Group aquatic training improves gait efficiency in adolescents with cerebral palsy

Purpose.?To evaluate the effect and feasibility of a 10-week group aquatic training programme on gait efficiency in adolescents with cerebral palsy (CP). The secondary purpose was to determine the exercise intensity during aquatic training in a heterogeneous group of adolescents with CP and to investigate the impact of the training programme on the musculoskeletal system.

Method.?Twelve ambulatory adolescents with spastic CP were recruited. They participated in 20 aquatic training sessions (45?min twice a week). Three physical therapists and a sports teacher supervised the training sessions. Participants wore a heart rate monitor to assess sessions' intensity and a floatation device as appropriate. The primary outcome measure was gait efficiency as measured by the gait energy expenditure index (EEI). The secondary measures were (1) gait spatiotemporal parameters, (2) maximal isometric knee strength and (3) gross motor function.

Results.?Ten adolescents completed the training programme. No adverse effect was reported. Average exercise intensity was mild to moderate for more than half of the training session. A significant reduction of the EEI and the heart rate during walking was observed following the training programme. No significant change was observed on secondary outcome measures.

Conclusions.?Group aquatic training increases gait efficiency in adolescents with CP. This improvement is related to systemic cardiorespiratory adaptations. Group aquatic training programme is feasible in adolescents presenting CP at different levels of severity.     

Physical strain of comfortable walking in children with mild cerebral palsy

Purpose.?To evaluate the physical strain of comfortable walking in children with mild cerebral palsy ((CP)) in comparison to typically developing ((TD)) children. Physical strain was defined as the oxygen uptake during walking ((VO_2walk)) expressed as a percentage of their maximal aerobic capacity ((VO_2peak)).

Method.?Eighteen children ((aged 8–16 years)) participated, including eight ambulant children ((four girls, four boys)) with mild spastic CP ((three hemiplegia, five diplegia, GMFCS I: n == 7 and II: n == 1)) and 10 TD children. VO_2walk was measured during 5?min of walking on an indoor track at comfortable walking speed. VO_2peak was measured in a shuttle run test.

Results.?VO_2walk was significantly higher in CP ((19.7 ((2.8)) ml//kg//min)) compared to TD ((16.8 ((3.6)) ml//kg//min, p == 0.033)), while walking speed did not differ significantly between groups. VO_2peak was significantly lower in CP ((37.2 ((2.2)) ml//kg//min)) compared to TD ((45.0 ((5.3)) ml//kg//min, p == 0.001)). Consequently, the physical strain during walking was significantly higher in CP ((52 ((7.7)) %%)) compared to TD ((36 ((8.4)) %%, p == 0.001)).

Conclusions.?The higher physical strain during comfortable walking of children with mild CP compared to TD children may be related to reported problems with fatigue in this population, and suggest a need for physical aerobic training programmes.     

Goal-directed functional therapy: A longitudinal study on gross motor function in children with cerebral palsy

Purpose.?To investigate gross motor function and goal attainment in children with cerebral palsy before, during and after goal-directed functional therapy (GDT), to evaluate body functions, and explore relationships.

Method.?Prospective longitudinal intervention study. Twenty-two children, uni- or bilateral CP, 1–6 years (mean: 46 months SD: 16 months), classified in GMFCS and MACS level I–IV participated. Outcome measures were Gross Motor Function Measure (GMFM-66), performed at seven occasions, Goal Attainment Scale, assessments of passive range of motion, spasticity and selective motor control (SMC). Baseline, the GDT-intervention and the follow-up period were 12 weeks each.

Results.?Improvements were demonstrated in GMFM-66 during the intervention (mean difference: 5.07, CI: 3.8–6.4, p?<?0.001). The baseline and follow-up assessments were stable. Evaluations of ankle dorsiflexion displayed small improvement (mean difference: 9°, CI: 5–13, p?<?0.001). Estimations of spasticity and SMC did not demonstrate significant changes. Goal attainment to the expected level or higher was achieved in 93/110 goals and further improved at the long-term follow-up (103/110).

Conclusion.?Gross motor function improved during GDT, and was maintained 12 weeks later. The goals were reached to a high extent, and the children gradually progressed towards their goals after the end of the intervention. The therapy did not induce any deterioration of body functions.     

Using the manual ability classification system in young adults with cerebral palsy and normal intelligence

Purpose.?The study aimed to establish whether the manual ability classification system (MACS), a valid classification system for manual ability in children with cerebral palsy (CP), is applicable in young adults with CP and normal intelligence.

Subjects.?The participants (n?=?83) were young adults with CP and normal intelligence and had a mean age of 19.9 years.

Method.?In this study, inter observer reliability of the MACS was determined. We investigated relationships between the MACS level and patient characteristics (such as the gross motor function classification system (GMFCS) level, limb distribution of the spastic paresis and educational level) and with functional activities of the upper extremity (assessed with the Melbourne assessment, the Abilhand questionnaire and the domain self-care of the functional independence measure (FIM)). Furthermore, with a linear regression analysis it was determined whether the MACS is a significant determinant of activity limitations and participation restrictions.

Results.?The reliability was good (intraclass correlation coefficient 0.83). The Spearman correlation coefficients with GMFCS level, limb distribution of the spastic paresis and educational level were 0.53, 0.46, and 0.26, respectively. MACS level correlated moderately with outcome measures of functional activities (correlations ranging from??0.38 to??0.55). MACS level is, in addition to the GMFCS level, an important determinant for limitations in activities and restrictions in participation.

Conclusion.?We conclude that the MACS is a feasible method to classify manual ability in young adults with CP and normal intelligence with a good manual ability.     

Efficacy of Partial Body Weight-Supported Treadmill Training Compared With Overground Walking Practice for Children With Cerebral Palsy: A Randomized Controlled Trial

Willoughby KL, Dodd KJ, Shields N, Foley S. Efficacy of partial body weight-supported treadmill training compared with overground walking practice for children with cerebral palsy: a randomized controlled trial.

Objective

To evaluate the efficacy of 9 weeks of twice-weekly partial body weight-supported treadmill training (PBWSTT) for children with cerebral palsy (CP) and moderate to severe walking difficulty compared with overground walking.

Design

Randomized controlled trial.

Setting

Metropolitan Specialist School for children with moderate to severe physical and/or intellectual disabilities.

Participants

Thirty-four children classified level III or IV by the Gross Motor Function Classification System were recruited and randomly allocated to experimental or control groups. Of these, 26 (15 girls, 11 boys; mean age 10y, 10mo ± 3y, 11mo [range, 5-18y]) completed training and testing.

Interventions

Both groups completed 9 weeks of twice-weekly walking training. The experimental group completed PBWSTT, and the control group completed overground walking practice.

Main Outcome Measures

Ten-meter walk test (self-selected walking speed), 10-minute walk (walking endurance), School Function Assessment.

Results

The overground walking group showed a trend for an increase in the distance walked over 10 minutes (F=3.004, P=.097). There was no statistically significant difference in self-selected walking speed over 10 meters or in walking function in the school environment as measured by the School Function Assessment.

Conclusions

PBWSTT is safe and feasible to implement in a special school setting; however, it may be no more effective than overground walking for improving walking speed and endurance for children with CP. Continued emphasis on progressive reduction of body weight support along with adding concurrent overground walking practice to a treadmill training protocol may increase the intensity of training and assist with carryover of improvements to overground walking. Treadmill training programs that include concurrent overground walking as an additional key feature of the training protocol need to be rigorously evaluated for children with CP.     

Measuring impairment and functional limitations in children with cerebral palsy

Objective.?The disablement model provides a theoretical framework for the assessments of individuals with cerebral palsy (CP). The purpose of this study was to evaluate the relative validity of multiple measures for impairment and functional limitations and to estimate the relationship between the two global factors using confirmatory factor analysis.

Methods.?Over 50 measures of impairment and functional limitations were collected for 57 children with spastic CP. There were 12, 10, 5, 7 and 23 children who were classified in Gross Motor Function Classification System (GMFCS) Levels I to V, respectively.

Results.?The measures of impairment with the highest factor loadings were several single-item ratings of spasticity; the Modified Ashworth hamstring and biceps ratings, and goniometric measures. All of the functional limitation measures had high factor loadings, including the gross motor function measure, GMFCS, the Paediatric Evaluation of Disability Inventory and WeeFIM self care and mobility scales. The correlation between the global factors of impairment and functional limitations was 0.96, indicating that the two factors are highly correlated in spastic CP.

Conclusion.?The disablement model is a valuable theoretical tool that can be used to organise assessments in CP and to explain how they are related.     

减重平板步行训练对学龄脑瘫患儿行走功能的影响

目的探讨减重平板步行训练对学龄脑瘫患儿康复疗效的影响。方法将35例脑瘫患儿分为3组：①减重训练组(即减重平板步行训练结合运动疗法,11例);②非减重训练组(即平板步行训练结合运动疗法,12例);③常规训练组(即常规步行训练,12例)。所有脑瘫患儿入选后分别在训练前和训练8周、12周时进行以下评定：粗大运动功能量表(GMFM)中的站立和行走两项,步行能力(WA),步行效率(WE)和功能性步行分级(FAC)。结果3组脑瘫患儿的各项评定指标在康复训练前无显著性差异(P>0.05)。经过12周的训练后,康复疗效较训练前改善(P<0.05)。GMFM、WA、WE和FAC均显示,减重平板步行训练效果显著(P<0.001)。结论减重平板步行训练可明显改善脑瘫患儿步行能力和步行效率,提高脑瘫患儿粗大运动功能中的站立与行走功能以及功能性步行分级。     

The efficacy of GMFM-88 and GMFM-66 to detect changes in gross motor function in children with cerebral palsy (CP): a literature review

Abstract

Aim: The purpose of this study was to review published research on the use of the Gross Motor Function Measure (GMFM-88) and (GMFM-66) as outcome measures to determine if these tools detect changes in gross motor function in children with cerebral palsy (CP) undergoing interventions. Methods: A comprehensive literature search was conducted using Medline and PubMed to identify studies published from January 2000 through January 2011 that reported the accuracy of GMFM-88 and GMFM-66 to measure changes over time in children with CP undergoing interventions. The keywords used for the search were “GMFM” and “CP”. Two of the authors (M.A. and S.B.) reviewed the titles and abstracts found in the databases. The methodological quality of the studies was assessed by using the Critical Review Form-Quantitative Studies. Results: Of 62 papers initially identified, 21 studies fulfilled the inclusion criteria. These articles consist of three longitudinal studies, six randomized controlled trials, four repeated measure design, six pre–post test design, a case series and one non-randomized prospective study. The included studies were generally of moderate to high methodological quality. The studies included children from a wide age range of 10?months to 16?years. According to the National Health and Medical Research Council, the study designs were level II, III-2, III-3 and IV. Conclusion: The review suggests that the GMFM-88 and GMFM-66 are useful as outcome measures to detect changes in gross motor function in children with CP undergoing interventions.

• Implications for Rehabilitation

• Accurate measurement of change in gross motor skill acquisition is important to determine effectiveness of intervention programs in children with cerebral palsy (CP).

• The Gross Motor Function Measure (GMFM-88 and GMFM-66) are common tools used by rehabilitation specialists to measure gross motor function in children with CP.

• The GMFM appears to be an effective outcome tool for measuring change in gross motor function according to a small number of randomized control studies utilizing participant populations of convenience.

     

Robotic gait trainer in water: Development of an underwater gait-training orthosis

Purpose.?To develop a robotic gait trainer that can be used in water (RGTW) and achieve repetitive physiological gait patterns to improve the movement dysfunctions.

Method.?The RGTW is a hip-knee-ankle-foot orthosis with pneumatic actuators; the control software was developed on the basis of the angular motions of the hip and knee joint of a healthy subject as he walked in water. Three-dimensional motions and electromyographic (EMG) activities were recorded in nine healthy subjects to evaluate the efficacy of using the RGTW while walking on a treadmill in water.

Results.?The device could preserve the angular displacement patterns of the hip and knee and foot trajectories under all experimental conditions. The tibialis anterior EMG activities in the late swing phase and the biceps femoris throughout the stance phase were reduced whose joint torques were assisted by the RGTW while walking on a treadmill in water.

Conclusion.?Using the RGTW could expect not only the effect of the hydrotherapy but also the standard treadmill gait training, in particular, and may be particularly effective for treating individuals with hip joint movement dysfunction.     

The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy

Purpose.?To assess the effectiveness of a hinged ankle-foot orthoses on gait impairments and energy expenditure in children with hemiplegic cerebral palsy (CP) whom orthoses were indicated to control equines.

Method.?Eleven children (seven males, four females) who had a diagnosis of hemiplegic cerebral palsy were included in the study. Each child underwent gait analysis and energy consumption studies with and without ankle-foot orthosis (AFO). The AFOs were all custom-made for the individual child and had plantarflexion stop at 0° with no dorsoflexion stop. The Vicon 512 Motion analysis system was used for gait analysis. Walking energy expenditure measurements were done with breath by breath method using an open-circuit indirect calorimeter (Vmax 29c, Sensormedics, USA). All tests were carried out on the same day with enough resting period.

Results.?AFO application, as compared with the barefoot condition improved walking speed, stride length and single support time. Double support time was decreased significantly with AFOs and no change in cadance. Ankle dorsiflexion at initial contact, midstance and midswing showed significiant increase. Knee flexion at initial contact was decreased and no significant change in maximum knee extension at stance and maximum knee flexion at swing was obtained. The oxygen consumption was significantly reduced during AFO walking.

Conclusion.?The hinged AFO is useful in controlling dynamic equinus deformity and reducing the energy expenditure of gait in children with hemiplegic spastic cerebral palsy.     

Effect of robotic locomotor training in an individual with Parkinson's disease: a case report

Purpose.?The purpose was to test the effect of robot-assisted gait therapy with the Lokomat system in one representative individual with Parkinson's disease (PD).

Methods.?The patient was a 67-year-old female with more than an 8-year history of PD. The manifestations of the disease included depressive mood with lack of motivation, moderate bradykinesia, rigidity and resting tremor, both involving more the right side of the body, slow and shuffling gait with episodes of freezing and risk of falling. The patient underwent six sessions of robot-assisted gait training. The practice included treadmill walking at variable speed for 25–40?min with a partial body weight support and assistance from the Lokomat orthosis.

Results.?After the therapy, the patient increased the gait speed, stride length and foot clearance during over ground walking. She reduced the time required to complete a 180° turn and the latency of gait initiation. Improvements were observed in some items of the Unified Parkinson's Disease Rating Scale including motivation, bradykinesia, rigidity, freezing, leg agility, gait and posture.

Conclusions.?Although the results supported the feasibility of using robot-assisted gait therapy in the rehabilitation an individual with PD, further studies are needed to assess a potential advantage of the Lokomat system over conventional locomotor training for this population.     

Method of analysing the performance of self-paced and engine induced cycling in children with cerebral palsy

Purpose. To develop a method of quantifying the features of cycling in children with CP by comparing them to typically developed children, and to demonstrate the applications of this tool for evaluating treatment effects in children with CP.

Methods. Twenty-seven typically developed children and 51 with CP, classified by their gross motor function levels, were studied. Angular velocities were measured during self-paced active cycling and during passive cycling imposed by an electrically powered stationary cycle. Angular velocities were compared with the gross motor function levels, Modified Ashworth Scale and the Adductor Tone Rating.

Results. Significant differences between children with CP and those typically developed demonstrated in passive mode that the cycling task is sensitive to differences in resistance offered by the subjects. Active and passive cycling velocities differ significantly between groups classified by their functional levels (p < 0.01). Children with CP in the mild group showed no differences from typically developed children. The correlations between passive cycling and clinical tests were significant and higher at higher speeds (r = 0.62). Correlations with anthropometric measurements for the typically developed group associated the cycling task with growth and development, and for children with CP with motor control adjustments and impairments.

Conclusions. Measuring of these two cycling modes could be applicable in assessing lower extremity function in children with CP and changes following interventions.     

Glide-symmetric locomotion reinforcement in patients with multiple sclerosis by visual feedback

Purpose.?To compare the effects of gait training with distinct glide-symmetric visual feedback cues, adapted to the geometry of human locomotion, to the effects of training with visual cues of no distinct symmetry, on the walking abilities of subjects with gait disorders due to multiple sclerosis (MS).

Methods.?Ten patients trained with transverse lines while 11 patients trained with checkerboard tiles, both provided by a wearable virtual reality device. Baseline performance (walking speed and stride length along a 10?m straight track) was measured before device use. Following 20?min training with the device and 10?min rest, performance without the device was measured again and compared to the baseline performance.

Results.?The average improvement in the group using the visual cue of transverse lines was 7.79%?±?4.24% in walking speed and 7.20%?±?3.92% in stride length. The average improvement in the group using the visual cue of checkerboard tiles was 21.09%?±?18.39% in walking speed and 12.99%?±?1.72% in stride length.

Conclusions.?Patients with gait disorders due to MS, training with a glide-symmetric visual feedback cue, showed a significantly higher improvement in their gait parameters than patients training with a visual feedback cue of no without distinct symmetry.     

Psychometric evaluation of the functional walking test for children withcerebral palsy

Purpose.?This study examined the psychometric properties of the functional walking test (FWT).

Method.?Fifty-six subjects with cerebral palsy (CP) (21 females and 35 males, mean age 9 years 6 months, SD 3 years 9months, range 4–17 years) were assessed on two occasions, 6 months apart, using both the FWT and the gross motor function measure (GMFM).

Results.?Generalisability correlation coefficients (GCC) for all 11 items were high (0.91–0.99). Inter-rater reliability was also high with excellent consensus in the scores given by the eight raters (intra-class correlation coefficient and GCC 0.99). Intra-rater reliability was equally high (GCC 0.99). The internal consistency of the FWT was estimated using Cronbach's α as 0.95 and 0.94 at Time 1 and 2, respectively. The FWT had a high degree of correlation with the GMFM, when total scores were compared at Time 1 and 2 (Pearson's r == 0.86 and 0.87, n == 56, p < 0.01). The FWT also found statistically significant differences in total scores between the three Gross Motor Function Classification System (GMFCS) levels. The correlation between the FWT scores and GMFCS was ?0.70 at Time 1 and ?0.76 Time 2 (p < 0.01) indicating the construct validity of the FWT.

Conclusions.?This study has demonstrated that the FWT has sound psychometric properties and is valid and reliable in a sample population of ambulant children with CP.     

Course of health-related quality of life in 9–16-year-old children with cerebral palsy: Associations with gross motor abilities and mental health

Purpose.?To chart the 3-year course of health-related quality of life (HRQoL) of 9–13-year-old children with cerebral palsy (CP), and to determine its relationship with gross motor abilities and mental health.

Methods.?Children (n?=?91; 58 boys, mean age 11 years, age ranging from 8 years and 6 months to 13 years and 8 months) and parents were assessed annually with the TNO-AZL questionnaires for children's health-related quality of life as a dependent variable, and the gross motor function measure for children with CP and the child behaviour check list as independent variables.

Results.?The children reported lower HRQoL compared with children in the general population, but reported a higher HRQoL than their parents. The HRQoL remained fairly stable over the 3 years, except for an increase in the autonomy domain. The HRQOL was moderately associated with gross motor abilities, and negatively associated with internalising mental health problems. Externalising problems were only negatively associated with parent-reported HRQoL.

Conclusions.?Children with CP are more resilient and positive about their HRQoL than their parents think they are. In general, mental health in children with CP appeared to be important in understanding their perceived QoL, in addition to the severity of the CP itself.     

The psychosocial well-being of parents of children with cerebral palsy: a comparison study

Purpose.?Parents of children with cerebral palsy (CP) may be at risk from poor psychosocial well-being, compared with parents of children without a long-term health condition (LTHC). However, research has produced some conflicting findings on the topic and no comparison studies have been conducted in the UK. Furthermore, studies have only used measures of negative psychosocial well-being. The aim of this study was to conduct a comparative study of parents of children with CP and parents of children without a LTHC in the UK.

Method.?Seventy parents of children with CP and 70 parents of children without a LTHC completed self-administered questionnaires, comprising measures of psychosocial distress and positive psychosocial well-being.

Results.?This study demonstrated that parents of children with CP have significantly poorer psychosocial well-being compared with parents of children without a LTHC: parents of children with CP had lower satisfaction with life and higher levels of anxious and depressed mood.

Conclusions.?These results suggest caring for a child with CP may put parents at risk from poor psychosocial well-being. Interventions to improve parental well-being are urgently needed.     

Reliability and cross-cultural validation of the Turkish version of Manual Ability Classification System (MACS) for children with cerebral palsy

Purpose.?To determine the reliability and cross-cultural validation of the Turkish translation of the Manual Ability Classification System (MACS) for children with cerebral palsy (CP) and to investigate the relation to gross motor function and other comorbidities.

Methods.?After the forward and backward translation procedures, inter-rater and test–retest reliability was assessed between parents, physiotherapists and physicians using the intra-class correlation coefficient (ICC). Children (N?=?118, 4 to 18 years, mean age 9 years 4 months; 68 boys, 50 girls) with various types of CP were classified. Additional data on the Gross Motor Function Classification System (GMFCS), intellectual delay, visual acuity, and epilepsy were collected.

Results.?The inter-rater reliability was high; the ICC ranged from 0.89 to 0.96 among different professionals and parents. Between two persons of the same profession it ranged from 0.97 to 0.98. For the test–retest reliability it ranged from 0.91 to 0.98. Total agreement between the GMFCS and the MACS occurred in only 45% of the children. The level of the MACS was found to correlate with the accompanying comorbidities, namely intellectual delay and epilepsy.

Conclusion.?The Turkish version of the MACS is found to be valid and reliable, and is suggested to be appropriate for the assessment of manual ability within the Turkish population.     

A critical review of powered mobility assessment and training for children

Purpose.?Assessment and training of young children using powered mobility tends to be based on expert opinion although research in this area has recently been completed. This review critiques available research and discusses the studies in relation to theory and expert opinion.

Method.?A literature review was completed to identify research regarding powered mobility training for children with developmental disabilities. Two recent qualitative studies were identified and their models and assessment tools were compared and discussed with recommendations for clinical practice and research.

Results.?The focus of the two studies is on a continuum of learning, the reciprocal relationship of trainer and trainee, and impact of the social and attitudinal environment on powered mobility skill development. The assessment tools and training protocols are backed up by motor learning principles and expert opinion. Further research is required to incorporate the tools into clinical practice and to examine additional psychometric properties.

Conclusions.?Rather than focusing on readiness skills or pass/fail tests, clinicians should explore early mobility options for clients at the beginning of the continuum of learning, reflect on how they relate to and impact on their clients' learning, and set up the environment to facilitate independent learning and exploration.