Relationship between functional lower limb capacity and falls in ambulant children with cerebral palsy.

Activate-CP: Let's Ride a Bike! Efficacy of a functional-electrical-stimulation cycling, adapted cycling and goal-directed training program for children with cerebral palsy

Relationship Between Walk Tests and Parental Reports of Walking Abilities in Children With Cerebral Palsy

Functional progressive resistance training improves muscle strength but not walking ability in 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.

PURPOSE: Cerebral palsy (CP) is the most common childhood movement dysfunction secondary to a brain injury around birth. These children can be classified as ambulatory or non-ambulatory based on their functional abilities. Importantly, they expend significantly increased energy expenditure during movement. Muscle mitochondria, specifically the electron transport system are responsible for oxidative capacity, energy production and are associated with functional capacity. Unfortunately, mitochondrial oxidative capacity in children with CP and its association with different functional levels is not known. We measured maximum mitochondrial respiration rates directly from biopsies in children with CP, compared across ambulatory levels. METHODS: Twenty children (6-16 years, 10 M/6F, Ambulatory-12), undergoing surgery participated in this study. Twenty-nine biopsies were obtained from adductors, vastus lateralis, gastrocnemius. Carbohydrate and fatty acid respirometry substrate-uncoupler-inhibitor titration (SUIT) protocols were performed on permeabilized muscle fiber bundles. In addition, muscle homogenate was used to measure citrate synthase activity as a marker of mitochondrial content. Ambulatory capacity was measured using 6-minute walk tests (n=7), muscle strength, and gait velocity (n=15) during routine therapy visits. RESULTS: Surprisingly, maximal mitochondrial phosphorylation capacity was similar across between functionally ambulatory and non-ambulatory children (77.1± 23.9 vs. 84.9± 24.0 pmol O2/s/mg). This was uncorrelated with mitochondrial content (p>0.1), as measured by citrate synthase. Mitochondria in children with CP still preferentially used carbohydrates over fatty acids based on state-3 respiration. Functionally ambulatory children showed positive associations between mitochondrial function and ambulatory capacity measures (r2 values for gait velocity=0.50, 6-meter walk test=0.33, p< 0.05). CONCLUSIONS: Mitochondrial function are typically associated with activity level. Surprisingly, functionally ambulatory children with CP did not have greater mitochondrial function compared to non-ambulatory children and might even be lower. Importantly, within ambulatory children walking capacity was related to maximal mitochondrial function.

This work explores the relationships of muscle strength and areal bone mineral density (aBMD) in ambulatory children with cerebral palsy (CP). The knee extensor strength, but not motor function, was related to aBMD. Thus, muscle strength, especially antigravity muscle strength, was more associated with aBMD in these children than motor function. Muscle strength is related to bone density in normal children. However, no studies have examined these relationships in ambulatory children with CP. This work explores the relationships of muscle strength and aBMD in ambulatory children with CP. Forty-eight ambulatory children with spastic CP, aged 5-15 years, were classified into two groups based on Gross Motor Function Classification System levels: I (n = 28) and II (n = 20). Another 31 normal development (ND) children were recruited as the comparison group for the aBMD. Children with CP underwent assessments of growth, lumbar and distal femur aBMD, Gross Motor Function Measure-66 (GMFM-66), and muscle strength of knee extensor and flexor by isokinetic dynamometer. The distal femur aBMD, but not lumbar aBMD, was lower in children with CP than in ND children (p < 0.05). Children with level I had greater knee flexor strength and GMFM-66 scores than those with level II (p < 0.001). However, the knee extensor strength and distal femur and lumbar aBMD did not differ between two groups. Regression analysis revealed the weight and knee extensor strength, but not GMFM-66 scores, were related positively to the distal femur and lumbar aBMD (adjusted r (2) = 0.56-0.65, p < 0.001). These results suggest the muscle strength, especially antigravity muscle strength, were more associated with the bone density of ambulatory children with CP than motor function. The data may allow clinicians for early identifying the ambulatory CP children of potential low bone density.

Gait pathology subtypes are not associated with self-reported fall frequency in children with cerebral palsy

To validate the Muscle Power Sprint Test (MPST) against the Wingate Anaerobic cycling Test (WAnT) in a group of youth with cerebral palsy (CP). Twenty children and adolescents (11 boys and 9 girls; mean age = 14.8 years) with spastic CP, and classified as either level I or II of the Gross Motor Function Classification System, completed the study. Very strong significant correlations were seen for peak power (PP) and mean power (MP) from the MPST and WAnT PP and MP values (PP: r = 0.731, P < .001; MP: r = 0.903, P < .001). The results of this study show that the MPST is a valid test for measuring anaerobic capacity in children with CP, and that this test can be used as an evaluation tool for anaerobic performance in exercise interventions focusing on children and adolescents with CP who are able to walk or run independently.

Does Home-Based Progressive Resistance or High-Intensity Circuit Training Improve Strength, Function, Activity or Participation in Children With Cerebral Palsy?

Purpose To determine if Pilates-based exercise classes could be feasible and effective in changing gait kinematics and balance in ambulant children with Cerebral Palsy (CP). Materials and Methods A single-blind multi-centre randomised controlled trial compared a four-week, twice-weekly Pilates-based exercise class to a usual exercise control, for ambulant children with CP. Clinical outcome measures were three-dimensional trunk and lower limb kinematics during walking on level ground, uneven ground and crossing an obstacle; and clinical balance measures. Feasibility outcomes were adherence and enjoyment. Results Forty-six children (29 male, mean age 10 years 8 months (range 7–17 years), 23 per group) participated. After the four-week intervention, there were no significant between-group differences in trunk or lower limb gait kinematics. Differences were detected in Berg Balance Scale (1.38 points, 95% CI 0.58–2.18) and Functional Walking Test (1.40 points, 95% CI 0.58–2.22), but they were less than the minimum clinically important difference and therefore clinically insignificant. Median class attendance was 5/8 classes. Conclusion Pilates-based exercises did not change lower limb or trunk kinematics during walking in children with CP and had a clinically insignificant impact on balance. Lower than anticipated adherence prompts consideration of more flexible delivery of future interventions. Implications for Rehabilitation Ambulant children with CP can experience impairment of trunk control, negatively impacting balance and gait. In this study, Pilates-based exercise classes did not change kinematics of the trunk or lower limbs during walking and led to negligible improvement in functional balance. Children did not manage to do their Home Exercise Programme, indicating that Pilates-based exercise should be delivered within supervised practice. Children missed on average one in three classes due to unforeseen circumstances, so this should be anticipated when planning group classes.

To examine the relationship between clinic-based walking capacity measures and community-based walking activity in ambulatory children with cerebral palsy (CP). A secondary analysis of a cross-sectional cohort was employed at tertiary care children's hospital; n= 128, ages 2-9 years, Gross Motor Function Classification System (GMFCS) I-III. Walking capacity was captured with 1- and 6-minute walk tests (1MWT, 6MWT), Gross Motor Function Measure-walk/run/jump score (GMFM-E), and Activity Scale for Kids performance version (ASKp-30). Walking activity performance in the community was quantified by StepWatch (SW). Moderate correlations were documented for 6MWT to SW outputs of walking level, moderate high intensity, 60-minute peak and peak activity index (r= 0.55-0.58, p< 0.01). GMFM-E correlated with all SW outputs (r= 0.55-0.69, p< 0.01) except 1-minute peak walking rate. Per regression modeling, GMFM-E was associated with walking level and intensity (p< 0.02) and 6MWT related to high intensity walking (p< 0.4, R=2 0.28-0.48). 6MWT and GMFM-E have the strongest associations with level, amount and intensity of walking in daily life. Results suggest that the 6MWT and GMFM-E can be employed to estimate community walking activity in ambulatory children with CP. Future studies should focus on environmental and personal factors that influence community walking performance.

Cerebral Palsy (CP) is the largest contributor to childhood physical disability with abnormal gait pattern such as toe walking commonly reported. The International Classification of Functioning (ICF) in disabilities framework outlines three domains to consider when looking at impact of a disability on a child; body/structure, activity and participation. Activity and participation targeted interventions using Motor Learning Theory (MLT) have shown positive results on walking performance, gross motor skills and upper limb rehabilitation in CP. MLT encompasses multiple concepts that shape our understanding of how motor skills are acquired and developed. This study aims to determine feasibility and acceptability of a novel motor learning-based intervention for lower extremities (MOBILE) targeting walking performance in ambulant children with CP to inform a future randomized controlled trial (RCT). Fourteen ambulant children with CP, aged 6-17, with a walking goal will be recruited from community disability services. They will undergo a tailored intensive MOBILE intervention to target walking goals amounting to 30 hours practice in 6 weeks or less. Outcomes will include feasibility of recruitment, adherence, retention and outcome measures, and acceptability of the intervention. Clinical outcome measures will include the Gait Outcomes Assessment List, Six Minute Walk Test, modified Timed Up and Go, Ten metre walk test, Range of Motion and the Child Health Utility instrument. Feasibility outcomes will be reported using descriptive statistics such as percentages and confidence intervals. Long-term retention of walking improvements in CP following interventions targeting the body/structure domain of the ICF are reportedly poor. The MOBILE intervention based on its theoretical framework could lead to improvements in walking performance with a possibility of long-term retention and impact on activity and participation. The feasibility of the study design and acceptability of the intervention needs to be investigated to inform a future definitive trial.

Background Cerebral Palsy (CP) is the largest contributor to childhood physical disability with abnormal gait pattern such as toe walking commonly reported. The International Classification of Functioning (ICF) in disabilities framework outlines three domains to consider when looking at impact of a disability on a child; body/structure, activity and participation. Activity and participation targeted interventions using Motor Learning Theory (MLT) have shown positive results on walking performance, gross motor skills and upper limb rehabilitation in CP. MLT encompasses multiple concepts that shape our understanding of how motor skills are acquired and developed. This study aims to determine feasibility and acceptability of a novel motor learning-based intervention for lower extremities (MOBILE) targeting walking performance in ambulant children with CP to inform a future randomized controlled trial (RCT). Methods Fourteen ambulant children with CP, aged 6–17, with a walking goal will be recruited from community disability services. They will undergo a tailored intensive MOBILE intervention to target walking goals amounting to 30 hours practice in 6 weeks or less. Outcomes will include feasibility of recruitment, adherence, retention and outcome measures, and acceptability of the intervention. Clinical outcome measures will include the Gait Outcomes Assessment List, Six Minute Walk Test, modified Timed Up and Go, Ten metre walk test, Range of Motion and the Child Health Utility instrument. Feasibility outcomes will be reported using descriptive statistics such as percentages and confidence intervals. Discussion Long-term retention of walking improvements in CP following interventions targeting the body/structure domain of the ICF are reportedly poor. The MOBILE intervention based on its theoretical framework could lead to improvements in walking performance with a possibility of long-term retention and impact on activity and participation. The feasibility of the study design and acceptability of the intervention needs to be investigated to inform a future definitive trial.

Background Cerebral Palsy (CP) is the largest contributor to childhood physical disability with abnormal gait pattern such as toe walking commonly reported. The International Classification of Functioning (ICF) in disabilities framework outlines three domains to consider when looking at impact of a disability on a child; body/structure, activity and participation. Activity and participation targeted interventions using Motor Learning Theory (MLT) have shown positive results on walking performance, gross motor skills and upper limb rehabilitation in CP. MLT encompasses multiple concepts that shape our understanding of how motor skills are acquired and developed. This study aims to determine feasibility and acceptability of a novel motor learning-based intervention for lower extremities (MOBILE) targeting walking performance in ambulant children with CP to inform a future randomized controlled trial (RCT). Methods Fourteen ambulant children with CP, aged 6–17, with a walking goal will be recruited from community disability services. They will undergo a tailored intensive MOBILE intervention to target walking goals amounting to 30 hours practice in 6 weeks or less. Outcomes will include feasibility of recruitment, adherence, retention and outcome measures, and acceptability of the intervention. Clinical outcome measures will include the Gait Outcomes Assessment List, Six Minute Walk Test, modified Timed Up and Go, Ten metre walk test, Range of Motion and the Child Health Utility instrument. Feasibility outcomes will be reported using descriptive statistics such as percentages and confidence intervals. Discussion Long-term retention of walking improvements in CP following interventions targeting the body/structure domain of the ICF are reportedly poor. The MOBILE intervention based on its theoretical framework could lead to improvements in walking performance with a possibility of long-term retention and impact on activity and participation. The feasibility of the study design and acceptability of the intervention needs to be investigated to inform a future definitive trial.

Background Cerebral Palsy (CP) is the largest contributor to childhood physical disability with abnormal gait pattern such as toe walking commonly reported. The International Classification of Functioning (ICF) in disabilities framework outlines three domains to consider when looking at impact of a disability on a child; body/structure, activity and participation. Interventions to target body/structure have been widely studied but the focus is now shifting towards activity and participation. Activity and participation targeted interventions using Motor Learning Theory (MLT) have shown positive results on walking performance, gross motor skills and upper limb rehabilitation in CP. This study aims to determine feasibility and acceptability of a motor learning-based intervention for lower extremities (MOBILE) targeting walking performance in ambulant children with CP to inform a future randomized controlled trial (RCT). Methods Fourteen ambulant children with CP, aged 6–17, with a walking goal will be recruited from community disability services. They will undergo a tailored intensive MOBILE intervention to target walking goals amounting to 30 hours practice in 6 weeks or less. Outcomes will include feasibility of recruitment, adherence, retention and outcome measures, and acceptability of the intervention. Clinical outcome measures will include the Gait Outcomes Assessment List, Six Minute Walk Test, modified Timed Up and Go, Ten metre walk test, Range of Motion and the Child Health Utility instrument. Feasibility outcomes will be reported using descriptive statistics such as percentages and confidence intervals. Discussion Long-term retention of walking improvements in CP following interventions targeting the body/structure domain of the ICF are reportedly poor. The MOBILE intervention based on its theoretical framework could lead to improvements in walking performance with a possibility of long-term retention and impact on activity and participation. The feasibility of the study design and acceptability of the intervention needs to be investigated to inform a future definitive trial.