Physical activity stimulation program for children with cerebral palsy did not improve physical activity: a randomised trial

AbstractQuestion: In children with cerebral palsy, does a 6-month physical activity stimulation program improve physical activity, mobility capacity, fitness, fatigue and attitude towards sports more than usual paediatric physiotherapy? Design: Multicentre randomised controlled trial with concealed allocation, blinded assessments and intention-to-treat analysis. Participants: Forty-nine walking children (28 males) aged 7–13 years with spastic cerebral palsy and severity of the disability classified as Gross Motor Function Classification System level I–III. Intervention: The intervention group followed a 6-month physical activity stimulation program involving counselling through motivational interviewing, home-based physiotherapy, and 4 months of fitness training. The control group continued their usual paediatric physiotherapy. Outcome measures: Primary outcomes were walking activity (assessed objectively with an activity monitor) and parent-reported physical activity (Activity Questionnaire for Adults and Adolescents). Secondary outcomes were: mobility capacity, consisting of Gross Motor Function Measure-66 (GMFM-66), walking capacity and functional strength, fitness (aerobic and anaerobic capacity, muscle strength), self-reported fatigue, and attitude towards sport (child and parent). Assessments were performed at baseline, 4 months, 6 months and 12 months. Results: There were no significant intervention effects for physical activity or secondary outcomes at any assessment time. Positive trends were found for parent-reported time at moderate-to-vigorous intensity (between-group change ratio=2.2, 95% CI 1.1 to 4.4) and GMFM-66 (mean between-group difference=2.8 points, 95% CI 0.2 to 5.4) at 6 months, but not at 12 months. There was a trend for a small, but clinically irrelevant, improvement in the children's attitudes towards the disadvantages of sports at 6 months, and towards the advantages of sports at 12 months. Conclusions: This physical activity stimulation program, that combined fitness training, counselling and home-based therapy, was not effective in children with cerebral palsy. Further research should examine the potential of each component of the intervention for improving physical activity in this population. Trial registration: NTR2099. [Van Wely L, Balemans ACJ, Becher JG, Dallmeijer AJ (2014) Physical activity stimulation program for children with cerebral palsy did not improve physical activity: a randomised trial. Journal of Physiotherapy 60: 40–49

Daily physical activity and exercise for people with long term neurological conditions:A delicate balance between training and recovery

Objective: In this paper we aim to provide insight, based on a comprehensive review of the literature, that may be helpful when enrolling people with long term neurological conditions (LTNC) into daily physical activity or exercise programs. We will discuss the following issues: 1) balance between training and recovery; 2) intensities of common physical activities like walking; and 3) consequences for daily physical activity and exercise prescription. Material and Methods: A comprehensive review of studies up to July 2017 was performed. Databases searched were PubMed, EMBASE, SPORTDiscus, and PsychINFO. Results: Five papers, that provided useful data on relative intensity of walking (i.e., the oxygen consumption of the activity relative to the maximal capacity) in people with LTNC, were identified and analysed. For stroke survivors the relative intensity of walking was between 62.3 and 69.8%. For children with cerebral palsy (CP) these values ranged from 52 to 78%, and for adults with CP an average relative intensity of 52% was found. These levels of relative intensity are considerably higher compared to those experienced by able-bodied children (36±8.4%) and adults (27±6%). Conclusion: For a group of people with LTNC, walking can be categorized as a moderate physical activity while for others it might be a vigorous physical activity. When developing a physical activity or exercise program, insight into the intensity of physical activities is important

Real-time daily fatigue, sleep, physical activity, and health-related fitness in adults with cerebral palsy

Aim: To explore whether subgroups of adults with cerebral palsy (CP) with different fatigue diurnal profiles can be discerned, and to explore whether sleep, physical activity, or health-related fitness are associated with these profiles. Method: Thirty-two adults (median age 29 years 8 months; range 20–54 years; 11 males, 21 females) with spastic CP (Gross Motor Function Classification System levels I–III) with physical activity-related fatigue complaints participated. Real-time fatigue and physical activity were assessed for 7 consecutive days by short message service text four times during the day and by wearing an accelerometer respectively. Sleep was assessed by the Pittsburgh Sleep Quality Index, and fitness by assessing body composition and aerobic capacity. Latent class growth modelling was used to classify subgroups according to their diurnal profiles of real-time fatigue. Univariable multinomial logistic regression analysis explored whether participant characteristics, sleep, physical activity, or health-related fitness were associated with diurnal profiles. Results: Three distinct fatigue diurnal profiles were identified: stable low (n = 10), increasing (n = 14), and stable high (n = 8). Only aerobic capacity was associated with fatigue profiles (odds ratio 1.15, 95% confidence interval 1.00–1.34; p = 0.05). Interpretation: Fatigue in adults with CP may be low or high stable or may increase during the day. These findings indicate the relevance of assessing fatigue variability. What this paper adds: We found three patterns of daily fatigue in adults with cerebral palsy (CP). Only aerobic capacity was associated with fatigue profiles in adults with CP. Moment-to-moment variations in fatigue can help with personalized fatigue management

Dutch multidisciplinary guideline on Achilles tendinopathy

Objective To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients. Design Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase. Data sources Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference. Study eligibility criteria Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module. Data extraction and synthesis To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations. Primary outcome measure The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions. Results Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy. Summary/conclusion Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice

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 BI [n=7]) and typically developing (TD) participants (n=20; mean age, 11.8 +/- 3.5y). Interventions: Not applicable. Main Outcome Measures: Oxygen consumption (Vo(2)walk), speed, and EC were determined during walking at a comfortable speed. Peak oxygen consumption (Vo(2)peak) 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: (Vo(2)walk/dVo(2)peak)x100. 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 Vo(2)walk at or above their anaerobic threshold as compared with 10% of TD participants (P=.007). Phenotypes showed that a reduced Vo(2)peak (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 Vo(2)peak 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. (C) 2017 by the American Congress of Rehabilitation Medicin

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

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. 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. Repeated measures were used to assess test-retest reliability. 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). 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. The small sample size did not allow separate analysis of reliability per GMFCS level. 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 II

Energy cost during walking in association with age and body height in children and young adults with cerebral palsy

Aim This cross-sectional study into children and young adults with cerebral palsy (CP) aimed to assess the association of gross energy cost (EC), net EC and net nondimensional (NN) EC during walking with age and body height, compared to typically developing (TD) peers. Method Data was collected in 128 participants with CP (mean age 11y9mo; GMFCS I,n = 48; II,n = 56; III, n = 24) and in 63 TD peers (mean age 12y5mo). Energy cost was assessed by measuring the oxygen consumption during over-ground walking at comfortable speed. Outcome measures derived from the assessment included the gross and net EC, and NN EC. Differences between the groups in the association between gross, net and NN EC with age and body height, were investigated with regression analyses and interaction effects (p < 0.05). Results Interaction effects for age and body height by group were not significant, indicating similar associations for gross, net and NN EC with age or body height among groups. The models showed a significant decline for gross, net and NN EC with increasing age per year (respectively −0.201 J kg−1·m−1; −0.073 J kg−1 m−1; −0.007) and body height per cm (respectively −0.057 J kg−1 m−1; −0.021 J kg−1 m−1; −0.002). Interpretation Despite higher gross and net EC values for CP compared to TD participants, similar declines in EC outcomes can be expected with growth for participants aged 4–22 years with CP. All energy cost outcomes showed a decline with growth, indicating that correcting for this decline is required when evaluating changes in gross EC, and, to a lesser extent, in net and NN EC in response to treatment or from natural course over time

Effects of a School-Based Sports Program on Physical Fitness, Physical Activity, and Cardiometabolic Health in Youth With Physical Disabilities: Data From the Sport-2-Stay-Fit Study

ObjectiveTo investigate the effects of a school-based once-a-week sports program on physical fitness, physical activity, and cardiometabolic health in children and adolescents with a physical disability.MethodsThis controlled clinical trial included 71 children and adolescents from four schools for special education [mean age 13.7 (2.9) years, range 8–19, 55% boys]. Participants had various chronic health conditions including cerebral palsy (37%), other neuromuscular (44%), metabolic (8%), musculoskeletal (7%), and cardiovascular (4%) disorders. Before recruitment and based on the presence of school-based sports, schools were assigned as sport or control group. School-based sports were initiated and provided by motivated experienced physical educators. The sport group (n = 31) participated in a once-a-week school-based sports program for 6 months, which included team sports. The control group (n = 40) followed the regular curriculum. Anaerobic performance was assessed by the Muscle Power Sprint Test. Secondary outcome measures included aerobic performance, VO2 peak, strength, physical activity, blood pressure, arterial stiffness, body composition, and the metabolic profile.ResultsA significant improvement of 16% in favor of the sport group was found for anaerobic performance (p = 0.003). In addition, the sport group lost 2.8% more fat mass compared to the control group (p = 0.007). No changes were found for aerobic performance, VO2 peak, physical activity, blood pressure, arterial stiffness, and the metabolic profile.ConclusionAnaerobic performance and fat mass improved following a school-based sports program. These effects are promising for long-term fitness and health promotion, because sports sessions at school eliminate certain barriers for sports participation and adding a once-a-week sports session showed already positive effects for 6 months.Clinical Trial RegistrationThis trial was registered with the Dutch Trial Registry (NTR4698)

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

A comparison of the physiology of sedentary behavior and light physical activity in adults with and without a physical disability

Background: It is questionable whether postures that are regarded as sedentary behavior in able-bodied persons evoke comparable physiological responses in adults with stroke or cerebral palsy (CP). This study aimed to compare metabolic demand and muscle activity in healthy controls, adults with stroke, and adults with CP during sedentary behavior and light physical activities. Methods: Seventy-one adults (45.6 [18.9] y, range 18–86) participated in this study, of which there were 18 controls, 31 with stroke, and 22 with CP. The metabolic equivalent of task (MET) and level of muscle activation were assessed for different sedentary positions (sitting supported and unsupported) and light physical activities (standing and walking). Results: During sitting supported and unsupported, people with mild to moderate stroke and CP show comparable MET and electromyographic values as controls. While sitting unsupported, people with severe stroke show higher METs and electromyographic values (P < .001), and people with severe CP only show higher METs compared with controls (P < .05) but all below 1.5 METs. Standing increased electromyographic values in people with severe stroke or CP (P < .001) and reached values above 1.5 METs. Conclusions: Physiologic responses during sedentary behavior are comparable for controls and adults with mild to moderate stroke and CP, whereas higher metabolic demands and muscle activity (stroke only) were observed in severely affected individuals