Comparison of Habitual Physical Activity and Sedentary Behavior in Adolescents and Young Adults With and Without Cerebral Palsy.

PURPOSE: The comparison of habitual physical activity and sedentary time in teenagers and young adults with cerebral palsy (CP) with typically developed (TD) peers can serve to quantify activity shortcomings. METHODS: Patterns of sedentary, upright, standing, and walking components of habitual physical activity were compared in age-matched (16.8 y) groups of 54 youths with bilateral spastic CP (38 who walk with limitations and 16 who require mobility devices) and 41 TD youths in the Middle East. Activity and sedentary behavior were measured over 96 hours by activPAL3 physical activity monitors. RESULTS: Participants with CP spent more time sedentary (8%) and sitting (37%) and less time standing (20%) and walking (40%) than TD (all Ps < .01). These trends were enhanced in the participants with CP requiring mobility devices. Shorter sedentary events (those <60-min duration) were similar for TD and CP groups, but CP had significantly more long sedentary events (>2 h) and significantly fewer upright events (taking <30, 30-60, and >60 min) and less total upright time than TD. CONCLUSION: Ambulant participants with CP, as well as TD youth must be encouraged to take more breaks from being sedentary and include more frequent and longer upright events.

Effects of Exercise Interventions on Habitual Physical Activity and Sedentary Behavior in Adolescents With Cerebral Palsy.

PURPOSE: Exercise interventions have been shown to increase motor capacities in adolescents with cerebral palsy; however, how they affect habitual physical activity (HPA) and sedentary behavior is unclear. The main objective was to correlate changes in HPA with changes in mobility capacity following exercise interventions. METHODS: A total of 54 participants (aged 12-20 y) with bilateral spastic cerebral palsy at Gross Motor Function Classification System (GMFCS) levels II and III received 4 months of group progressive resistance training or treadmill training. Mobility measurements and HPA (averaged over 96 h) were made before and after interventions. RESULTS: Averaged baseline mobility and HPA measures and improvements in each after both interventions were positively correlated in all participants. Percentage of sedentary/awake time decreased 2%, with significant increases in HPA measures of step count (16%), walk time (14%), and upright time (9%). Mobility measures and HPA changes were quite similar between Gross Motor Function Classification System levels, but improvement in HPA after group progressive resistance training was greater than after treadmill training (12% vs 4%) and correlated with mobility improvement. CONCLUSIONS: Mobility capacity improved after these interventions and was clearly associated with improved HPA. The group progressive resistance training intervention seems preferable to improve HPA, perhaps related to greater social interaction and motivation provided by group training.

Duration and patterns of habitual physical activity in adolescents and young adults with cerebral palsy.

AIM: Adolescents and young adults with cerebral palsy (CP) show reduced motor function and gait efficiency, and lower levels of habitual physical activity (HPA), than adolescents with typical development and children with CP. This study examined activity duration and patterns in this population in the Middle East through long-term monitoring of a large sample using accelerometers. METHOD: Adolescents and young adults with bilateral CP at Gross Motor Function Classification System (GMFCS) levels II, III, and IV, were monitored in their habitual environment for four consecutive days with ActivPAL3 monitors. Time spent in sedentary, standing, and walking activities, and frequency of walking steps and transitions, were analysed for each GMFCS level. RESULTS: Measurements were made on 222 participants (132 males, 90 females; mean age 16 y 9 mo SD 2y, range 13 y 4 mo-22 y). The Mann-Whitney U test demonstrated significant differences (p<0.05) between GMFCS levels, showing reduced walking and standing activity and increased sedentary duration at higher GMFCS levels (p<0.001), except for increased standing time between GMFCS levels II and III (p=0.07). Participants in educational facilities exhibited less sedentary behaviour than those who were homebound (p<0.05). INTERPRETATION: These descriptions of duration and frequency of active and sedentary behaviours may serve as a basis for recommendations to minimize inactivity in this population. Adolescents and young adults with CP in the Middle East demonstrate similar patterns of HPA to their peers in other regions.

Individualized treadmill and strength training for chronic stroke rehabilitation: effects of imbalance.

BACKGROUND AND PURPOSE: Stroke survivors often have significant walking limitations and are at high risk for falling. Treadmill training, as a rehabilitation approach in stroke survivors, and its relationship to balance ability has not been widely studied. The main goal of this study was to investigate the effectiveness of an individualized treadmill-strength training protocol on functional outcomes in chronic stroke survivors. METHODS: Thirty adult participants with chronic stroke were recruited from 1 European and 4 Middle Eastern countries. Each completed 36 sessions of treadmill-strength training. The rehabilitation protocol was individualized according to each patient's cardiovascular fitness. Ten-meter walk test (10MWT), Berg Balance Scale (BBS), and 6-minute walk test (6MWT) were measured before (T0) and after training (T1) and 6 months later (T2). Paired t tests were used to test differences with training (T1 - T0) and retention after training (T2 - T1). RESULTS: Increases in all 3 measures from T0 to T1 were significant. There were no changes in 10MWT and BBS from T1 to T2, but 6MWT tended to increase. Separate analyses for subjects with BBS scores <41 at T0 demonstrated comparatively greater improvements from T0 to T1 than in those with BBS scores ≯40. Those with low scores also significantly increased from T1 to T2 in both walk tests. DISCUSSION: These findings suggest that a protocol combining treadmill with strength training has beneficial long-term effects on functional walking measures after chronic stroke, especially in patients who initially have low balance ability.

Perceived barriers and facilitators for increasing the physical activity of adolescents and young adults with cerebral palsy: a focus group study.

PURPOSE: Identifying the factors impacting physical activity (PA) among adolescents and young adults with cerebral palsy (CP). METHODS: Four focus groups were conducted, with a total of 22 participants with CP, aged 14-24 years, Gross Motor Function Classification (GMFCS) I-III. Our qualitative analysis drew on grounded theory and used Atlas software. RESULTS: Findings revealed four categories of factors impacting PA: (1) Musculoskeletal-pain and additional impairments related to activity limitations; (2) knowledge and exercising skills, and life skills such as problem-solving, decision-making, planning and organizing; (3) availability: lack of transportation, professional guidance, adapted and community-based programs, especially enjoyable activities; (4) social support from professionals (mainly physiotherapists) and peer support with socializing opportunities. Many opposed parental involvement. Those who attended special education schools and had moderate to severe learning disabilities saw PA as an opportunity for social contacts, limited by lack of availability. Those in mainstream schools with mild to no learning disabilities used PA for relieving pain and preserving function, limited by difficulty balancing PA and life goals. CONCLUSIONS: Service providers should inculcate knowledge and active-living skills during the transition to adulthood. Professional guidance needed to ensure inclusion in communal PA and offer adapted programs for young people with CP.IMPLICATIONS FOR REHABILITATIONThere is a need for ongoing, accessible, adapted, community-based physical activity programs for young adults with CP guided by skilled professionals that can provide them with opportunities for enjoyable activities involving social interactions.When planning treatment interventions for children and young individuals with CP, healthcare providers should be aware of past therapeutic experiences and in collaboration with parents, are encouraged to be sensitive to possible tensions which may exist regarding their body care.Healthcare and educational professionals should provide young people with CP and their families with theoretical and practical knowledge about physical activity and its health benefits, as well as information about exercise options.Developing life skills in young adults with CP is important for helping them to effectively engage in physical activity and develop the competencies needed to achieve long term physical care.

Effectiveness of motor learning coaching in children with cerebral palsy: a randomized controlled trial.

OBJECTIVE: To evaluate effectiveness of motor learning coaching on retention and transfer of gross motor function in children with cerebral palsy. DESIGN: Block randomized trial, matched for age and gross motor function. SETTING: Coordinated, multinational study (Israel, Jordan and Palestinian Authority) in schools and rehabilitation centers. SUBJECTS: 78 children with spastic cerebral palsy, gross motor functional levels II and III, aged 66 to 146 months. INTERVENTIONS: 1 hr/day, 3 days/week for 3 months treatment with motor learning coaching or neurodevelopmental treatment: two groups. MAIN MEASURES: Gross motor function Measure (GMFM-66), stair-climbing mechanical efficiency (ME) and parent questionnaire rating their child's mobility. Immediate treatment effects were assessed after 3 months and retention determined from follow-up measurements 6 months after treatment. RESULTS: GMFM-66, ME and parent questionnaires were obtained from 65, 31 and 64 subjects, respectively. Although both groups increased GMFM-66 score over 3 months, measurements 6 months later indicated retention was significantly superior by 2.7 in the motor learning coaching children of level-II. Similar retention trend was evident for ME, increasing 6 months after motor learning coaching by 1.1% and declining 0.3% after neurodevelopmental treatment. Mobility performance in the outdoors and community environment increased 13% from 3 to 9 months after motor learning coaching and decreased 12% after neurodevelopmental treatment. Minor group differences occurred in children of level-III. CONCLUSIONS: In higher functioning children with cerebral palsy, the motor learning coaching treatment resulted in significantly greater retention of gross motor function and transfer of mobility performance to unstructured environments than neurodevelopmental treatment.

The effects of femoral derotation osteotomy in children with cerebral palsy: an evaluation using energy cost and functional mobility.

BACKGROUND: The effect of femoral derotation osteotomy (FDO) in children with cerebral palsy (CP) has hitherto been examined using various outcome measures including range of motion of lower extremity joints and gait parameters. However, functional ambulation following this procedure has been scarcely investigated. OBJECTIVE: To evaluate the effect of FDO on energy cost during stair climbing and functional mobility in children with CP. METHOD: A prospective case series study was conducted on 18 children with CP, 11 at Gross Motor Functional Classification System (GMFCS) II and 7 with GMFCS III, aged 8.5 +/- 1.24 years (range, 6.9-11 years) who underwent FDO to correct hip internal rotation. The energy cost was measured using the heart beat cost index (HBCI) during stair climbing test, whereas functional mobility was assessed using the Gillette Functional Assessment Questionnaire (FAQ). Tests were administered before surgery (P0), 6 months (P1), and at approximately a year postoperatively (P2). RESULTS: Compared with P0, significant changes in hip rotation were observed at P1 and P2. There was a significant improvement in HBCI from P0 to P2, whereas FAQ improved significantly from P1 to P2. A moderate correlation was found between HBCI and GMFCS at all times (r = 0.61-0.78). Negative correlations were found between the HBCI and FAQ and between GMFCS and FAQ at all times (r = -0.5). CONCLUSION: This study indicates that children with CP may benefit functionally from FDO as judged by HBCI and functional mobility rating.

Repeatability of net mechanical efficiency during stair climbing in children with cerebral palsy.

PURPOSE: To determine the smallest significant change in mechanical efficiency (MEnet) measured by a stair-climbing test. METHODS: Duplicate stair-climbing tests (T1 and T2), with more than a 30-minute rest between, were performed by 51 children with diplegic cerebral palsy (CP) at levels II and III of Gross Motor Function Classification System (GMFCS) and 9 children with typical development, aged 5.5 to 13.0 years. RESULTS: The T2 versus T1 slope values of MEnet for CP and typical development did not significantly differ from 1.00. MEnet was significantly higher for GMFCS level II (7.0%) than level III (1.2%). The mean percentage of difference was 7.8% (T2 > T1) for the children with CP, with a 95% confidence interval of -39% to +54%. The 95% confidence interval for MEnet scores computed from the standard error of the mean (SEM) of the percentage of differences was 4.0 to 4.5 for CP. CONCLUSIONS: An increase of >13.4% in MEnet score (eg, mean increase from 4.0% to 4.5%) can indicate improved motor status resulting from interventions.

Prediction of mechanical efficiency from heart rate during stair-climbing in children with cerebral palsy.

Measuring mechanical efficiency (ME) is potentially useful to assess motor performance in individuals with physical disabilities. The purpose of this study was to determine the accuracy of predicting ME from heart rate (HR) during a self-paced stair-climbing test in children with a range of motor abilities. The participants were 12 normally developed children (ND) and 24 with cerebral palsy (CP), ranging in age from 5 to 15 years (mean: 8 years). Five were at level II, 11 at level III and 8 at level IV according to the gross motor function classification system. ME was calculated as the ratio of external work to O(2) uptake (VO(2) ml/min) measured or predicted from HR. The absolute values of VO(2) and HR during stair-climbing were not significantly correlated. However, the correlation between values above resting (dVO(2) and dHR) was significant (r=0.61). Furthermore, when including body weight as a second variable the prediction of dVO(2) was significantly improved (r=0.85). This resulted in a high correlation (r=0.96) between measured and predicted net ME (ME(net)). Predicted ME(net) for 25 stair-climbing tests repeated after an average of 6 months resulted in an r-value of 0.92 with predicted ME(net) of the first test. This study demonstrates that ME(net) during stair-climbing can be predicted in children with a broad range of motor abilities from dHR and may be a simple tool to help define developmental stages or evaluating intervention efficacy.

Effects of a group circuit progressive resistance training program compared with a treadmill training program for adolescents with cerebral palsy.

OBJECTIVE: To determine whether goal-directed group circuit progressive resistance exercise training (GT) can improve motor function in adolescents with cerebral palsy (CP) and to compare outcomes with a treadmill training (TT) intervention. METHODS: In a multi-centered matched pairs study, 95 adolescents with spastic CP (GMFCS II-III) were allocated to GT or TT interventions for 30 bi-weekly one hour training. Outcome measures of GMFM-66, GMFM-D%, GMFM-E%, TUG, 10 meter walk test (10 MWT), and 6 minute walk test (6 MWT) were made at baseline (T1), after interventions (T2) and 6 months post training (T3). RESULTS: Both training programs induced significant improvement in all outcome measures (T2-T1) that were mostly retained at T3. At the end of the intervention, the GT group showed an advantage in all measured changes compared to the TT group and in percentage changes. Differences were significant (p < 0.02) for GMFM-66, GMFM-D%, GMFM-E% and TUG. The advantage trend for the GT group was less apparent at follow up (T3-T1). CONCLUSION: Both programs were effective in improving motor function in adolescents with cerebral palsy. The GT program had generally greater benefits based on the functional measures.

A stair-climbing test for measuring mechanical efficiency of ambulation in adults with chronic stroke.

PURPOSE: Mechanical efficiency can assess motor performance in individuals with physical disabilities. The purpose was to determine the utility of predicting it from heart rate (HR) during a self-paced stair-climbing test in adults with chronic hemiparesis after stroke and to determine the minimal detectable change of net mechanical efficiency (MEnet) measured by this exercise. METHODS: First, 15 subjects with chronic hemiparesis participated in a validation study (A) and then 28 took part in a repeatability study (B). In study A the MEnet was calculated from external work and oxygen uptake above rest (dVO2), as directly measured and as predicted from body weight and increase in heart rate (dHR). In study B, predicted dVO2 was used to obtain MEnet for duplicate stair-climbing tests (T1, T2) with >30 min rest between. RESULTS: Measured MEnet was closely related to predicted MEnet (r = 0.97, p < 0.001). In study B predicted MEnet for T2 and T1 were closely related (r = 0.91, ICC = 0.90). CONCLUSION: With a minimal detectable change of 0.6% (0.053 of average MEnet score of 10.4%), MEnet values from the stair-climbing test seem sufficiently meaningful to estimate ambulatory ability and its changes with interventions or walking aids in adults with hemiparesis. IMPLICATIONS FOR REHABILITATION: Ambulatory ability can be estimated from mechanical efficiency, obtained from a 5-min stair-climbing test utilizing a 4-step stair, to measure external work, and the change in heart rate above rest to estimate the metabolic cost of the task. A change of > 0.6% in mechanical efficiency by this stair-climbing test indicates a significant change in ambulatory ability of persons with hemiparesis.

A stair-climbing test for ambulatory assessment of children with cerebral palsy.

The purpose of this study was to develop a stair-climbing test to measure energy cost (EC) and mechanical efficiency (ME) in children with cerebral palsy (CP) to evaluate ambulation-related motor function and its changes after intervention or maturation. Five normally developed (ND) and 10 children with CP were tested. The gross ME (MEg) was calculated from the work done (W) and the total energy cost (oxygen consumption) measured while repeatedly ascending and descending four steps for approximately 5 min without subtracting the resting metabolic rate. The MEg was significantly lower in CP than ND (3% versus 20%, P < 0.001). The test was repeated in the 10 children with CP after a 4-month therapy recess. The MEg values correlated with the initial tests, with a small, significant increase of 2%. When calculating net ME (MEn) from W and the energy cost above resting, the correlation of MEn values before and after therapy was inferior to that using MEg values. Similarly, individual ME values obtained by estimating energy cost from the increase in heart rate (HR) during stair-climbing also correlated poorly, with large variability. These results show that MEg may be used to evaluate changes in motor function resulting from age-related development or therapy. MEg is as good or superior to MEn; the extra time required to obtain resting energy cost and heart rate values is not necessary when measurements are desired within the same individual.

Changes over years in gross motor function of 3-8 year old children with cerebral palsy: using the Gross Motor Function Measure (GMFM-88).

BACKGROUND: In the developing child the nervous system undergoes a maturation process. The development and organization of any motor ability is the naturally adopted preference among the possibilities and constraints. The motor behavior of children with cerebral palsy is a personal automatic preference based on such constraints. One of the clinical measures designed for measuring the function of children with CP is the Gross Motor Function Measure. Motor development curves for children with CP have been established based on the GMFM instrument and Gross Motor Function Classification System. OBJECTIVES: To examine the change over time in gross motor function for children with CP attending a special education school for handicapped children in Israel. METHOD: We conducted a retrospective review of the medical records of children at various ages and with varying degrees of severity who were being treated by a multidisciplinary team. The study population comprised 106 children aged 3-8 years with CP who were attending the school of special education at Assaf Harofeh Medical Center. The GMFM-88 test was performed annually for the study children over a 7 year period (1995-2001). RESULTS: During the study period the GMFM scores improved significantly. The rate of improvement and top achievements over the years differed according to the severity of the motor impairment. The gross motor development reached a plateau at the age of 6-7 years. CONCLUSIONS: The changes in gross motor development of the study population were similar to the profile of changes in the developmental process of children who develop normally. The nature of the curves of gross motor change for the children with CP should be borne in mind when designing individual treatment goals and strategies for a child.

Training to walk amid uncertainty with Re-Step: measurements and changes with perturbation training for hemiparesis and cerebral palsy.

PURPOSE: To describe Re-Step™, a novel mechatronic shoe system that measures center of pressure (COP) gait parameters and complexity of COP dispersion while walking, and to demonstrate these measurements in healthy controls and individuals with hemiparesis and cerebral palsy (CP) before and after perturbation training. METHOD: The Re-Step™ was used to induce programmed chaotic perturbations to the feet while walking for 30 min for 36 sessions over 12-weeks of training in two subjects with hemiparesis and two with CP. RESULTS: Baseline measurements of complexity indices (fractal dimension and approximate entropy) tended to be higher in controls than in those with disabilities, while COP variability, mean and variability of step time and COP dispersion were lower. After training the disabled subjects these measurement values tended toward those of the controls, along with a decrease in step time, 10 m walk time, average step time, percentage of double support and increased Berg balance score. CONCLUSIONS: This pilot trial reveals the feasibility and applicability of this unique measurement and perturbation system for evaluating functional disabilities and changes with interventions to improve walking. Implication for Rehabilitation Walking, of individuals with cerebral palsy and hemiparesis following stroke, can be viewed in terms of a rigid motor behavior that prevents adaptation to changing environmental conditions. Re-Step system (a) measures and records linear and non-linear gait parameters during free walking to provide a detailed evaluation of walking disabilities, (b) is an intervention training modality that applies unexpected perturbations during walking. This perturbation intervention may improve gait and motor functions of individuals with hemiparesis and cerebral plasy.

Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy.

This study compared the efficacy of Adeli suit treatment (AST) with neurodevelopmental treatment (NDT) in children with cerebral palsy (CP). Twenty-four children with CP, Levels II to IV according to the Gross Motor Function Classification System (GMFCS), were matched by age and functional status and randomly assigned to the AST or NDT treatment groups. In the AST group (n=12; eight males, four females; mean age 8.3 y [SD 2.0]), six children had spastic/ataxic diplegia, one triplegia and five spastic/mixed quadriplegia. In the NDT group (n=12; nine males, three females; mean age 8.1 y [SD 2.2]), five children had spastic diplegia and seven had spastic/mixed quadriplegia. Both groups were treated for 4 weeks (2 hours daily, 5 days per week, 20 sessions). To compare treatments, the Gross Motor Function Measure (GMFM-66) and the mechanical efficiency index (EIHB) during stair-climbing were measured at baseline, immediately after 1 month of treatment, and 10 months after baseline. The small but significant time effects for GMFM-66 and EIHB that were noted after 1 month of both intensive physiotherapy courses were greater than expected from natural maturation of children with CP at this age. Improvements in motor skills and their retention 9 months after treatment were not significantly different between the two treatment modes. Post hoc analysis indicated a greater increase in EIHB after 1 month (p=0.16) and 10 months (p=0.004) in AST than that in NDT, predominantly in the children with higher motor function (GMFCS Levels II and III). The results suggest that AST might improve mechanical efficiency without a corresponding gain in gross motor skills, especially in children with higher levels of motor function.