cerebral palsy. METHODS: Twenty-two children with bi- or unilateral spastic cerebral palsy, Gross Motor Function Classification System levels I and II, aged 4 to 10 years will be recruited. A double-baseline design will be used to compare a 14-week functional power training (3 times a week) program with a 14-week usual care period and a 14-week follow-up period. The power exercises will be loaded and performed at 50% to 70% of the maximum unloaded speed. Load will be increased when exercises are performed faster than 70% of the unloaded speed. Primary outcomes will be sprinting capacity (15-m Muscle Power Sprint Test) and goal attainment scaling score of walking-related treatment goals. Secondary outcomes will be walking speed (1-min walk test), endurance (10-m shuttle run test), gross motor function, lower-limb strength, and parent-reported mobility.

Physical Strain: A New Perspective on Walking in Cerebral Palsy.

OBJECTIVES: To describe (1) physical strain of walking, (2) the proportion of participants walking above the anaerobic threshold, and (3) 4 phenotypes of physical strain of walking on the basis of deviations in aerobic capacity and walking energy cost (EC) in children and adolescents with cerebral palsy (CP). DESIGN: Cohort study. SETTING: Academic medical center. PARTICIPANTS: A sample (N=57) of participants (n=37; mean age, 13.5±4.0y) with CP (Gross Motor Function Classification System [GMFCS] levels I [n=13], II [n=17], and III [n=7]) and typically developing (TD) participants (n=20; mean age, 11.8±3.5y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Oxygen consumption (Vo2walk), speed, and EC were determined during walking at a comfortable speed. Peak oxygen consumption (Vo2peak) and anaerobic threshold were measured during a maximal cycling exercise test. Aerobic capacity was reduced if lower than the 10th percentile, and EC was increased if higher than 3SD. Physical strain was defined as follows: (Vo2walk/Vo2peak)×100. RESULTS: Participants with CP had a higher physical strain (GMFCS level I, 55%±12% GMFCS level II, 62%±17%; GMFCS level III, 78%±14%) than did TD participants (40%±11%) (P<.001). Forty-three percent of participants with CP showed a Vo2walk at or above their anaerobic threshold as compared with 10% of TD participants (P=.007). Phenotypes showed that a reduced Vo2peak (n=9) or an increased EC (n=9) lead to an 18% to 20% higher physical strain, whereas a combination (n=12) leads to a 40% increase. CONCLUSIONS: Children and adolescents with CP walk at a high physical strain, approximating intense exercise and a considerable proportion walks close to or above their anaerobic threshold, probably explaining fatigue and reduced walking distance. Both an increased EC and a reduced Vo2peak contribute to high physical strain in children or adolescents with CP. The different causes of high physical strain in individuals with CP require different intervention strategies.

Energy cost during walking in association with age and body height in children and young adults with cerebral palsy.

AIM: This cross-sectional study into children and young adults with cerebral palsy (CP) aimed to assess the association of gross energy cost (EC), net EC and net nondimensional (NN) EC during walking with age and body height, compared to typically developing (TD) peers. METHOD: Data was collected in 128 participants with CP (mean age 11y9mo; GMFCS I,n=48; II,n=56; III, n=24) and in 63 TD peers (mean age 12y5mo). Energy cost was assessed by measuring the oxygen consumption during over-ground walking at comfortable speed. Outcome measures derived from the assessment included the gross and net EC, and NN EC. Differences between the groups in the association between gross, net and NN EC with age and body height, were investigated with regression analyses and interaction effects (p<0.05). RESULTS: Interaction effects for age and body height by group were not significant, indicating similar associations for gross, net and NN EC with age or body height among groups. The models showed a significant decline for gross, net and NN EC with increasing age per year (respectively -0.201Jkg-1m-1; -0.073Jkg-1m-1; -0.007) and body height per cm (respectively -0.057Jkg-1m-1; -0.021Jkg-1m-1; -0.002). INTERPRETATION: Despite higher gross and net EC values for CP compared to TD participants , similar declines in EC outcomes can be expected with growth for participants aged 4-22 years with CP. All energy cost outcomes showed a decline with growth, indicating that correcting for this decline is required when evaluating changes in gross EC, and, to a lesser extent, in net and NN EC in response to treatment or from natural course over time.

Isometric muscle strength and mobility capacity in children with cerebral palsy.

PURPOSE: To determine the relationship between isometric leg muscle strength and mobility capacity in children with cerebral palsy (CP) compared to typically developing (TD) peers. METHOD: Participants were 62 children with CP (6-13 years), able to walk with (n = 10) or without (n = 52) walking aids, and 47 TD children. Isometric muscle strength of five muscle groups of the leg was measured using hand-held dynamometry. Mobility capacity was assessed with the 1-min walk, the 10-m walk, sit-to-stand, lateral-step-up and timed-stair tests. RESULTS: Isometric strength of children with CP was reduced to 36-82% of TD. When adjusted for age and height, the percentage of variance in mobility capacity that was explained by isometric strength of the leg muscles was 21-24% (walking speed), 25% (sit-to-stand), 28% (lateral-step-up) and 35% (timed-stair) in children with CP. Hip abductors and knee flexors had the largest contribution to the explained variance, while knee extensors showed the weakest correlation. Weak or no associations were found between strength and mobility capacity in TD children. CONCLUSION: Isometric strength, especially hip abductor and knee flexor strength, is moderately related to mobility capacity in children with CP, but not in TD children. To what extent training of these muscle groups will lead to better mobility capacity needs further study. Implications for Rehabilitation Strength training in children with cerebral palsy (CP) may be targeted more specifically at hip abductors and knee flexors. The moderate associations imply that large improvements in mobility capacity may not be expected when strength increases.

Reliability and Construct Validity of the 6-Minute Racerunner Test in Children and Youth with Cerebral Palsy, GMFCS Levels III and IV.

AIM: To determine the test-retest reliability and construct validity of a novel 6-Minute Racerunner Test (6MRT) in children and youth with cerebral palsy (CP) classified as Gross Motor Function Classification System (GMFCS) levels III and IV. The racerunner is a step-propelled tricycle. METHODS: The participants were 38 children and youth with CP (mean age 11 y 2 m, SD 3 y 7 m; GMFCS III, n = 19; IV, n = 19). Racerunner capability was determined as the distance covered during the 6MRT on three occasions. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), and smallest detectable differences (SDD) were calculated to assess test-retest reliability. RESULTS: The ICC for tests 2 and 3 were 0.89 (SDD 37%; 147 m) for children in level III and 0.91 for children in level IV (SDD 52%; 118 m). When the average of two separate test occasions was used, the SDDs were reduced to 26% (104 m; level III) and 37% (118 m; level IV). For tests 1 to 3, the mean distance covered increased from 345 m (SD 148 m) to 413 m (SD 137 m) for children in level III, and from 193 m (SD 100 m) to 239 m (SD 148 m) for children in level IV. CONCLUSIONS: Results suggest high test-retest reliability. However, large SDDs indicate that a single 6MRT measurement is only useful for individual evaluation when large improvements are expected, or when taking the average of two tests. The 6MRT discriminated the distance covered between children and youth in levels III and IV, supporting construct validity.