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Rodríguez-Grande EI, Buitrago-López A, Torres-Narváez MR, Serrano-Villar Y, Verdugo-Paiva F, Ávila C. Therapeutic exercise to improve motor function among children with Down Syndrome aged 0 to 3 years: a systematic literature review and meta‑analysis. Sci Rep 2022; 12:13051. [PMID: 35906275 PMCID: PMC9338268 DOI: 10.1038/s41598-022-16332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 07/08/2022] [Indexed: 11/09/2022] Open
Abstract
The effects and the prescription parameters of therapeutic exercise are not clear. For this reason, is needed to determine the effect of therapeutic exercises on the motor function of children with Down Syndrome (DS) aged 0 to 3 years. The present study is systematic review and meta-analysis of effectiveness outcomes in this population: gait, balance, motor development, fine motor skills, and executive functions. The databases of PubMed, PEDro, EMBASE, SCIELO, Lilacs, Cochrane library were searched from January to December 2019. We recruited Randomized Controlled Trials (RCTs) which met the inclusion criteria in our study. Six studies and 151 participants were included. Two types of therapeutic exercises, aerobic and neuromuscular, were identified. Both types of exercise were effective in improving outcomes. There were no differences between the modes of application of the exercise. No differences were identified between the treadmill and the physiotherapy plan for the reduction of the time to reach independent walking, Mean Difference (MD) 46.79, 95% Confidence Interval (IC) (− 32.60, 126.19), nor for the increase in walking speed MD 0.10 IC (− 0.02, 0.21) m/s. This study suggests that aerobic exercise therapy has a potentially effective role to promote the gait and motor development of children with DS aged 0 to 3 years when it is applied using a treadmill with a frequency of 5 days, a duration of 6–8 min, and an intensity of between 0.2 and 0.5 m/s. Studies with less heterogeneity and larger sample sizes are required.
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Affiliation(s)
- Eliana-Isabel Rodríguez-Grande
- Master's and PhD programs in Clinical Epidemiology, Pontificia Universidad Javeriana, Bogotá, Colombia. .,School of Medicine and Health Sciences, Universidad del Rosario, GI Rehabilitation Sciences, Carrera 24 N. 63D - 69, PBX 2970200 Ext. 3420, Bogotá, Cundinamarca, Colombia.
| | - Adriana Buitrago-López
- Erasmus University Rotterdam, Rotterdam, The Netherlands.,Universidad Católica de Paraná, Curitiba, Brazil.,Department of Clinical Epidemiology and Biostatistics, School of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Martha-Rocio Torres-Narváez
- School of Medicine and Health Sciences, Universidad del Rosario, GI Rehabilitation Sciences, Physiotherapy Program, Bogotá, Colombia
| | | | - Francisca Verdugo-Paiva
- Centro Evidencia UC, School of Medicine, Pontificia Universidad Católica, Santiago de Chile, Chile.,Fundación Epistemonikos, Santiago de Chile, Chile
| | - Camila Ávila
- Fundación Epistemonikos, Santiago de Chile, Chile
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Abstract
Cerebral palsy (CP) is a disorder characterized by abnormal tone, posture and movement and clinically classified based on the predominant motor syndrome-spastic hemiplegia, spastic diplegia, spastic quadriplegia, and extrapyramidal or dyskinetic. The incidence of CP is 2-3 per 1,000 live births. Prematurity and low birthweight are important risk factors for CP; however, multiple other factors have been associated with an increased risk for CP, including maternal infections, and multiple gestation. In most cases of CP the initial injury to the brain occurs during early fetal brain development; intracerebral hemorrhage and periventricular leukomalacia are the main pathologic findings found in preterm infants who develop CP. The diagnosis of CP is primarily based on clinical findings. Early diagnosis is possible based on a combination of clinical history, use of standardized neuromotor assessment and findings on magnetic resonance imaging (MRI); however, in most clinical settings CP is more reliably recognized by 2 years of age. MRI scan is indicated to delineate the extent of brain lesions and to identify congenital brain malformations. Genetic tests and tests for inborn errors of metabolism are indicated based on clinical findings to identify specific disorders. Because CP is associated with multiple associated and secondary medical conditions, its management requires a multidisciplinary team approach. Most children with CP grow up to be productive adults.
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Affiliation(s)
- Dilip R Patel
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kamalazoo, MI, USA
| | - Mekala Neelakantan
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kamalazoo, MI, USA
| | - Karan Pandher
- Chicago Medical School at Rosalind Franklin University, Chicago, IL, USA
| | - Joav Merrick
- Hadassah Hebrew University Medical Center, Jarusalem, Israel.,University of Kentucky, Lexington, KY, USA.,School of Public Health, Georgia State University, Atlanta, GA, USA
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Ferrante R, Hendershot S, Baranet K, Barbosa G, Carey H, Maitre N, Lo W, Pan J, Heathcock J. Daily and Weekly Rehabilitation Delivery for Young Children With Gross Motor Delay: A Randomized Clinical Trial Protocol (the DRIVE Study). Pediatr Phys Ther 2019; 31:217-224. [PMID: 30865149 PMCID: PMC7029804 DOI: 10.1097/pep.0000000000000594] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The proposed project tests the principle that frequency of rehabilitation is an important regulator of therapeutic response in infants. METHODS We will randomize 75 infants with cerebral palsy, 6 to 24 months of age and/or Gross Motor Function Classification System levels III to V (higher severity), to determine the short-term and long-term effects of 3 dosing protocols consisting of an identical number of 2-hour sessions of the same motor learning-based therapy applied over a different total number of calendar weeks. RESULTS AND CONCLUSIONS The results will inform clinicians, families, and scientists about dosing and will provide needed recommendations for frequency of rehabilitation to optimize motor function and development of young children with cerebral palsy.
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Affiliation(s)
- Rachel Ferrante
- Nationwide Children's Hospital (Drs Ferrante, Hendershot, Baranet, Maitre, and Lo), Columbus, Ohio; The Ohio State University (Drs Barbosa, Pan, and Heathcock), Columbus, Ohio; Kettering College (Dr Carey), Kettering, Ohio
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Valentín‐Gudiol M, Mattern‐Baxter K, Girabent‐Farrés M, Bagur‐Calafat C, Hadders‐Algra M, Angulo‐Barroso RM. Treadmill interventions in children under six years of age at risk of neuromotor delay. Cochrane Database Syst Rev 2017; 7:CD009242. [PMID: 28755534 PMCID: PMC6483121 DOI: 10.1002/14651858.cd009242.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Delayed motor development may occur in children with Down syndrome, cerebral palsy, general developmental delay or children born preterm. It limits the child's exploration of the environment and can hinder cognitive and social-emotional development. Literature suggests that task-specific training, such as locomotor treadmill training, facilitates motor development. OBJECTIVES To assess the effectiveness of treadmill interventions on locomotor development in children with delayed ambulation or in pre-ambulatory children (or both), who are under six years of age and who are at risk for neuromotor delay. SEARCH METHODS In May 2017, we searched CENTRAL, MEDLINE, Embase, six other databases and a number of trials registers. We also searched the reference lists of relevant studies and systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that evaluated the effect of treadmill intervention in the target population. DATA COLLECTION AND ANALYSIS Four authors independently extracted the data. Outcome parameters were structured according to the International Classification of Functioning, Disability and Health model. MAIN RESULTS This is an update of a Cochrane review from 2011, which included five trials. This update includes seven studies on treadmill intervention in 175 children: 104 were allocated to treadmill groups, and 71 were controls. The studies varied in population (children with Down syndrome, cerebral palsy, developmental delay or at moderate risk for neuromotor delay); comparison type (treadmill versus no treadmill; treadmill with versus without orthoses; high- versus low-intensity training); study duration, and assessed outcomes. Due to the diversity of the studies, only data from five studies were used in meta-analyses for five outcomes: age of independent walking onset, overall gross motor function, gross motor function related to standing and walking, and gait velocity. GRADE assessments of quality of the evidence ranged from high to very low.The effects of treadmill intervention on independent walking onset compared to no treadmill intervention was population dependent, but showed no overall effect (mean difference (MD) -2.08, 95% confidence intervals (CI) -5.38 to 1.22, 2 studies, 58 children; moderate-quality evidence): 30 children with Down syndrome benefited from treadmill training (MD -4.00, 95% CI -6.96 to -1.04), but 28 children at moderate risk of developmental delay did not (MD -0.60, 95% CI -2.34 to 1.14). We found no evidence regarding walking onset in two studies that compared treadmill intervention with and without orthotics in 17 children (MD 0.10, 95% CI -5.96 to 6.16), and high- versus low-intensity treadmill interventions in 30 children with Down syndrome (MD -2.13, 95% -4.96 to 0.70).Treadmill intervention did not improve overall gross motor function (MD 0.88, 95% CI -4.54 to 6.30, 2 studies, 36 children; moderate-quality evidence) or gross motor skills related to standing (MD 5.41, 95% CI -1.64 to 12.43, 2 studies, 32 children; low-quality evidence), and had a negligible improvement in gross motor skills related to walking (MD 4.51, 95% CI 0.29 to 8.73, 2 studies, 32 children; low-quality evidence). It led to improved walking skills in 20 ambulatory children with developmental delay (MD 7.60, 95% CI 0.88 to 14.32, 1 study) and favourable gross motor skills in 12 children with cerebral palsy (MD 8.00, 95% CI 3.18 to 12.82). A study which compared treadmill intervention with and without orthotics in 17 children with Down syndrome suggested that adding orthotics might hinder overall gross motor progress (MD -8.40, 95% CI -14.55 to -2.25).Overall, treadmill intervention showed a very small increase in walking speed compared to no treadmill intervention (MD 0.23, 95% CI 0.08 to 0.37, 2 studies, 32 children; high-quality evidence). Treadmill intervention increased walking speed in 20 ambulatory children with developmental delay (MD 0.25, 95% CI 0.08 to 0.42), but not in 12 children with cerebral palsy (MD 0.18, 95% CI -0.09 to 0.45). AUTHORS' CONCLUSIONS This update of the review from 2011 provides additional evidence of the efficacy of treadmill intervention for certain groups of children up to six years of age, but power to find significant results still remains limited. The current findings indicate that treadmill intervention may accelerate the development of independent walking in children with Down syndrome and may accelerate motor skill attainment in children with cerebral palsy and general developmental delay. Future research should first confirm these findings with larger and better designed studies, especially for infants with cerebral palsy and developmental delay. Once efficacy is established, research should examine the optimal dosage of treadmill intervention in these populations.
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Affiliation(s)
- Marta Valentín‐Gudiol
- Universitat Internacional de CatalunyaDepartment of Physical TherapyBarcelonaSpain
- Ramon Llull UniversityBlanquerna School of Health SciencesBarcelonaSpain
| | - Katrin Mattern‐Baxter
- California State UniversityDepartment of Physical Therapy6000 J StSacramentoCaliforniaUSA95819
| | - Montserrat Girabent‐Farrés
- Universitat Internacional de CatalunyaDepartment of Physical Therapy, Biostatistics UnitC/ Josep trueta, s/nSant Cugat del VallèsBarcelonaSpain08195
| | | | - Mijna Hadders‐Algra
- University of Groningen, University Medical Center Groningen, Department of PaediatricsHanzeplein 1GroningenNetherlands9713 GZ
| | - Rosa Maria Angulo‐Barroso
- University of BarcelonaDepartment of Health and Applied Sciences, National Institute of Physical EducationAve. de L'Estadi 12‐22BarcelonaBarcelonaSpain08036
- California State UniversityDepartment of KinesiologyNorthridgeCaliforniaUSA
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Robertson J, Hatton C, Baines S, Emerson E. Systematic Reviews of the Health or Health care of People with Intellectual Disabilities: A Systematic Review to Identify Gaps in the Evidence Base. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2015; 28:455-523. [DOI: 10.1111/jar.12149] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2014] [Indexed: 01/08/2023]
Affiliation(s)
- Janet Robertson
- Centre for Disability Research; Division of Health Research; Lancaster University; Lancaster UK
| | - Chris Hatton
- Centre for Disability Research; Division of Health Research; Lancaster University; Lancaster UK
| | - Susannah Baines
- Centre for Disability Research; Division of Health Research; Lancaster University; Lancaster UK
| | - Eric Emerson
- Centre for Disability Research; Division of Health Research; Lancaster University; Lancaster UK
- Centre for Disability Research and Policy; University of Sydney; Sydney NSW Australia
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Millichap JG. Gait Training and Ankle Dorsiflexors in Cerebral Palsy. Pediatr Neurol Briefs 2015; 29:22. [PMID: 26933564 PMCID: PMC4747261 DOI: 10.15844/pedneurbriefs-29-3-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- J. Gordon Millichap
- Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
- Correspondence: Dr. J. Gordon Millichap, E-mail:
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Grecco LAC, E Mendonça M, Duarte NAC, Zanon N, Fregni F, Oliveira CS. Transcranial Direct Current Stimulation Combined with Treadmill Gait Training in Delayed Neuro-psychomotor Development. J Phys Ther Sci 2014; 26:945-50. [PMID: 25013302 PMCID: PMC4085227 DOI: 10.1589/jpts.26.945] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 01/08/2014] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The aim of the present study was to describe the results of transcranial direct current stimulation combined with treadmill training in a child with delayed neuro-psychomotor development. [Subject and Methods] Transcranial direct current stimulation (intensity: 1 mA) was applied over the primary motor cortex for 20 minutes during simultaneous treadmill training (2.5 km/h) in ten sessions. [Results] Clinically significant improvement was found in motor development (fine motor subscale, 23 to 25; gross motor subscale, 32 to 41). Reductions in mean oscillation of the center of pressure were found in the anteroposterior (239.2 to 146.5 mm) and mediolateral (177.4 to 149.2 mm) directions. Increases occurred in cadence (106 to 123 steps/minute), step length (0.16 to 0.23 m), step width (0.09 to 0.14 m) and gait velocity with support (0.3 to 0.7 m/s). [Conclusion] After treatment, the child was able to initiate the standing position for the first time and walk without support.
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Affiliation(s)
| | - Mariana E Mendonça
- Neurosciences and Behavior, Psychology Institute,
University of São Paulo, Brazil
| | | | - Nelci Zanon
- Pediatric Neurosurgery, University Federal de São Paulo,
Brazil
| | - Felipe Fregni
- Neurosciences and Behavior, Psychology Institute,
University of São Paulo, Brazil
- Rehabilitation Sciences, University Nove de Julho,
Brazil
- Pediatric Neurosurgery, University Federal de São Paulo,
Brazil
- Department of Physical Medicine and Rehabilitation,
Spaulding Rehabilitation Hospital, USA
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Webber SC, Horvey KJ, Yurach Pikaluk MT, Butcher SJ. Cardiovascular responses in older adults with total knee arthroplasty at rest and with exercise on a positive pressure treadmill. Eur J Appl Physiol 2013; 114:653-62. [PMID: 24362964 DOI: 10.1007/s00421-013-2798-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE We investigated cardiovascular responses at rest and during submaximal exercise on a lower body positive pressure treadmill in older adults with total knee arthroplasty (TKA). METHODS Twenty-four adults (mean age 64.6 ± 7.9 SD) with unilateral TKA participated (median time since surgery 8.0 weeks). Heart rate and blood pressure responses were measured at rest standing on the positive pressure treadmill with 0, 10, 20, and 30 mmHg applied. Heart rate, blood pressure, oxygen consumption, minute ventilation, knee pain and perceived exertion were measured during submaximal exercise tests (0 and 40% body weight support) conducted 1 week apart. RESULTS At rest there were no differences in blood pressure across different treadmill pressures, but heart rate was significantly lower when 30 mmHg was applied compared to ambient pressure conditions (P < 0.05). Participants averaged 5.1 exercise test stages with 0% body weight support (maximum speed 2.5 mph, 0% incline) and 6.4 stages with 40% body weight support (maximum speed 3.0 mph, 10% incline). During exercise, heart rate, systolic blood pressure, oxygen consumption, and minute ventilation were lower when 40% body weight support was provided for a given test stage (P < 0.01). Diastolic blood pressure, knee pain and perceived exertion did not differ with body weight support but increased with increasing exercise test stages (P < 0.05). CONCLUSIONS Provision of body weight support allowed TKA patients to walk at faster speeds and/or to tolerate greater incline with relatively lower levels of heart rate, blood pressure, and oxygen consumption.
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Affiliation(s)
- Sandra C Webber
- Department of Physical Therapy, School of Medical Rehabilitation, Faculty of Medicine, University of Manitoba, R106-771 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada,
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Turolla A, Dam M, Ventura L, Tonin P, Agostini M, Zucconi C, Kiper P, Cagnin A, Piron L. Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial. J Neuroeng Rehabil 2013; 10:85. [PMID: 23914733 PMCID: PMC3734026 DOI: 10.1186/1743-0003-10-85] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 06/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent evidence has demonstrated the efficacy of Virtual Reality (VR) for stroke rehabilitation nonetheless its benefits and limitations in large population of patients have not yet been studied. OBJECTIVES To evaluate the effectiveness of non-immersive VR treatment for the restoration of the upper limb motor function and its impact on the activities of daily living capacities in post-stroke patients. METHODS A pragmatic clinical trial was conducted among post-stroke patients admitted to our rehabilitation hospital. We enrolled 376 subjects who had a motor arm subscore on the Italian version of the National Institutes of Health Stroke Scale (It-NIHSS) between 1 and 3 and without severe neuropsychological impairments interfering with recovery. Patients were allocated to two treatments groups, receiving combined VR and upper limb conventional (ULC) therapy or ULC therapy alone. The treatment programs consisted of 2 hours of daily therapy, delivered 5 days per week, for 4 weeks. The outcome measures were the Fugl-Meyer Upper Extremity (F-M UE) and Functional Independence Measure (FIM) scales. RESULTS Both treatments significantly improved F-M UE and FIM scores, but the improvement obtained with VR rehabilitation was significantly greater than that achieved with ULC therapy alone. The estimated effect size of the minimal difference between groups in F-M UE and FIM scores was 2.5 ± 0.5 (P < 0.001) pts and 3.2 ± 1.2 (P = 0.007) pts, respectively. CONCLUSIONS VR rehabilitation in post-stroke patients seems more effective than conventional interventions in restoring upper limb motor impairments and motor related functional abilities. TRIAL REGISTRATION Italian Ministry of Health IRCCS Research Programme 2590412.
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Affiliation(s)
- Andrea Turolla
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
| | - Mauro Dam
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
| | - Laura Ventura
- Department of Statistics, University of Padova, Via Cesare Battisti, 241 – 35121 Padova, Italy
| | - Paolo Tonin
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
| | - Michela Agostini
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
| | - Carla Zucconi
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
| | - Pawel Kiper
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
| | - Annachiara Cagnin
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
- Department of Neuroscience: SNPSRR, University of Padova, Via Giustiniani, 5 – 35128 Padova, Italy
| | - Lamberto Piron
- I.R.C.C.S. Fondazione Ospedale San Camillo, Via Alberoni, 70-30126 Venezia-Lido, Italy
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PROSSER LAURAA, OHLRICH LAURIEB, CURATALO LINDSEYA, ALTER KATHARINEE, DAMIANO DIANEL. Feasibility and preliminary effectiveness of a novel mobility training intervention in infants and toddlers with cerebral palsy. Dev Neurorehabil 2012; 15:259-66. [PMID: 22670679 PMCID: PMC3594802 DOI: 10.3109/17518423.2012.687782] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To design a novel mobility training intervention incorporating infant motor learning and neurorehabilitation principles and investigate its feasibility, tolerability and effect on motor development in toddlers with cerebral palsy (CP). METHODS A single-subject research design with repeated measures during 6-week baseline and intervention phases and after treatment withdrawal was used. Five participants attended therapy utilizing novel dynamic weight assistance technology, which allowed practice of motor skills beyond participants' current abilities. RESULTS Average attendance and engagement rates exceeded 90%. Gains in gross motor function were observed after treatment that exceeded the expected rate in four of the five participants. Rates of motor development during treatment were 10.8, 3.8, 7.0, 15.1, and 0.3 times greater than during baseline for the five participants, respectively. CONCLUSIONS This intervention was tolerated and demonstrated the potential to alter the trajectory of motor development in CP, providing proof of concept for further investigation.
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Affiliation(s)
- LAURA A. PROSSER
- Division of Rehabilitation Medicine, The Children’s Hospital of Philadelphia, PA, USA
| | - LAURIE B. OHLRICH
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - LINDSEY A. CURATALO
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - KATHARINE E. ALTER
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA,Department of Physical Medicine, Mount Washington Pediatric Hospital, Baltimore, MD, USA
| | - DIANE L. DAMIANO
- Functional & Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
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