Maximal Aerobic and Anaerobic Exercise Responses in Children with Cerebral Palsy

Validation of the 6-Minute Frame Running Test as a Cardiopulmonary Exercise Test for Adolescents and Young Adults With Cerebral Palsy

BACKGROUND

Individuals with cerebral palsy (CP) are at risk of poor health due to low aerobic fitness, yet valid assessment methods are limited, especially for individuals with severe CP. This study validated the 6-Minute Frame Running Test (6-MFRT) for assessing aerobic capacity in adolescents and young adults with CP.

METHOD

Cardiorespiratory responses, blood lactate levels, and subjective exertion during the 6-MFRT were compared with data from the Frame Running Incremental Treadmill Test (FRITT) in 16 participants with CP, age 23 (6.5) years, with Gross Motor Function Classification System Levels II-V.

RESULTS

A strong correlation was found between peak oxygen uptake (VO2peak) in the 6-MFRT and FRITT (r = .95, p < .001) and between 6-MFRT distance and VO2peak (r = .71, p = .005). No significant difference in VO2peak was observed between tests (p = .186).

CONCLUSION

The 6-MFRT is a field test for estimating aerobic capacity in frame-running athletes with CP.

Quantifying altered oxygen kinetics and reducing metabolic test times for children with cerebral palsy: a dual-exponential Bayesian modeling approach

Prior research using indirect calorimetry has shown that children with cerebral palsy (CP) exhibit significantly increased energetic costs during walking. However, metabolic testing to obtain oxygen cost is challenging. As a result, differences in oxygen uptake kinetics (V̇o2) in CP compared with their typically developing peers remain unexplored. Step changes in work rate have been shown to result in an exponential V̇o2 response with three distinct phases 1) cardiodynamic, 2) primary, and 3) steady-state. Here, we applied a dual-exponential Bayesian model to assess the time constant of the primary phase V̇o2 response from resting to walking in children with CP. In addition, we evaluated the model's ability to estimate steady-state V̇o2 using shorter test durations. From a sample of 263 children with CP, the median V̇o2 time constant was 33.1 s (5th-95th percentile range: 14.5-69.8 s), significantly longer than reported values for typically developing children (range of means: 10.2-31.6 s). Furthermore, the model accurately estimated steady-state V̇o2 using only the first 3 min of metabolic data compared with the typical 6 min used in current clinical practice. The 3-min estimate explained >95% of the 6-min estimate variance, with <5% mean absolute error. Slower oxygen kinetics in children with CP suggest impairments in metabolic control, potentially contributing to their higher energy demands. Although the exact mechanisms remain unclear, this study provides valuable insights into the walking energetics of children with CP and presents a more efficient method for analyzing V̇o2 for this population.NEW & NOTEWORTHY We used a Bayesian model to study oxygen kinetics in children with CP. First, we quantified the oxygen kinetics time constant, finding no significant differences across GMFCS, sex, or age despite slower kinetics compared with typically developing peers. Next, we validated the model's ability to estimate steady-state V̇o2 with only 3 min of data, halving the usual testing time. This method has important implications for faster, accurate metabolic analyses in clinical and research settings.

Efficacy of in-person and telepractice-based extended Lee Silverman Voice Treatment LOUD® on dysarthria and dysphagia in adults with cerebral palsy

Objective

With advancements in digital health technologies, telepractice has become crucial for providing accessible medical interventions. Cerebral palsy (CP) frequently results in comorbidities including dysarthria and dysphagia, leading to restrictions in activities. This study evaluates the efficacy of both in-person and telepractice-based intensive voice therapy in improving speech, swallowing functions, and related quality of life measures in adults with CP.

Methods

The Lee Silverman Voice Treatment (LSVT) LOUD®, a speech-behavior therapy, was administered to 16 CP subjects (9 men and 7 women; mean age = 43.4 ± 10.43 years) via in-person extended version of LSVT LOUD® (LSVT-X), and telepractice program of LSVT-X (LSVT-X e-LOUD®). Outcomes, including maximum phonation time (MPT), voice intensity, diadochokinetic rate (DDK), Voice Handicap Index (VHI), swallowing quality of life (SWAL-QOL), and Videofluoroscopic Dysphagia Scale (VDS), were assessed pre- and post-treatment.

Results

Significant improvements were noted in speech functions: MPT (p = 0.006), voice intensity (p = 0.004), DDK /puh/ (p = 0.043), and DDK/puh-tuh-kuh/ (p = 0.031). Swallowing function improved significantly in the pharyngeal phase on the VDS. Quality of life measures showed improvement in physical (p = 0.003), emotional (p = 0.000), total score of VHI (p = 0.001), fear (p = 0.031), sleep (p = 0.013), fatigue (p = 0.003), and total score of SWAL-QOL (p = 0.019). These improvements were consistent in both LSVT-X and LSVT-X e-LOUD® groups.

Conclusions

Both in-person and telepractice-based LSVT-X enhance speech, swallowing functions, and quality of life in adults with CP. LSVT-X e-LOUD® can be utilized as a digital therapeutic intervention for dysphagia and dysarthria, offering accessible and flexible treatment options aligned with digital health advancements.

Aerobic fitness in children with cerebral palsy compared to typically developing peers: A systematic review and meta-analysis

BACKGROUND

In the public health domain, aerobic fitness is an important predictor of both health and disease.

OBJECTIVE

To determine aerobic fitness in children with cerebral palsy (CP) compared to typically developing (TD) peers measured with a maximal exercise test.

METHODS

A systematic literature search was conducted in PubMed (MEDLINE), PsycArticles, PsycInfo, CINAHL, and SPORTDiscus (EBSCO). Original studies that reported findings on aerobic fitness expressed as peak oxygen uptake (VO2peak) during a maximal exercise test measured with a gas analysis system, in children with CP, aged 18 years or younger, were included. VO2peak values were pooled, using the generic inverse variance method, for type of maximal exercise test, Gross Motor Function Classification System (GMFCS) level, distribution of CP, and sex.

RESULTS

Thirty-six studies with a total of 510 children with CP (GMFCS I-IV) and 173 TD peers were included. VO2peak was measured using cycle ergometer test (n = 16), treadmill exercise test (n = 13), arm crank ergometer test (n = 6), shuttle run test (n = 3), and shuttle ride test (n = 1). The overall pooled VO2peak in children with CP was 32.84 mL/kg/min (SE 1.28) and 45.02 mL/kg/min (SE 1.32) in TD peers, with a difference between CP and TD of -12.17 mL/kg/min (95% CI: -16.70, -7.64). Subgroup analyses revealed that aerobic fitness was most compromised in children at higher GMFCS levels and boys with CP.

CONCLUSION

Aerobic fitness is severely compromised in children with CP. Promoting a healthy lifestyle and increasing participation in physical activities for young people with CP is recommended. The study protocol was prospectively registered in the PROSPERO registry with reference number CRD42021292879.

Effect of Cardiovascular Endurance Training on the Exercise Capacity and Endurance in Children With Cerebral Palsy

BACKGROUND

Cerebral palsy (CP) is non-progressive brain damage that occurs before, during, or shortly after birth. CP is associated with poor physical fitness, which is linked to health problems and the development of secondary illnesses like obesity, cardiovascular disease, and diabetes. Compared to healthy peers without CP, children with CP have considerably lower VO2 peaks, which reduces their performance and aerobic capacity.

OBJECTIVE

This study aimed to evaluate changes in exercise capacity and endurance among children with CP, as well as fatigue levels among their parents and caregivers, after participation in cardiovascular endurance training.

METHODOLOGY

This study included 16 children aged 7-12 years with CP (Gross Motor Function Classification System levels I, II, or III). Participants completed a 12-week cardiovascular endurance program consisting of 60-minute sessions three times weekly designed to achieve 64-95% of their heart rate maximum,based on the American College of Sports Medicine guidelines. Pre- and post-intervention measurements were recorded for the following: distance covered in a six-minute walk, maximal oxygen consumption (VO2 max) level, Early Activity Scale for Endurance rating, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Fatigue Scale score and PROMIS Parent Proxy Scale and Fatigue Scale scores.  Result: Upon completing the cardiovascular endurance training, the distance covered during a six-minute walk improved by 20.95 points, resting heart rate by 5.19 points, VO2 max by 0.06 points, Early Activity Scale for Endurance by 4.06 points, PROMIS Pediatric Fatigue Scale by 7.29 points, PROMIS Parent Proxy Scale by 6.81 points, and PROMIS Fatigue Scale by 5.07 points. The maximum heart rate also showed a slight improvement of 0.33 points (p<0.01).

CONCLUSION

A structured exercise protocol aimed at improving cardiovascular endurance can benefit children with CP by improving their exercise capacity and endurance, which in turn can help decrease fatigue levels among their parents and caregivers.

Telehealth Movement-to-Music With Arm-Based Sprint-Intensity Interval Training to Improve Cardiometabolic Health and Cardiorespiratory Fitness in Children With Cerebral Palsy: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Children with mobility disabilities, including those with cerebral palsy, have limited options and limited time to exercise to manage their cardiometabolic health and cardiorespiratory fitness. Regular cardiovascular exercise during childhood is a critical health behavior for preventing health decline in adulthood. Thus, there is an urgent need for accessible, age-appropriate, convenient exercise modalities in this group. Sprint-intensity interval training (SIT), combined with telehealth procedures, may be ideal for children with disabilities. SIT includes repetitive bouts of maximal exercise effort combined with rest periods, which can be effective in eliciting comparable results to moderate-exercise training with very short training durations.

OBJECTIVE

This phase 1 pilot feasibility randomized controlled trial aims to investigate the potential effects of a 12-week SIT program on indicators of cardiorespiratory fitness and cardiometabolic health among children with cerebral palsy. An ancillary aim is to evaluate the feasibility of the program through several process feasibility metrics.

METHODS

This study uses a 2-armed parallel group design. A total of 50 physically inactive children with cerebral palsy (aged 6-17 years) will be randomly allocated into 1 of 2 groups: a 12-week SIT or a waitlist control group that continues habitual activity for 12 weeks. The SIT prescription includes 3 tele-supervised sessions per week with 30 repeated sequences of 4 seconds of maximal arm exercise, with active recovery, warm-up, and cooldown periods (for an approximately 20-minute total session). SIT includes guided videos with child-themed arm routines and music. The exercise sessions will be remotely supervised through a web-based videoconference application and include safety monitoring equipment. Outcomes are measured at pre- and postintervention (weeks 0 and 13, respectively). Health outcome measures include peak oxygen consumption (VO2 peak), measured by a graded exercise test; high-sensitivity C-reactive protein and blood insulin, hemoglobin A1c, triglycerides, and cholesterol using a finger stick dried blood spot test; blood pressure, using a sphygmomanometer; and body composition (total mass, total lean mass, tissue % lean, and tissue % fat) using dual x-ray absorptiometry. Feasibility will be evaluated by the following metrics: adverse events or problems experienced throughout the intervention related to participant safety; perceived enjoyment; and recruitment, enrollment, and attrition rates.

RESULTS

Recruitment procedures started in November 2023. All data are anticipated to be collected by February 2025. Full trial results are anticipated to be analyzed and submitted for publication by March 2025. Secondary analyses of data will be subsequently published.

CONCLUSIONS

This trial tests an accessible and low-cost exercise program that leverages principles of high-intensity exercise to provide a convenient program for children with physical disabilities. Knowledge obtained from this study will inform the development of a larger trial for improving the cardiometabolic health, cardiorespiratory fitness, and well-being of children with physical disabilities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05619211; https://clinicaltrials.gov/study/NCT05619211.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56499.

Fatigue-related gait adaptations in children with cerebral palsy

AIM

To obtain insights into the effects of fatigue on the kinematics, kinetics, and energy cost of walking (ECoW) in children with cerebral palsy (CP).

METHOD

In this prospective observational study, 12 children with CP (mean age 12 years 9 months, SD 2 years 7 months; four females, eight males) and 15 typically developing children (mean age 10 years 8 months, SD 2 years 4 months; seven females, eight males) followed a prolonged intensity-based walking protocol on an instrumented treadmill, combined with gas analysis measurements. The protocol consisted of consecutive stages, including a 6-minute walking exercise (6MW) at comfortable speed, 2 minutes of moderate-intensity walking (MIW) (with a heart rate > 70% of its predicted maximal), and 4 minutes walking after MIW. If necessary, the speed and slope were incremented to reach MIW. Outcomes were evaluated at the beginning and end of the 6MW and after MIW.

RESULTS

With prolonged walking, Gait Profile Scores deteriorated slightly for both groups (p < 0.01). Knee flexion increased during early stance (p = 0.004) and ankle dorsiflexion increased during late stance (p = 0.034) in children with CP only. Negligible effects were found for kinetics. No demonstrable change in ECoW was found in either group (p = 0.195).

INTERPRETATION

Kinematic deviations in children with CP are progressive with prolonged walking. The large variation in adaptations indicates that an individual approach is recommended to investigate the effects of physical fatigue on gait in clinical practice.

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

PURPOSE

To determine the physiological response and association to peak oxygen uptake of the 6-minute Frame Running test (6-MFRT) in persons with cerebral palsy (CP).

METHODS

Twenty-four participants with CP, Gross Motor Function Classification System II/III/IV, performed the 6-MFRT. Distance, peak heart rate (HR peak ), peak respiratory exchange ratio (RER peak ), and peak oxygen uptake ( O 2peak ) were measured.

RESULTS

HR peak ranged from 146 to 201 beats per minute, RER peak from 0.94 to 1.49, 6-MFRT distance from 179 to 1220 m and O 2peak from 0.62 to 2.18 L/min. HR peak was achieved in 63%, RER peak in 71%. A strong correlation was observed between 6-MFRT and O 2peak .

CONCLUSIONS

The 6-MFRT represented a (near) maximum effort for 75% of the participants and the 6-MFRT can be used to estimate oxygen consumption on an individual basis.

Effect of Lower Extremity Muscle Strength on Aerobic Capacity in Adults with Cerebral Palsy

The purpose of this study is to analyze the effect of lower extremity muscle strength of HIP joint and KNEE joint on the aerobic capacity to provide the basic data for developing an exercise program that can effectively improve the aerobic capacity of adults with cerebral palsy (CP) by identifying the part of the lower extremity muscle. A total of 18 ambulant adults with CP were recruited for this study. Seven ambulant adults with CP were excluded because they did not achieve the criteria of maximal exercise. The data from 11 subjects (11 men) with CP were used for the analysis. The mean (±SD) age, height, weight, and BMI of the subjects were 37.00 ± 12.72 years, 170.45 ± 6.37 cm, 67.02 ± 8.62 kg, and 23.09 ± 2.78 kg/m2, respectively. To measure the muscle strength of HIP joint and KNEE joint in lower extremities, the variables of the isokinetic muscle strength and the muscular endurance were performed using the isokinetic equipment (Biodex Co., Shirley, NY, USA). For the isokinetic muscle strength measurement of HIP joint, the 45°/sprotocol indicating the muscle power and the 300°/s protocol indicating the muscle endurance were used. Additionally, the measurement of KNEE joint was performed once on the left and right side, using the protocol of 60°/s indicating the muscle power and 300°/s indicating the muscular endurance. Progressive exercise tests were conducted on the treadmill (Quinton model—4500) using previously developed protocols targeting CP. The initial protocol speeds were 5 km/h−1 and 2 km/h−1 for the subjects who have been classified as Gross Motor Function Classification System (GMFCS) level I and II, respectively. Using a portable cardiopulmonary indirect breath-by-breath calorimetry system (MetaMax 3B; Cortex Biophysik, Leipzig, Germany), pulmonary ventilation (VE), respiratory exchange ratio (RER), and oxygen uptake (VO2) have been persistently measured. HR monitor (Polar Electro, Kempele, Finland polar Co. RS-800) was used to measure heart rate (HR). A correlation analysis was conducted to find out how the lower extremity muscle strength and aerobic capacity with cerebral palsy are related. Therefore, as a result, VO2peak among aerobic capacity displayed a significant positive correlation in 45° and 300°/s peak torque/BW of HIP joint, and with 60° and 300°/s peak torque/BW of KNEE joint. It was the same with 60°/s Agon/Antag ratio of KNEE Joint (p < 0.05). VEpeak showed a significant positive correlation with 45° and 300°/s peak torque/BW of HIP joint, as well as correlation with 60° and 300°/s peak torque/BW and 60°/s Agon/Antag ratio of KNEE joint (p < 0.05). However, HRpeak showed a significant positive correlation only in 45°/s peak torque/BW of HIP joint (p < 0.05). The result of step-wise analysis was to find out which muscle strength significantly affects VO2peak and HRpeak among aerobic abilities in the lower extremity muscles of those disabled with cerebral palsy. Among the muscle functions of lower extremity muscle strength, 300°/s peak torque/BW of KNEE Joint was found to have the greatest effect on VO2peak (p < 0.001). As a result, 300°/s peak torque/BW of KNEE Joint was found to be the predictable factor that could explain the VO2peak in the disabled people with cerebral palsy at 67% (R2 = 0.661). In particular, among the muscle functions of lower extremity muscle strength at 45°/s peak, torque/BW of HIP Joint was found to have the greatest effect on HRpeak (p < 0.001). As a result, this factor was found to be the predictable factor that could explain the HRpeak in disabled people with cerebral palsy at 39% (R2 = 0.392). In this study, the muscle strength of the lower extremity of CP was closely related to the aerobic capacity, and the muscle endurance of KNEE Joint and the muscle power of HIP Joint were found to be important factors to predict the aerobic capacity of CP.

The effect of prolonged walking on muscle fatigue and neuromuscular control in children with cerebral palsy

BACKGROUND

Muscle fatigue of the lower limbs is considered a main contributor to the perceived fatigue in children with cerebral palsy (CP) and is expected to occur during prolonged walking. In adults without disabilities, muscle fatigue has been proposed to be associated with adaptations in complexity of neuromuscular control.

RESEARCH QUESTION

What are the effects of prolonged walking on signs of muscle fatigue and complexity of neuromuscular control in children with CP?

METHODS

Ten children with CP and fifteen typically developing (TD) children performed a standardised protocol on an instrumented treadmill consisting of three stages: six-minutes walking at preferred speed (6 MW), moderate-intensity walking (MIW, with two minutes at heart rate > 70% of predicted maximal heart rate) and four-minutes walking at preferred speed (post-MIW). Electromyography (EMG) data were analysed for eight muscles of one leg during three time periods: 6 MW-start, 6 MW-end and post-MIW. Signs of muscle fatigue were quantified as changes in EMG median frequency and EMG root mean square (RMS). Complexity of neuromuscular control was quantified by total variance accounted for by one synergy (tVAF1). Muscle coactivation was assessed for antagonistic muscle pairs.

RESULTS

EMG median frequency was decreased at 6 MW-end and post-MIW compared to 6 MW-start in children with CP (p < 0.05), but not in TD children. In both groups, EMG-RMS (p < 0.01) and muscle coactivation (p < 0.01) were decreased at 6 MW-end and post-MIW compared to 6 MW-start. tVAF1 decreased slightly at 6 MW-end and post-MIW compared to 6 MW-start in both groups (p < 0.05). Changes were most pronounced from 6 MW-start to 6 MW-end.

SIGNIFICANCE

Children with CP presented signs of muscle fatigue after prolonged walking, while no effects were found for TD. Both groups showed minimal changes in tVAF1, suggesting signs of muscle fatigue are not associated with changes in complexity of neuromuscular control.

Comparison of Anaerobic Exercise Capacity in Children With Familial Mediterranean Fever and Healthy Controls

BACKGROUND/OBJECTIVE

Anaerobic exercise capacity is an important component of performing daily activities during childhood. However, diminished anaerobic exercise capacity has been reported in children with chronic conditions. Therefore, the aim of this study was to compare anaerobic exercise capacities between children with familial Mediterranean fever (FMF) and healthy peers.

METHODS

Twenty-one children with FMF (FMF group) and 21 physically matched healthy controls (control group) were included. Peak power, peak power/kg, average power, and average power were evaluated using the Wingate Anaerobic Test.

RESULTS

The peak power (FMF group: 254.8 W [IQR 25/75: 216.4/293.0 W] vs control group: 333.7 W [IQR 25/75: 241.3/570.5 W], p = 0.009), peak power/kg (FMF group: 6.3 W/kg [IQR 25/75: 5.2/7.0 W/kg] vs control group: 7.0 W/kg [IQR 25/75: 6.1/8.6 W/kg], p = 0.046), average power (FMF group: 186.0 W [IQR 25/75: 164.3/211.2 W] vs control group: 231.8 W [IQR 25/75: 181.8/338.1 W], p = 0.006), and average power/kg (FMF group: 4.5 W/kg [IQR 25/75: 3.8/5.0 W/kg] vs control group: 5.1 W/kg [IQR 25/75: 4.2/5.9 W/kg], p = 0.040) were found significantly higher in the control group compared with FMF group.

CONCLUSIONS

Children with FMF seems to have diminished anaerobic exercise capacity compared with their healthy peers.

Energetics of walking in individuals with cerebral palsy and typical development, across severity and age: A systematic review and meta-analysis

BACKGROUND

Individuals with cerebral palsy (CP) report physical fatigue as a main cause of limitation, deterioration and eventually cessation of their walking ability. A consequence of higher level of fatigue in individuals with CP leads to a less efficient and long-distance walking ability.

RESEARCH QUESTION

This systematic review investigates the difference in 1) walking energy expenditure between individuals with CP and age-matched typically developing (TD) individuals; and 2) energetics of walking across Gross Motor Function Classification System (GMFCS) levels and age.

METHODS

Five electronic databases (PubMed, Web of Science, CINAHL, ScienceDirect and Scopus) were searched using search terms related to CP and energetics of walking.

RESULTS

Forty-one studies met inclusion criteria. Thirty-one studies compared energy expenditure between CP and age-matched controls. Twelve studies correlated energy expenditure and oxygen cost across GMFCS levels. Three studies investigated the walking efficiency across different ages or over a time period. A significant increase of energy expenditure and oxygen cost was found in individuals with CP compared to TD age-matched individuals, with a strong relationship across GMFCS levels.

SIGNIFICANCE

Despite significant differences between individuals with CP compared to TD peers, variability in methods and testing protocols may play a confounding role. Analysis suggests oxygen cost being the preferred/unbiased physiological parameter to assess walking efficacy in CP. To date, there is a knowledge gap on age-related changes of walking efficiency across GMFCS levels and wider span of age ranges. Further systematic research looking at longitudinal age-related changes of energetics of walking in this population is warranted.

Effect of Community-Based Functional Aerobic Training on Motor Performance and Quality of Life of Children with Spastic Cerebral Palsy

Background

Efficacies of community-based exercise programmes have been well reported but there is scarce information on the expediency of community-based rehabilitation in a society where many of children with disabilities live in poorly resourced settings with extremely limited rehabilitative services. The study investigated the effects of community-based functional aerobic exercise (CBFAE) on gross motor function, walking distance, and quality of life of children with cerebral palsy (CP).

Methods

Quasi-experimental design was used. Children with gross motor function classification system (GMFCS) levels I – II participated in eight weeks CBFAE training four times/week, 50 minutes/day at 40–80% maximum heart rate. Gross motor function (GMF), walk distance and quality of life were assessed pre and post CBFAE training.

Results

Significant improvement observed in GMF (Dstanding) (8.2%, P=.000), GMF (E-walking+running+jumping (5.12%, P=.004), walking distance (6.09%, P=.009). Higher significant positive effects of CBFAE observed in Social wellbeing and acceptance (107.10%, P=.000), and participation and physical health (105.04%, P=.005) by children parent proxy. Self-reported results showed that for CBFAE, significant positive improvements were higher in Pain and impact of disability (67.93%, P=.049) and Participation and physical health (60.00%, P=.042).

Conclusion

CBFAE training contributes majorly to improved standing, walking, jumping and running and selfesteem, quality of life of children with spastic CP. Clinicians and exercise therapists should essentially incorporate CBFAE training and activities into the management of children with CP for improved mobility and functional performances.

Effect of Community-Based Functional Aerobic Training on Motor Performance and Quality of Life of Children with Spastic Cerebral Palsy

Background

Efficacies of community-based exercise programmes have been well reported, but there is scarce information on the expediency of community-based rehabilitation in a society where many children with disabilities live in poorly resourced settings with extremely limited rehabilitative services. This study investigated the effects of community-based functional aerobic exercise (CBFAE) on gross motor function, walking distance, and quality of life of children with cerebral palsy (CP).

Methods

Quasi-experimental design was used. Children with gross motor function classification system (GMFCS) levels I – II participated in eight weeks CBFAE training four times/week, 50 minutes/day at 40–80% maximum heart rate. Gross motor function (GMF), walking distance and quality of life were assessed pre and post CBFAE training.

Results

Significant improvement was observed in GMF (Dstanding) (8.2%, P=.000), GMF (E-walking + running+ jumping (5.12%, P=.004), walking distance (6.09%, P=.009). Higher significant positive effects of CBFAE were observed in Social wellbeing and acceptance (107.10%, P=.000), and participation and physical health (105.04%, P=.005) by children parent proxy. Self-reported results showed that for CBFAE, significant positive improvements were higher in pain and impact of disability (67.93%, P=.049) and participation and physical health (60.00%, P=.042).

Conclusion

CBFAE training contributes majorly to improved standing, walking, jumping and running and self-esteem, quality of life of children with spastic CP. Clinicians and exercise therapists should essentially incorporate CBFAE training and activities into the management of children with CP for improved mobility and functional performances.

Safety and feasibility of symptom-limited cardiopulmonary exercise test using the modified Naughton protocol in children with cerebral palsy: An observational study

ABSTRACT

Variables derived from the cardiopulmonary exercise test (CPX) provide objective information regarding the exercise capacity of children with cerebral palsy (CP), which can be used as the basis for exercise recommendations. Performing maximal CPX might not be appropriate, safe, or practical for children with CP. In the present study, the safety and feasibility of symptom-limited CPX using the modified Naughton protocol, a submaximal protocol, were investigated in children with CP, Gross Motor Function Classification System (GMFCS) level I or II. The present study included 40 children aged 6 to 12 years with CP who underwent symptom-limited CPX. CPX was performed to measure cardiopulmonary fitness using a treadmill with a modified Naughton protocol. Motor capacity was assessed using the Gross Motor Function Measure (GMFM), Pediatric Balance Scale (PBS), Timed Up and Go (TUG) test, and 6-minute walk test. Thirty-seven children with CP successfully completed testing without any adverse events during or immediately after CPX (dropout rate 7.5%). The reason for test termination was dyspnea (51.4%) or leg fatigue (48.6%). Based on the respiratory exchange ratio (RER), 21 of 37 (56.8%) children chose premature termination. The relationship between the reason for test termination and RER was not statistically significant (Spearman rho = 0.082, P = .631). CPX exercise time was strongly correlated with GMFM (Spearman rho = 0.714) and moderate correlation with PBS (Spearman rho = 0.690) and TUG (Spearman rho = 0.537). Peak oxygen uptake during CPX showed a weak correlation with GMFM and a moderate correlation with PBS. This study revealed that symptom-limited CPX using the modified Naughton protocol was safe and feasible for children with CP and GMFCS level I or II.

Impact of the Paralympic Games on the Beliefs of Children with Physical Disabilities Engaging in Sports and Physical Activities: A Chinese Perspective

The purpose of this qualitative study was to explore the beliefs of Chinese children with physical disabilities engaging in sports and physical activity (PA), and the impact of the Paralympic Games on these beliefs. Five Chinese children with physical disabilities (female = 2, male = 3) were recruited for participating in the workshops of the Paralympic Games and PA, and received individual semi-structured interviews before and after the workshop implementations. Interview transcripts were analysed and presented as descriptive summaries. Three themes emerged based on the analysis of the participants' interview data: (1) shocked, knowledgeable, and useful; (2) willingness to try, and (3) hope to obtain support. Results indicated that children with physical disabilities in this study acknowledged the positive outcomes of participating in the workshops of the Paralympic Games on the sports and PA engagement attitude change. However, children with disabilities also expressed that they need more related knowledge and information. The results of the study revealed that impairment and contextual factors (i.e., lack of support from family and physical education teachers, unsafe environments, and negative attitudes of peers without disabilities) were barriers to sports and PA engagement among children with physical disabilities in this study.

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

PURPOSE

To evaluate whether changes in lower-limb muscle strength explain changes in walking capacity during 14-week periods of usual care, power training and follow-up for children with spastic cerebral palsy.

METHODS

Secondary analysis of a previously conducted double-baseline controlled trial of 22 children with spastic cerebral palsy. Generalized estimating equations were used to evaluate the relationships between within-subject changes in isometric muscle strength and walking capacity over 3 periods.

RESULTS

Changes in hip abductor strength were associated with changes in the Muscle Power Sprint Test, changes in gastrocnemius and hip abductor strength were associated with changes in the Shuttle Run Test, and changes in gastrocnemius strength were associated with changes in the 1-minute walk test. All associations supported better walking capacity with increased strength.

CONCLUSION

Walking capacity, especially sprint capacity, can be improved by increasing strength by functional power training in this population.

Aquatic high intensity interval training to improve aerobic capacity is feasible in adolescents with cerebral palsy: pilot randomised controlled trial

OBJECTIVE

To investigate feasibility of aquatic high intensity interval training for adolescents with cerebral palsy, who can ambulate independently but may choose a mobility aid in some circumstances.

DESIGN

Pilot randomised controlled trial.

METHOD

Following baseline assessments, participants were randomised to usual care or ten weeks of twice weekly aquatic high intensity interval training. Each class comprised 10 one-minute exercise intervals separated by one-minute rest. High intensity exercise was defined as the attainment of ⩾80% of peak heart rate measured by telemetry.

SETTING

Tertiary paediatric hospital.

MAIN MEASURES

Primary outcomes related to the feasibility of the protocol to progress to a definitive trial. Consumer feedback was obtained.

RESULTS

Of 119 potential participants, 46 appeared eligible and 17 consented, resulting in a recruitment fraction of 37% (95% CI 23-52). Twelve completed baseline assessments and were randomised (5 males; 14 years 7 months SD 2 years 0 months). In the intervention group, of the 1190 exercise stations (across all participants and sessions), heart rate data were available for 1180 stations and high intensity exercise was achieved during 1111 stations (93%, 95% CI 92-95). All randomised participants completed the study and reported that the intervention was fun and provided friendship opportunities. There were no major adverse events or exacerbation of pain.

CONCLUSIONS

Aquatic high intensity interval training in ambulant adolescents with cerebral palsy is feasible, while maintaining adherence and fidelity. Uncertainty remains on the efficacy of the intervention, highlighting the need for a large definitive trial.

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

PURPOSE

To examine whether general fatigue and fatigue during or after walking are related to energy demands during walking and physical fitness in children and young adults with physical disabilities.

METHODS

Sixty-eight individuals with physical disabilities participated. General fatigue (Checklist Individual Strength [CIS8R] questionnaire), walking-induced fatigue (OMNI [OMNIwalk] scale after walking for 6 min), gross and net energy costs (ECs) of walking, physical strain of walking, and aerobic and anaerobic fitness were measured.

RESULTS

Regression analyses showed no relations with the CIS8R. For all participants, a higher net EC was weakly related to an increased OMNIwalk. For teenagers only, low anaerobic fitness and high physical strain of walking values were moderately related to high OMNIwalk scores.

CONCLUSION

Low anaerobic fitness and high physical strain values partly explain fatigue after walking in teenagers with cerebral palsy, but not in younger children. General fatigue was not explained by low fitness levels or high energy demands of walking.

Evidence-based Approach to Physical Therapy in Cerebral Palsy

Physiotherapy plays a key role in the management of cerebral palsy (CP) and comprises of various therapeutic interventions in enhancing the various physiological and functional outcomes. Though physiotherapy is used widely and recommended by all members of the health-care team, the effectiveness of physiotherapy is inconsistent. The objective of this review was to summarize and evaluate the effectiveness of physiotherapy interventions in children with CP. PubMed and Cochrane database were searched from January 2006 to April 2017 using the Medical Subject Heading and general keywords. Only systematic reviews and meta-analysis on PT interventions in children diagnosed with CP were included. Two reviewers independently assessed the methodological quality and retrieved the results. Thirty-four systematic reviews were identified that distinguished 15 different interventions. Moderate evidence of effectiveness was found for constraint-induced movement therapy for upper limb recovery, goal-directed/functional training, and gait training to improve gait speed. Conflicting evidence was found for the role of exercises on strength training and cardiorespiratory training. Intervention such as neurodevelopmental therapy (NDT) was found ineffective. This review suffer from limitations such as including reviews that had small sample size and that had considered heterogeneity of treatment interventions. Hence, the effectiveness of most PT interventions is found to be limited. On the basis of the present evidence, functional goal-oriented approaches are found to be effective and future research is required to determine the best ways to improve functional outcomes in children with CP.

The impact of high and low-intensity exercise in adolescents with movement impairment

Five to six percent of young people have movement impairment (MI) associated with reduced exercise tolerance and physical activity levels which persist into adulthood. To better understand the exercise experience in MI, we determined the physiological and perceptual responses during and following a bout of exercise performed at different intensities typically experienced during sport in youth with MI. Thirty-eight adolescents (11-18 years) categorised on the Bruininks-Oseretsky Test of Motor Proficiency-2 Short-Form performed a peak oxygen uptake bike test ([Formula: see text]) test at visit 1 (V1). At visits 2 (V2) and 3 (V3), participants were randomly assigned to both low-intensity (LI) 30min exercise at 50% peak power output (PPO50%) and high-intensity (HI) 30s cycling at PPO100%, interspersed with 30s rest, for 30min protocol (matched for total work). Heart rate (HR) and rating of perceived exertion (RPE) for legs, breathing and overall was measured before, during and at 1, 3 and 7-min post-exercise (P1, P3, P7). There was a significant difference in [Formula: see text] between groups (MI:31.5±9.2 vs. NMI:40.0±9.5ml⋅kg-1⋅min-1, p<0.05). PPO was significantly lower in MI group (MI:157±61 vs. NMI:216±57 W)(p<0.05). HRavg during HI-cycling was reduced in MI (140±18 vs. 157±14bpm, p<0.05), but not LI (133±18 vs. 143±17bpm, p>0.05). Both groups experienced similar RPE for breathing and overall (MI:7.0±3.0 vs. NMI:6.0±2.0, p>0.05) at both intensities, but reported higher legs RPE towards the end (p<0.01). Significant differences were found in HRrecovery at P1 post-HI (MI:128±25.9 vs. NMI:154±20.2, p<0.05) but not for legs RPE. Perceived fatigue appears to limit exercise in youth with MI in both high and low-intensity exercise types. Our findings suggest interventions reducing perceived fatigue during exercise may improve exercise tolerance and positively impact on engagement in physical activities.

Body mass index and fitness in high-functioning children and adolescents with cerebral palsy: What happened over a decade?

BACKGROUND

In recent decades, improving fitness has become an important goal in rehabilitation medicine in children and adolescents with cerebral palsy (CP).

AIMS

To compare body mass index (BMI), performance-related fitness, and cardiorespiratory fitness of children with CP measured in 2014 with a comparable sample from 2004.

METHODS AND PROCEDURES

In total, 25 high-functioning children with CP (i.e., GMFCS I-II) measured in 2004 (13 boys; mean age 13.2 (2.6) years) were matched to 25 children measured in 2014. Outcomes included body mass and BMI, muscle power sprint test (MPST), 10×5m sprint test, and a shuttle run test (SRT). Data of 15 participants from 2004 (10 boys; mean age 12.6 (2.5) years) were matched and analysed for VO₂peak.

OUTCOMES AND RESULTS

Body mass and BMI were higher (both: p<0.05) in the 2014 cohort compared to the 2004 cohort. Further, performance-related fitness was better for the 2014 cohort on the MPST (p=0.004), the 10×5m sprint test (p=0.001), and the SRT (p<0.001). However, there were no differences for VO₂peak.

CONCLUSIONS AND IMPLICATIONS

In high-funcitoning children with CP, there are positive ecological time trends in performance-related fitness, but not in VO₂peak between 2004 and 2014. The substantial higher body mass and BMI is alarming and requires further investigation.

Evidence for increasing physical activity in children with physical disabilities: a systematic review

AIM

To summarize the best evidence of interventions for increasing physical activity in children with physical disabilities.

METHOD

A systematic review was conducted using an electronic search executed in Academic Search Elite, Academic Search Premier, CINAHL, Embase, MEDLINE, PEDro, PsychINFO, and SPORTDiscus up to February 2016. The selection of articles was performed independently by two researchers according to predetermined eligibility criteria. Data extraction, methodological quality, and levels of evidence were independently assessed by two researchers using a data-collection form from the Cochrane Collaboration and according to the guidelines of the American Academy for Cerebral Palsy and Developmental Medicine.

RESULTS

Seven studies were included. Five randomized controlled trials ranged from strong level I to weak level II studies, and two pre-post design studies were classified as level IV. There is level I evidence for no effect of physical training on objectively measured physical activity, conflicting level II evidence for interventions with a behavioural component on the increase of objectively measured physical activity directly after the intervention, and level II evidence for no effect during follow-up. Results are limited to children with cerebral palsy as no other diagnoses were included.

INTERPRETATION

Increasing physical activity in children with physical disabilities is very complex and demands further development and research.

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

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

Physical Strain: A New Perspective on Walking in Cerebral Palsy

OBJECTIVES

To describe (1) physical strain of walking, (2) the proportion of participants walking above the anaerobic threshold, and (3) 4 phenotypes of physical strain of walking on the basis of deviations in aerobic capacity and walking energy cost (EC) in children and adolescents with cerebral palsy (CP).

DESIGN

Cohort study.

SETTING

Academic medical center.

PARTICIPANTS

A sample (N=57) of participants (n=37; mean age, 13.5±4.0y) with CP (Gross Motor Function Classification System [GMFCS] levels I [n=13], II [n=17], and III [n=7]) and typically developing (TD) participants (n=20; mean age, 11.8±3.5y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Oxygen consumption (Vo₂walk), speed, and EC were determined during walking at a comfortable speed. Peak oxygen consumption (Vo₂peak) and anaerobic threshold were measured during a maximal cycling exercise test. Aerobic capacity was reduced if lower than the 10th percentile, and EC was increased if higher than 3SD. Physical strain was defined as follows: (Vo₂walk/Vo₂peak)×100.

RESULTS

Participants with CP had a higher physical strain (GMFCS level I, 55%±12% GMFCS level II, 62%±17%; GMFCS level III, 78%±14%) than did TD participants (40%±11%) (P<.001). Forty-three percent of participants with CP showed a Vo₂walk at or above their anaerobic threshold as compared with 10% of TD participants (P=.007). Phenotypes showed that a reduced Vo₂peak (n=9) or an increased EC (n=9) lead to an 18% to 20% higher physical strain, whereas a combination (n=12) leads to a 40% increase.

CONCLUSIONS

Children and adolescents with CP walk at a high physical strain, approximating intense exercise and a considerable proportion walks close to or above their anaerobic threshold, probably explaining fatigue and reduced walking distance. Both an increased EC and a reduced Vo₂peak contribute to high physical strain in children or adolescents with CP. The different causes of high physical strain in individuals with CP require different intervention strategies.

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

AIM

To determine the test-retest reliability and construct validity of a novel 6-Minute Racerunner Test (6MRT) in children and youth with cerebral palsy (CP) classified as Gross Motor Function Classification System (GMFCS) levels III and IV. The racerunner is a step-propelled tricycle.

METHODS

The participants were 38 children and youth with CP (mean age 11 y 2 m, SD 3 y 7 m; GMFCS III, n = 19; IV, n = 19). Racerunner capability was determined as the distance covered during the 6MRT on three occasions. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), and smallest detectable differences (SDD) were calculated to assess test-retest reliability.

RESULTS

The ICC for tests 2 and 3 were 0.89 (SDD 37%; 147 m) for children in level III and 0.91 for children in level IV (SDD 52%; 118 m). When the average of two separate test occasions was used, the SDDs were reduced to 26% (104 m; level III) and 37% (118 m; level IV). For tests 1 to 3, the mean distance covered increased from 345 m (SD 148 m) to 413 m (SD 137 m) for children in level III, and from 193 m (SD 100 m) to 239 m (SD 148 m) for children in level IV.

CONCLUSIONS

Results suggest high test-retest reliability. However, large SDDs indicate that a single 6MRT measurement is only useful for individual evaluation when large improvements are expected, or when taking the average of two tests. The 6MRT discriminated the distance covered between children and youth in levels III and IV, supporting construct validity.

Relations between muscle endurance and subjectively reported fatigue, walking capacity, and participation in mildly affected adolescents with cerebral palsy

AIM

To investigate the relation between muscle endurance and subjectively reported fatigue, walking capacity, and participation in mildly affected adolescents with cerebral palsy (CP) and peers with typical development.

METHOD

In this case-control study, knee extensor muscle endurance was estimated from individual load-endurance curves as the load corresponding to a 15-repetition maximum in 17 adolescents with spastic CP (six males, 11 females; age 12-19y) and 18 adolescents with typical development (eight males, 10 females; age 13-19y). Questionnaires were used to assess subjectively reported fatigue (Pediatric Quality of Life Inventory Multidimensional Fatigue Scale) and participation (Life-Habits questionnaire). Walking capacity was assessed using the 6-minute walk test. Relations were determined using multiple regression analyses.

RESULTS

Muscle endurance related significantly to subjectively reported fatigue and walking capacity in adolescents with CP, while no relations were found for adolescents with typical development (subjectively reported fatigue: regression coefficient β [95% confidence intervals] for CP=23.72 [6.26 to 41.18], for controls=2.72 [-10.26 to 15.69]; walking capacity β for CP=125m [-87 to 337], for controls=2m [-86 to 89]). The 15-repetition maximum did not relate to participation in adolescents with CP.

INTERPRETATION

Subjectively reported fatigue and reduced walking capacity in adolescents with CP are partly caused by lower muscle endurance of knee extensors. Training of muscle endurance might contribute to reducing the experience of fatigue and improving walking capacity. Reduced muscle endurance seems to have no effect on participation.

Exercise and physical activity recommendations for people with cerebral palsy

Physical activity and its promotion, as well as the avoidance of sedentary behaviour, play important roles in health promotion and prevention of lifestyle-related diseases. Guidelines for young people and adults with typical development are available from the World Health Organisation and American College of Sports Medicine. However, detailed recommendations for physical activity and sedentary behaviour have not been established for children, adolescents, and adults with cerebral palsy (CP). This paper presents the first CP-specific physical activity and exercise recommendations. The recommendations are based on (1) a comprehensive review and analysis of the literature, (2) expert opinion, and (3) extensive clinical experience. The evidence supporting these recommendations is based on randomized controlled trials and observational studies involving children, adolescents, and adults with CP, and buttressed by the previous guidelines for the general population. These recommendations may be used to guide healthcare providers on exercise and daily physical activity prescription for individuals with CP.

Cerebral palsy

Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.

Associations between fitness and mobility capacity in school-aged children with cerebral palsy: a longitudinal analysis

AIM

The aim of this study was to determine the longitudinal associations among fitness components and between fitness and mobility capacity in children with cerebral palsy (CP).

METHOD

Forty-six children (26 males, 20 females; mean age 9y 7mo [SD 1y 8mo]) with a bilateral (n=24) or a unilateral spastic CP (n=22) participated in aerobic and anaerobic fitness measurements on a cycle ergometer and isometric muscle strength tests (Gross Motor Function Classification System [GMFCS] level I [n=26], level II [n=12], level III [n=8]). Mobility capacity was assessed with the gross motor function measure (GMFM) and a walking capacity test. Associations over longitudinal measurements (three or four measurements over 1y) were determined since longitudinal data allow a more accurate estimation. The associations were determined using a mixed model with fixed effects (mobility capacity as dependent variables and fitness components as independent variables) and a random intercept.

RESULTS

In children with bilateral CP, changes in aerobic fitness were associated with changes in anaerobic fitness (p<0.001), and changes in aerobic fitness showed an association with changes in muscle strength (p<0.05). Anaerobic fitness was not associated with muscle strength. No associations between fitness components were found in unilateral CP. Anaerobic fitness and muscle strength were significant determinants for GMFM and walking capacity in bilateral but not in unilateral CP.

INTERPRETATION

The longitudinal associations between aerobic and anaerobic fitness and mobility indicate that increasing either aerobic or anaerobic fitness is associated with improvements in mobility in children with bilateral CP. While increasing anaerobic fitness might be beneficial for mobility capacity in children with bilateral CP, this is less likely for children with unilateral CP.

Longitudinal Relationship Among Physical Fitness, Walking-Related Physical Activity, and Fatigue in Children With Cerebral Palsy

BACKGROUND

A vicious circle of decreased physical fitness, early fatigue, and low physical activity levels (PAL) is thought to affect children with cerebral palsy (CP). However, the relationship of changes in physical fitness to changes in PAL and fatigue is unclear.

OBJECTIVE

The objective of this study was to investigate the associations among changes in physical fitness, walking-related PAL, and fatigue in children with CP.

DESIGN

This study was a secondary analysis of a randomized controlled trial with measurements at baseline, 6 months (after the intervention period), and 12 months.

METHODS

Twenty-four children with bilateral spastic CP and 22 with unilateral spastic CP, aged 7 to 13 years, all walking, participated in this study. Physical fitness was measured by aerobic capacity, anaerobic threshold, anaerobic capacity, and isometric and functional muscle strength. Walking-related PAL was measured using an ankle-worn activity monitor for 1 week. Fatigue was determined with the Pediatric Quality of Life (PedsQL) Multidimensional Fatigue Scale. Longitudinal associations were analyzed by random coefficient regression analysis.

RESULTS

In children with bilateral CP, all fitness parameters showed a positive, significant association with walking-related PAL, whereas no associations between physical fitness and walking-related PAL were seen in children with unilateral CP. No clinically relevant association between physical fitness and fatigue was found.

LIMITATIONS

Although random coefficient regression analysis can be used to investigate longitudinal associations between parameters, a causal relationship cannot be determined. The actual direction of the association between physical fitness and walking-related PAL, therefore, remains inconclusive.

CONCLUSIONS

Children with bilateral spastic CP might benefit from improved physical fitness to increase their PAL or vice versa, although this is not the case in children with unilateral CP. There appears to be no relationship between physical fitness and self-reported fatigue in children with CP. Interventions aimed at improving PAL may be differently targeted in children with either bilateral or unilateral CP.

Effects of seat surface inclination on respiration and speech production in children with spastic cerebral palsy

Background

Respiratory and speech problems are commonly observed in children with cerebral palsy (CP). The purpose of this study was to identify if inclination of seat surface could influence respiratory ability and speech production in children with spastic diplegic CP.

Methods

Sixteen children with spastic diplegic CP, ages 6 to 12 years old, participated in this study. The subjects’ respiratory ability (forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), peak expiratory flow (PEF), and maximum phonation time (MPT)) were measured in three sitting conditions: a seat surface inclined 0°, anterior 15°, and posterior 15°.

Results

FVC was significantly different across three inclinations of seat surface, F(2, 45) = 3.81, P = 0.03. In particular, the subjects’ FVC at a seat surface inclined anterior 15° was significantly greater than at a seat surface inclined posterior 15° (P < 0.05). However, FEV1, PEF, and MPT were not significantly affected by seat surface inclination (P > 0.05).

Conclusions

The results suggest that anterior inclination of seat surface may provide a positive effect on respiratory function in children with spastic diplegic CP.

The scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities

PURPOSE

The purpose of this report is to discuss the scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities.

SUMMARY OF KEY POINTS

Evidence is provided that supports integration of health promotion and fitness strategies in physical therapy clinical management. Physical therapists' roles in community-based adapted sports and fitness interventions and reimbursement considerations are discussed.

CONCLUSIONS

Physical therapists are in a unique position to provide expertise in the design and implementation of health promotion and fitness programs for youth with disabilities. These programs are important to promote active, healthy lifestyles and reduce comorbidities associated with sedentary behaviors and unhealthy weight, which are often seen in youth with disabilities.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Pediatric physical therapists should incorporate health promotion and fitness strategies into practice.

Health-related physical fitness for children with cerebral palsy

Low levels of physical activity are a global health concern for all children. Children with cerebral palsy have even lower physical activity levels than their typically developing peers. Low levels of physical activity, and thus an increased risk for related chronic diseases, are associated with deficits in health-related physical fitness. Recent research has provided therapists with the resources to effectively perform physical fitness testing and physical activity training in clinical settings with children who have cerebral palsy, although most testing and training data to date pertains to those who walk. Nevertheless, on the basis of the present evidence, all children with cerebral palsy should engage, to the extent they are able, in aerobic, anaerobic, and muscle-strengthening activities. Future research is required to determine the best ways to evaluate health-related physical fitness in nonambulatory children with cerebral palsy and foster long-term changes in physical activity behavior in all children with this condition.

Can a lifestyle intervention improve physical fitness in adolescents and young adults with spastic cerebral palsy? A randomized controlled trial

OBJECTIVE

To evaluate both the short- and long-term effectiveness of a lifestyle intervention on physical fitness in adolescents and young adults with cerebral palsy (CP).

DESIGN

Single-blind, randomized controlled trial.

SETTING

University hospitals and rehabilitation clinics.

PARTICIPANTS

Adolescents and young adults (N=57) with spastic CP classified in Gross Motor Function Classification System levels I through IV; of these, 42 completed the study.

INTERVENTION

A 6-month lifestyle intervention consisting of physical fitness training combined with counseling sessions focused on physical behavior and sports participation.

MAIN OUTCOME MEASURES

Physical fitness, including measures of cardiopulmonary fitness, muscle strength, and body composition.

RESULTS

Favorable short- and medium-term effects were found for peak oxygen consumption, oxygen consumption, and load on the anaerobic threshold and waist circumference. Favorable long-term effects were found for sum of skinfolds, systolic blood pressure, and total cholesterol.

CONCLUSIONS

This exploratory study showed that the lifestyle intervention was effective in improving cardiopulmonary fitness and body composition. Effects of body composition were maintained in the long term. However, the intervention needs to be optimized to increase muscle strength and for long-term retention of effects on aerobic capacity.

Reliability of a progressive maximal cycle ergometer test to assess peak oxygen uptake in children with mild to moderate cerebral palsy

BACKGROUND

Rehabilitation research in children with cerebral palsy (CP) is increasingly addressing cardiorespiratory fitness testing. However, evidence on the reliability of peak oxygen uptake (Vo2peak) measurements, considered the best indicator of aerobic fitness, is not available in this population.

OBJECTIVE

The objective of this study was to establish the reliability of a progressive maximal cycle ergometer test when assessing Vo2peak in children with mild to moderate CP.

DESIGN

Repeated measures were used to assess test-retest reliability.

METHODS

Eligible participants were ambulant, 6 to 14 years of age, and classified as level I, II, or III according to the Gross Motor Function Classification System (GMFCS). Two progressive maximal cycle ergometer tests were conducted (separated by 3 weeks), with the workload increasing every minute in steps of 3 to 11 W, dependent on height and GMFCS level. Reliability was determined by means of the intraclass correlation coefficient (ICC [2,1]) and smallest detectable change (SDC).

RESULTS

Twenty-one children participated (GMFCS I: n=4; GMFCS II: n=12; and GMFCS III: n=5). Sixteen of them (9 boys, 7 girls; GMFCS I: n=3; GMFCS II: n=11; and GMFCS III: n=2) performed 2 successful tests, separated by 9.5 days on average. Reliability for Vo2peak was excellent (ICC=.94, 95% confidence interval=.83-.98). The SDC was 5.72 mL/kg/min, reflecting 14.6% of the mean.

LIMITATIONS

The small sample size did not allow separate analysis of reliability per GMFCS level.

CONCLUSIONS

In children with CP of GMFCS levels I and II, a progressive maximal cycle ergometer test to assess Vo2peak is reliable and has the potential to detect change in cardiorespiratory fitness over time. Further study is needed to establish the reliability of Vo2peak in children of GMFCS level III.

The effectiveness of a physical activity stimulation programme for children with cerebral palsy on social participation, self-perception and quality of life: a randomized controlled trial

OBJECTIVE

To determine the effects of a six-month physical activity stimulation programme on social participation, self-perception and quality of life in children with cerebral palsy.

DESIGN

Multicentre randomized controlled trial with concealed allocation, blinded assessments and intention-to-treat analysis.

SETTING

Paediatric physiotherapy practices, special schools for children with a disability, and the child's own home.

SUBJECTS

Forty-nine children with spastic cerebral palsy (28 male), aged 7-13 years, able to walk with and without walking aids.

INTERVENTIONS

The intervention group followed a six-month physical activity stimulation programme involving counselling through motivational interviewing, home-based physiotherapy and four months of fitness training. The control group continued regular paediatric physiotherapy.

MAIN MEASURES

Outcomes included social participation in domestic life, social participation in recreation and leisure (Life-Habits for Children questionnaire and Children's Assessment of Participation and Enjoyment questionnaire), self-perception (Harter's Self-Perception Profile for Children) and parent-reported quality of life (Cerebral Palsy Quality of Life Questionnaire). Assessments were performed at baseline, at six months (except quality of life) and at twelve months.

RESULTS

Intervention resulted in a positive effect on social participation in domestic life at twelve months (mean between-group difference = 0.9, 95% confidence interval (CI) = 0.1 to 1.7 [1-10 scale], P = 0.03), but not at six months. No significant effects were found for social participation in recreation and leisure, self-perception at six months and twelve months or for quality of life at twelve months.

CONCLUSIONS

The combination of counselling, home-based physiotherapy and fitness training was not effective in improving social participation in recreation and leisure, self-perception or quality of life, but did show a potential for improving social participation in domestic life over the longer term.

Optimising Ankle Foot Orthoses for children with cerebral palsy walking with excessive knee flexion to improve their mobility and participation; protocol of the AFO-CP study

Background

Ankle-Foot-Orthoses with a ventral shell, also known as Floor Reaction Orthoses (FROs), are often used to reduce gait-related problems in children with spastic cerebral palsy (SCP), walking with excessive knee flexion. However, current evidence for the effectiveness (e.g. in terms of walking energy cost) of FROs is both limited and inconclusive. Much of this ambiguity may be due to a mismatch between the FRO ankle stiffness and the patient’s gait deviations.

The primary aim of this study is to evaluate the effect of FROs optimised for ankle stiffness on the walking energy cost in children with SCP, compared to walking with shoes alone. In addition, effects on various secondary outcome measures will be evaluated in order to identify possible working mechanisms and potential predictors of FRO treatment success.

Method/Design

A pre-post experimental study design will include 32 children with SCP, walking with excessive knee flexion in midstance, recruited from our university hospital and affiliated rehabilitation centres. All participants will receive a newly designed FRO, allowing ankle stiffness to be varied into three configurations by means of a hinge. Gait biomechanics will be assessed for each FRO configuration. The FRO that results in the greatest reduction in knee flexion during the single stance phase will be selected as the subject’s optimal FRO. Subsequently, the effects of wearing this optimal FRO will be evaluated after 12–20 weeks. The primary study parameter will be walking energy cost, with the most important secondary outcomes being intensity of participation, daily activity, walking speed and gait biomechanics.

Discussion

The AFO-CP trial will be the first experimental study to evaluate the effect of individually optimised FROs on mobility and participation. The evaluation will include outcome measures at all levels of the International Classification of Functioning, Disability and Health, providing a unique set of data with which to assess relationships between outcome measures. This will give insights into working mechanisms of FROs and will help to identify predictors of treatment success, both of which will contribute to improving FRO treatment in SCP in term.

Trial registration

This study is registered in the Dutch Trial Register as NTR3418.