Effects of forward tilted seating and foot-support on postural adjustments in children with spastic cerebral palsy: An EMG-study

ObjectiveTo evaluate the effect of 15° forward (FW) seat inclination and foot-support in children with cerebral palsy (CP) on postural adjustments during reaching.DesignObservational study repeated-measures design; step two of two-step-project.SettingLaboratory unit within University Hospital and two special education schools.Participants19 children (ten unilateral spastic CP (US-CP); nine bilateral spastic CP (BS-CP); Gross Motor Function Classification System levels I-III; 6–12 years old). Participants were able to take part for one one-hour session.InterventionReaching while sitting in four seating conditions (FW or horizontal seat; with or without foot-support) applied in randomized order.Outcome measuresSimultaneously, surface electromyography (EMG) of neck, trunk and arm muscles and kinematics of head and reaching arm (step one of two-step-project) were recorded. Primary outcome parameters were the ability to modulate EMG-amplitudes at baseline and during reaching (phasic muscle activity). Other EMG-parameters were direction-specificity (1st control level), and 2nd level of control parameters: recruitment order, and anticipatory postural activity. Motor behaviour measures: ability to modulate EMG-amplitudes to kinematic characteristics of reaching and head stability.ResultsOnly foot-support was associated with increased tonic background EMG-amplitudes and decreased phasic EMG-amplitudes of the trunk extensors in children with US-CP and BS-CP (mixed-models analyses; p-values <0.01). The foot-support effect was also associated with better kinematics of reaching (Spearman's Rho; p-values <0.01).ConclusionIn terms of postural adjustments during forward reaching, foot-support enhanced the children's capacity to modulate trunk extensor activity, which was associated with improved reaching quality. FW-tilting did not affect postural muscle activity.     

Where children sit in motor vehicles: a comparison of selected European and American cities

Objectives—To ascertain whether there are differences in child seating location between selected cities in the US and continental Europe, and if differences exist, to ascertain what factors predict them.

Setting—Boston and New Orleans, which have no laws regarding child seating location, and Paris, Frankfurt, and Brussels, which for approximately 20 years have had laws requiring children under the ages of 10 or 12 to sit in the rear.

Methods—Observations were made in the first quarter of 1997 at several locations in or near each city. The vehicle seating capacity, total number of occupants, the seating location of adults and children, and driver shoulder belt use were recorded for each vehicle with at least one child. The predictors of a vehicle having a child in the front were estimated using logistic regression.

Results—Data on 5501 children riding in 3778 vehicles were collected. Adjusting for differences in vehicle seating capacity, occupant mix, and driver shoulder belt use, vehicles in the European cities are significantly less likely to have a child in the front seat than vehicles in the American cities.

Conclusions—Cities with no history of laws prohibiting children from sitting in the front, vehicles with low seating capacity, vehicles with no adult (other than the driver) or many child passengers, and unbelted drivers were associated with a higher likelihood of children riding in the front seat. It is feasible for a society to insist, through custom and/or law, that children sit in the back seat.

     

Community-Based Upper Extremity Power Training for Youth with Cerebral Palsy: A Pilot Study

Abstract

Aim: To examine the effects of an upper-extremity, community-based, and power-training intervention.

Methods: Twelve participants with cerebral palsy (CP) [8 males, 4 females; mean age 14 years 6 months (SD 5 years 4 months), range 7–24] were randomly assigned to a rest-training (RT; n?=?6) or training-rest (n?=?6) group in this randomized, cross-over design. Training took place in participants’ home or school, three times per week for 6?weeks. We examined changes in upper extremity average power output (Pavg) in watts (W) and changes in function via the Pediatric Outcomes Data Collection Instrument (PODCI).

Results: Each participant completed at least 15 of the 18 total training sessions (91.2% adherence). Pavg increased 92.2% on average among participants (p < .05). There was a significant three-way interaction among treatment, sequence, and period with the data stratified by (Bimanual Fine Motor Function [BFMF]) level on the pain subscale of the PODCI (p?=?0.0118). All participants decreased pain after training with the exception of individuals with lower functioning (BFMF II-V) in the RT group.

Conclusion: A community-based upper extremity power-training intervention was feasible and effective at improving power among young people with CP and has the potential to improve pain.     

Therapeutic Effects of Horseback Riding Therapy on Gross Motor Function in Children with Cerebral Palsy: A Systematic Review

ABSTRACT

Purpose: This systematic review examined the efficacy of hippotherapy or therapeutic horseback riding (THR) on motor outcomes in children with cerebral palsy (CP). Methods: Databases were searched for clinical trials of hippotherapy or THR for children with CP. Results: Nine articles were included in this review. Although the current level of evidence is weak, our synthesis found that children with spastic CP, Gross Motor Function Classification System (GMFCS) levels I–III, aged 4 years and above are likely to have significant improvements on gross motor function as a result of hippotherapy and THR. Evidence indicates that 45-min sessions, once weekly for 8–10 weeks, result in significant effects. Conclusions: The current literature on hippotherapy and THR is limited. Large randomized controlled trials using specified protocols are needed to more conclusively determine the effects on children with CP. From the current evidence, it appears that hippotherapy and THR have positive effects on gross motor function in children with CP.     

Exploring Issues of Participation Among Adolescents with Cerebral Palsy: What's Important to Them?

ABSTRACT

The purpose of this cross-sectional study was to determine what participation issues are important to adolescents with cerebral palsy (CP). Two hundred and three adolescents with CP (mean age 16.0 ± 1.8 years) were assessed using the Canadian Occupational Performance Measure (COPM). This was done through semistructured interviews by trained physical and occupational therapists. Adolescents responded either directly (n = 144) or through a parent or a caregiver (n = 59) if they were unable to communicate. Issues were extracted from completed questionnaires and coded under three COPM categories (self-care, productivity, and leisure) and 16 subcategories. There was no association between the total number of issues identified and gender (p = .99), age (p = .88), type of respondent (adolescents versus parent) (p = .27), Gross Motor Function Classification System (GMFCS) level (p = .93), or 66-item Gross Motor Function Measure (GMFM-66) score (p = .45). The issues identified most frequently were related to active leisure (identified by 57% of participants), mobility (55%), school (48%), and socialization (44%). Interventions aimed at improving participation among adolescents with physical disabilities, such as CP, should be directed towards these four key areas. Health care professionals should also recognize and consider the interaction of person and environment when addressing issues related to participation.     

Effects of Aquatic Intervention on Gross Motor Skills in Children with Cerebral Palsy: A Systematic Review

Aims: To review the literature on the effects of aquatic intervention on gross motor skills for children with cerebral palsy (CP). Data sources: Six databases were searched from inception to January 2016. Review methods: Aquatic studies for children aged 1–21 years with any type or CP classification and at least one outcome measuring gross motor skills were included. Information was extracted on study design, outcomes, and aquatic program type, frequency, duration, and intensity. Quality was rated using the Centre of Evidence-Based Medicine: Levels of Evidence and the PEDro scale. Results: Of the 11 studies which met inclusion criteria, only two used randomized control trial design, and the results were mixed. Quality of evidence was rated as moderate to high for only one study. Most studies used quasi-experimental designs and reported improvements in gross motor skills for within group analyses after aquatic programs were held for two to three times per week and lasting for 6–16 weeks. Participants were classified according to the Gross Motor Function Classification System (GMFCS) levels I–V, and were aged 3–21 years. Mild to no adverse reactions were reported. Conclusions: Evidence on aquatic interventions for ambulatory children with CP is limited. Aquatic exercise is feasible and adverse effects are minimal; however, dosing parameters are unclear. Further research is needed to determine aquatic intervention effectiveness and exercise dosing across age categories and GMFCS levels.     

The Relationship Between Manual Ability and Ambulation in Adolescents with Cerebral Palsy

ABSTRACT

This study examined the relationship between gross motor function and manual ability in 120 adolescents with cerebral palsy (CP) (15.2, SD 2.1 years, 59.8% male). Adolescents were evaluated using the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS). A neurologist classified CP subtype. Most adolescents were ambulatory with or without utilization of aids (GMFCS level I: 35.0%, II: 30.0%, III: 5.8%, IV: 10.8%, and V: 18.3%). MACS levels were I: 34.2%, II: 25.8%, III: 16.7%, IV: 7.5%, and V: 15.8%. Correlations between GMFCS and MACS were strong in youth with quadriplegia (r = .89, p < .001), moderate in individuals with diplegia (r = .58, p = .01), but weakly associated for adolescents with hemiplegia (r = .24, p = .23). The findings provide evidence for maintaining a clinical distinction between spastic quadriplegia and spastic diplegia. Manual ability may not be congruent with mobility in adolescents with CP and should be specifically evaluated given its importance to daily life functioning.     

Motor Training and Physical Activity Among Preschoolers with Cerebral Palsy: A Survey of Parents’ Experiences

ABSTRACT

Objective: To describe motor training and physical activity among preschoolers with cerebral palsy (CP) in Norway, and assess associations between child, parent, and motor intervention characteristics, and parent-reported child benefits from interventions. Method: Survey of 360 parents and data from the Norwegian CP follow-up program. The response rate was 34%. Results: During the six months preceding the time of the survey, 75% of the children performed gross-motor training, 73% fine-motor training, 80% manual stretching, and 67% participated regularly in physical activities. The training was highly goal-directed, intensive, frequently incorporated in daily routines, and often with a high level of parental involvement. The use of goals was associated with higher parent-reported child benefits for all types of interventions. Moreover, the positive relationship, which was indicated between frequency of training, parent education, and parent-reported child benefits of gross-motor training, was not seen for fine-motor training. Conclusion: Parent-reported child benefits support goal-directed motor interventions, and the use of everyday activities to increase practice of motor skills.     

Six Years After a Modified Constraint Induced Movement Therapy (CIMT) Program—What Happens When the Children Have Become Young Adults?

ABSTRACT

The aim is to describe the development of hand function in young adults with unilateral cerebral palsy (CP), who participated in a 2-week Constraint Induced Movement Therapy (CIMT) camp 6 years earlier. Eleven participants, 16–21 years at follow-up, were assessed at three occasions during 2005 and once in 2011. At the 6-year follow-up, performance on the Assisting Hand Assessment and the Jebsen-Taylor Hand Function test remained unchanged (P > 0.05) from the first assessment before the camp. Grip strength (Grippit®) increased in both the involved (+80.9%) and non-involved hand (+94.4%) (P < 0.05), while performance on the Melbourne Assessment tended to decrease (?7%). In conclusion, it seems that young adults with unilateral CP maintain their hand function performance at the same level as in the early adolescent period. Interestingly, the grip strength increased over time also for the involved hand.     

Evaluation of the Reliability of the Challenge when used to Measure Advanced Motor Skills of Children with Cerebral Palsy

Aims: The Challenge was designed as an extension to the GMFM-66 to assess advanced motor skills of children with cerebral palsy (CP) who walk/run independently. This study evaluated the Challenge's inter-rater and test–retest reliability. Methods: Thirty children with CP (GMFCS level I [n = 24] and II [n = 6]) completed the Challenge, with re-testing one to two weeks later. Seven physiotherapist assessors passed the Challenge criterion test pre-administration. A single assessor administered and scored test and retest sessions (test–retest reliability). A second assessor independently scored one of these sessions (inter-rater reliability). Results: Inter-rater reliability was excellent (ICC = 0.97, 95%CI 0.94–0.99, CoV < 10%), with no bias (Bland-Altman plot). Test–retest ICC was excellent (ICC = 0.94, 95% CI 0.88–0.97. CoV < 10%, and Minimum Detectable Change (MDC₉₀) was 4.47 points. Many participants indicated practising at home pre-retest session. Conclusions: There was strong rating consistency between assessors. While test–retest ICC estimates were also high, Challenge scores were higher at retest. The MDC₉₀ was still in a range (>4.5 points) that seems clinically viable for change detection. Test–retest reliability could be reassessed with children instructed not to practice between assessments to determine the extent to which between-session practice influenced scores.     

Effects of Strength Training Aided by Electrical Stimulation on Wrist Muscle Characteristics and Hand Function of Children with Hemiplegic Cerebral Palsy

Nine children with spastic hemiplegic cerebral palsy underwent 24 sessions of wrist muscles strengthening in the extended wrist range aided by electrostimulation. Isometric strength of flexors and extensors was registered in three wrist positions (30° of flexion, neutral, and 30° of extension) to infer on angle–torque curves. Passive stiffness of wrist flexors and wrist flexion angle during manual tasks and hand function were also documented. Significant strength gains were observed at 30° of wrist extension for flexors (p = 0.029) and extensors (p = 0.024). No gains were observed at 30° of flexion. The difference in extensor strength between the three test positions changed after intervention (p < 0.034), suggesting a shift in the angle–torque curve. No changes were observed in passive stiffness (p = 0.506), wrist angle (p < 0.586), or hand function (p = 0.525). Strength training in specific joint ranges may alter angle–torque relationships. For functional gains to be observed, however, a more aggressive intervention and contextualized task training would probably be needed.     

Reproducibility of Tactile Assessments for Children with Unilateral Cerebral Palsy

ABSTRACT

A systematic review identified tactile assessments used in children with cerebral palsy (CP), but their reproducibility is unknown. Sixteen children with unilateral CP and 31 typically developing children (TDC) were assessed 2–4 weeks apart. Test–retest percent agreements within one point for children with unilateral CP (and TDC) were Semmes-Weinstein monofilaments: 75% (90%); single-point localization: 69% (97%); static two-point discrimination: 93% (97%); and moving two-point discrimination: 87% (97%). Test–retest reliability for registration and unilateral spatial tactile perception tests was high in children with CP (intraclass correlation coefficient [ICC] = 0.79–0.96). Two tests demonstrated a learning effect for children with CP, double simultaneous and tactile texture perception. Stereognosis had a ceiling effect for TDC (ICC = 0) and variability for children with CP (% exact agreement = 47%–50%). The Semmes-Weinstein monofilaments, single-point localization, and both static and moving two-point discrimination are recommended for use in practice and research. Although recommended to provide a comprehensive assessment, the measures of double simultaneous, stereognosis, and tactile texture perception may not be responsive to change over time in children with unilateral CP.     

A Systematic Review of Common Physiotherapy Interventions in School-Aged Children with Cerebral Palsy

ABSTRACT

This systematic review focused on the common conventional physiotherapy interventions used with children with cerebral palsy (CP), aged 4 to 18 years, and critically appraised the recent evidence of each of these interventions using the Oxford Centre for Evidence-Based Medicine Levels of Evidence. The search strategy yielded 34 articles after inclusion and exclusion criteria were applied. The investigated physiotherapy interventions included strength and functional training, weight-supported treadmill training (WBSTT), and neurodevelopmental treatment (NDT). A category of treatment dosage was also included. Strength training was the most studied intervention with significant improvements found in the strength of selected muscle groups using dynamometry, with fewer studies showing significant improvement in function. Functional training showed improvements in gross motor function, endurance, and temperospatial measures, such as gait speed and stride length. Nonsignificant trends of improvement on the Gross Motor Function Measure (GMFM) and gait velocity were found for WBSTT by a few studies with low levels of evidence (case series). Of three studies that evaluated NDT, one high-level evidence study, i.e., randomized controlled trial (RCT) found significant improvements on the GMFM. All studies reviewing treatment dosage had high levels of evidence (RCTs), yet found no significant differences for different intensities of treatment. These results indicate that the levels of evidence for physiotherapy interventions, particularly strengthening and to a lesser extent functional training, in school-aged children with CP has improved; however, further high-level evidence is needed for other interventions.     

The effect of passenger airbags on child seating behavior in motor vehicles

Objective. The purpose of this study was to determine the effect of the presence of passenger airbags on places where children sit when traveling in motor vehicles. Methodology. An observational and driver interview survey of 503 passenger vehicles was conducted in five New England states at randomly selected long- and short-distance travel sites during the summer of 1998. Each vehicle was occupied by at least 1 child <13 years of age. Seating position, vehicle information, and driver and passenger characteristics were collected. Logistic regression analysis was used to identify the association between the presence of passenger airbags in vehicles and the seating positions of children. Results. Controlling for the effects of the driver and vehicle characteristics, children <13 years of age were less likely to be observed riding in the front right seat when a passenger airbag was present in the vehicle (odds ratio:.34; 95% confidence interval:.19-.61). Of the vehicles carrying children, 23% had at least 1 child riding in the front seat. Children rode in the front seat in 17% of vehicles with a passenger airbag, and in 30% of those without a passenger airbag. Half of all vehicles without a teenage or adult passenger carried a child in the front seat. In 91% of vehicles with a child riding in the front seat, there was at least one available seat in the rear. Driver safety belt use, younger child age, and the presence of an adult passenger in the vehicle were all associated with children being seated in the rear. Conclusions. Some New England drivers are protecting children from the risks of passenger airbags by seating them in the rear. There remains, however, a substantial number of children who are being exposed to the risk of passenger airbag deployment.     

Factors Associated with Enhanced Gross Motor Progress in Children with Cerebral Palsy: A Register-Based Study

Aim: To examine associations between interventions and child characteristics; and enhanced gross motor progress in children with cerebral palsy (CP). Methods: Prospective cohort study based on 2048 assessments of 442 children (256 boys, 186 girls) aged 2–12 years registered in the Cerebral Palsy Follow-up Program and the Cerebral Palsy Register of Norway. Gross motor progress estimates were based on repeated measures of reference percentiles for the Gross Motor Function Measure (GMFM-66) in a linear mixed model. Mean follow-up time: 2.9 years. Results: Intensive training was the only intervention factor associated with enhanced gross motor progress (mean 3.3 percentiles, 95% CI: 1.0, 5.5 per period of ≥3 sessions per week and/or participation in an intensive program). Gross motor function was on average 24.2 percentiles (95% CI: 15.2, 33.2) lower in children with intellectual disability compared with others. Except for eating problems (–10.5 percentiles 95% CI: –18.5, –2.4) and ankle contractures by age (–1.9 percentiles 95% CI: –3.6, –0.2) no other factors examined were associated with long-term gross motor progress. Conclusions: Intensive training was associated with enhanced gross motor progress over an average of 2.9 years in children with CP. Intellectual disability was a strong negative prognostic factor. Preventing ankle contractures appears important for gross motor progress.     

Decline in severe spastic cerebral palsy at term in Denmark 1999–2007

Aim

To analyse trends in prevalence and severity of cerebral palsy (CP) in Denmark in birth years 1999–2007 and compare with previous periods.

Self-Care Trajectories and Reference Percentiles for Children with Cerebral Palsy

Abstract

Aims: To create longitudinal trajectories and reference percentiles for performance in self-care of children with cerebral palsy (CP).

Methods: Participants were 708 children with CP, 18?months through 11 years of age and their parents residing in 10 regions across Canada and the United States. Gross Motor Function Classification System (GMFCS) levels were determined by consensus between parents and therapists. Parents’ completed the Performance in Self-Care domain of the Child Engagement in Daily Life Measure two to five times at 6-month intervals. Nonlinear mixed-effects models were used to create longitudinal trajectories. Quantile regression was used to construct cross-sectional reference percentiles.

Results: The trajectories for children in levels I, II, and III are characterized by an average maximum score between 79.6 (level I) and 62.8 (level III) and an average attainment of 90% of the maximum score between 7 and 9?years of age. The trajectories for children in level IV and V show minimal change over time. Extreme variation in performance among children of the same age and GMFCS level complicate interpretation of percentile change of individual children.

Conclusion: The findings are useful for monitoring self-care of children with CP and evaluating change for children in GMFCS levels I–III.     

Consensus Planning Toward a Community-Based Approach to Promote Physical Activity in Youth with Cerebral Palsy

Aims: To engage researchers and knowledge-users in six Ontario communities in knowledge translation initiatives to identify community-informed elements to guide the development of an optimal physical activity program for youth with cerebral palsy (CP) and to support research efforts. Methods: The project included three iterative steps, i.e., an environmental scan of five communities, six regional planning meetings, and a member-checking survey, followed by a Delphi survey to reach consensus on the elements deemed most important. Results: Twenty-four elements were identified to include in programs promoting physical activity in youth with CP, which were organized in five categories: raise awareness of the options and opportunities (n = 4); pique interest and motivate youth to become and stay active (n = 9); ensure community programs are ready for youth with a disability (n = 2); be fit, fit in, and finding the best fit (n = 5); and explore the layers of physical activity and how they interact (n = 4). Conclusions: The 24 elements established characterize the key concepts that families and community stakeholders value when developing physical activity programs for youth with CP. When incorporated into clinical practice, each of the elements may be used to evaluate key aspects of outcome for individuals with CP.     

Prehospital Discharge Car Safety Seat Testing of Infants After Congenital Heart Surgery

Background This study aimed to expand the American Academy of Pediatrics (AAP) car safety seat testing recommendation to include high-risk infants after cardiac surgery. Methods Car safety seat testing (≤4 days before discharge), performed according to AAP guidelines, was retrospectively reviewed for 66 postoperative infants. Failure was defined as apnea, bradycardia, or oxygen desaturation. Results The average birth weight of the study infants was 3.1 ± 0.5 kg. Two patients were born at less than 37 weeks gestation. Surgical procedures included modified Blalock–Taussig shunt technique (n = 15), arterial switch operation (n = 12), Norwood Sano modification (n = 11), coarctation repair (n = 8), repair of tetralogy of Fallot (n = 6), repair of truncus arteriosus (n = 4), repair of total anomalous pulmonary venous return (n = 3), pacemaker placement (n = 2), repair of interrupted aortic arch and ventriculoseptal defect (VSD) (n = 1), repair of coarctation and VSD (n = 1), orthotopic heart transplant (n = 1), repair of VSD (n = 1), and patent ductus arteriosus ligation (n = 1). The average age at discharge was 28 ± 21 days. Four patients (6%) failed car safety seat testing because of a fall in oxygen saturation. One of the four patients passed on retesting after parental education, whereas three of the four (75%) were discharged home in a supine car safety seat. There was no relationship between the type of surgery and car safety seat test failure. Conclusion It may be beneficial to extend the AAP recommendations for car safety seat testing to include high-risk infants after cardiac surgery.     

Parents’ Experiences of Health and Needs When Supporting Their Adolescents With Cerebral Palsy During Transition to Adulthood

Aims: Parents are the primary support providers for adolescents with disabilities, their health and wellbeing is therefore of great importance when planning for youths’ transition into adulthood. The aim of this study was to gain a deeper understanding of how parents of adolescents with cerebral palsy (CP) experience their own health and wellbeing and their needs for support during the adolescent's transition to adulthood. Methods: An inductive qualitative approach was used, including interviews with 15 mothers and fathers to 10 adolescents with CP aged 17–18 years. Latent content analysis was used for analyzing the data. Results: The main theme “Friction blisters chafing and healing during transition” illustrates the parents' experiences. Five sub-themes formed the parents’ experiences of concerns along with sorrow and stress in life, worries about what was to come, their need for support, strategies for coping, and experiences of cohesion. Conclusions: Knowledge of parents’ experiences of their health, wellbeing, and needs provide valuable information for the planning of transition for adolescents with disabilities. Help with parents’ sorrow, stress, and worry in daily life might be facilitated and parental health safeguarded by a navigator who can both guide and give hands-on support.