Deborah E. Thorpe

Promotion of Physical Fitness and Prevention of Secondary Conditions for Children With Cerebral Palsy: Section on Pediatrics Research Summit Proceedings

Inadequate physical fitness is a major problem affecting the function and health of children with cerebral palsy (CP). Lack of optimal physical activity may contribute to the development of secondary conditions associated with CP such as chronic pain, fatigue, and osteoporosis. The purpose of this article is to highlight the content and recommendations of a Pediatrics Research Summit developed to foster collaborative research in this area. Two components of physical fitness—muscle strength and cardiorespiratory fitness—were emphasized. Although there is evidence to support the use of physical fitness interventions, there are many gaps in our current knowledge. Additional research of higher quality and rigor is needed in order to make definitive recommendations regarding the mode, intensity, frequency, and duration of exercise. Outcome measurements have focused on the body functions and structures level of the International Classification of Functioning, Disability and Health (ICF), and much less is known about effects at the activities and participation levels. Additionally, the influence of nutritional and growth factors on physical fitness has not been studied in this population, in which poor growth and skeletal fragility have been identified as serious health issues. Current intervention protocols and outcome measurements were critically evaluated, and recommendations were made for future research.

The association between insulin resistance and cytokines in adolescents: the role of weight status and exercise

Increased adiposity is associated with insulin resistance (IR) and an inflammatory response in adults. We tested the hypotheses that cytokines associated with adiposity are also correlated with IR in early adolescents and that these relationships are moderated by weight status, levels of vigorous physical activity (VPA), or maximal aerobic power (pVO2max). Body mass, stature, and a fasting blood sample were obtained from 120 midpubertal adolescents (60 girls and 60 boys). Habitual VPA was obtained by a survey. Predicted VO2max was determined using a cycle ergometer test. Weight status was based on body mass index (BMI) percentiles (normal weight=BMI<75th percentile, overweight=BMI>95th percentile). Glucose, insulin, adiponectin, resistin, tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 were measured; and IR index was based on the Homeostatic Model Assessment. Adiponectin, resistin, and TNF-alpha were associated with IR in all adolescents (R2=0.329, P<.001; R2=0.152, P=.001; and R2=0.141, P=.002; respectively); but interleukin-6 was not (R2=0.148, P=.114). The degree of association between adiponectin and IR was stronger in overweight than in normal-weight adolescents (P<.050). When regression models included weight status, neither TNF-alpha nor resistin was significantly related to IR (P>.050). Exercise did not moderate the association between these cytokines and IR. However, higher levels of VPA and/or pVO2max were associated with higher adiponectin, lower resistin, and lower TNF-alpha in at least one of the sexes. Our results indicate that the pathophysiology of obesity is already established in early adolescents. Increased adiposity, resulting in reduced adiponectin and increased resistin and TNF-alpha, may link these cytokines with IR in adolescents.

The effects of knowledge of performance and cognitive strategies on motor skill learning in children with cerebral palsy

Purpose: The purpose of this research was to examine the effects of presenting augmented information to children with cerebral palsy during practice of a novel motor skill. Methods: Single‐subject designs with nonconcurrent baselines were used to study improvements in performance. Thirteen children with cerebral palsy were randomly assigned to one of three practice protocols and performed 36 ten‐second trials to learn to move a Pedalo, a therapeutic exercise vehicle, backward. Each protocol involved a variable mix of practice under the following conditions: no augmented information, knowledge of performance, and knowledge of performance enhanced by a cognitive strategy. Performance was measured by changes in backward displacement (cm) of the Pedalo across trials. Results: All 13 subjects demonstrated improvement in performance across phases. However, only eight subjects (62%) demonstrated a significant improvement in performance when the baseline and retention phases were compared. Of these eight subjects, one demonstrated significant improvement in performance with practice alone, two when provided with knowledge of performance, and five when provided with knowledge of performance and a cognitive strategy. Conclusions: This study suggests that children with cerebral palsy benefit greatly from practice of motor tasks and that some of these children may benefit from the use of cognitive strategies to enhance the role of knowledge of performance during practice of motor skills. However, sufficient time is required to successfully integrate the feedback into performance.

A Pilot Study: Coordination of Precision Grip in Children and Adolescents with High Functioning Autism

Purpose: This pilot study compared temporal coordination during a precision grip task between 13 children and adolescents with autism spectrum disorders (ASD) who were high functioning and 13 peers with typical development. Methods: Temporal coordination between grip and load forces was measured using latency between onset of grip and load forces, grip force at onset of load force, peak grip force (PGF), and time to PGF. Results: Compared with peers with typical development, participants with ASD demonstrated prolonged latency between grip and load forces, elevated grip force at onset of load force, and increased movement variability. PGF and time to PGF were not significantly different between the 2 groups. Conclusions: These findings indicate temporal dyscoordination in participants with ASD. The findings also enhance our understanding of motor coordination deficits in persons with ASD and have theoretical as well as clinical implications.

The role of fitness in health and disease: Status of adults with cerebral palsy

Physical activity has significant health benefits and is positively associated with health‐related quality of life and psychosocial functioning. Persons with disability are at particular risk of inactivity. For adults with cerebral palsy (CP), impaired health and function typically impede participation in physical activity, setting into motion a downward spiral of prolonged inactivity. Adults with CP may not be engaging in sufficient physical activity to produce the improvements in fitness required to experience associated health benefits. However, the literature related to physical activity and fitness in adults with CP is sparse. As more and more persons with CP lead productive lives into their golden years, it is imperative that the scientific community provide definitive information to help guide decisions related to the type and extent of fitness‐related activities most beneficial to these individuals. This information will facilitate development of physical training programs that promote maintenance of function and fitness while preventing the onset of secondary conditions. This presentation will address the state‐of‐the‐science regarding physical activity and fitness for adults with CP and how fitness training relates to physical activity and health in this population. Gaps in the evidence, as well as possible directions for future research, will be presented.

Systematic review of the clinimetric properties of laboratory- and field-based aerobic and anaerobic fitness measures in children with cerebral palsy

OBJECTIVE To systematically evaluate the level of evidence of the clinimetric properties of measures of aerobic and anaerobic capacity used for children with cerebral palsy (CP). DATA SOURCES A systematic search of databases PubMed, Embase, SPORTDiscus, and PsycINFO through April 2011 was performed. STUDY SELECTION Two independent raters identified and examined studies that reported laboratory- or field-based measures of maximal aerobic or anaerobic capacity in children with CP aged 5 to 14 years. DATA EXTRACTION The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist was used by 2 independent raters to evaluate the methodologic quality of the included clinimetric studies and to identify measures used in these studies. DATA SYNTHESIS Twenty-four studies that used a maximal aerobic or anaerobic capacity measure were identified. Five studies reported clinimetric properties for 5 measures (2 aerobic and 3 anaerobic measures). Methodologic quality was excellent in 3 studies, showing good validity and reliability of field-based aerobic (Shuttle Run Test) and anaerobic (Muscle Power Sprint Test) measures. The studies on laboratory-based measures were rated fair, mainly because of inadequate statistics. The level of evidence was strong for good validity and reliability of the field-based tests. The level of evidence was unknown for validity and low to moderate for good reliability of laboratory-based tests. CONCLUSIONS There is a paucity of research on the clinimetric properties of measurement instruments to assess aerobic and anaerobic capacity for children with CP. Further clinimetric studies of laboratory-based measures in children with CP at all Gross Motor Function Classification System (GMFCS) levels, and clinimetric studies of field-based measures in children who are classified as GMFCS levels III to V are required.

Effects of Different Concurrent Cognitive Tasks on Temporal-distance Gait Variables in Children

Purpose: The study was designed to investigate the influence of three different concurrent cognitive tasks on gait characteristics in five‐ to seven‐year‐old children. Methods: Twenty‐seven subjects, 16 boys and 11 girls, between the ages of 5.0 and 7.8 years (M = 6.4 ± 0.8 years) participated in the study. A dual‐task paradigm was used. Each subject performed the following single and dual walking tasks: walking alone, walking while identifying pictures of common objects (visual identification), walking while identifying sounds (auditory identification), and walking while retaining a series of numbers in memory (memorization). Gait speed, cadence, and step length were compared among the four gait tasks using repeated‐measures analysis of covariance. Results: Gait speed was lower under all dual‐task conditions compared to the single‐task walking condition. Both cadence and step length decreased with concurrent performance of the visual and auditory identification tasks, while the memorization task affected only cadence. The interference effects of the cognitive tasks on gait were largest for the auditory identification task and smallest for the memorization task. Conclusion: These results indicate that children may have difficulty maintaining motor performance while simultaneously processing cognitive information. (Pediatr Phys Ther 2003;15:105‐113)

Coordination of precision grip in 2-6 years-old children with autism spectrum disorders compared to children developing typically and children with developmental disabilities

Impaired motor coordination is prevalent in children with Autism Spectrum Disorders (ASD) and affects adaptive skills. Little is known about the development of motor patterns in young children with ASD between 2 and 6 years of age. The purpose of the current study was threefold: (1) to describe developmental correlates of motor coordination in children with ASD, (2) to identify the extent to which motor coordination deficits are unique to ASD by using a control group of children with other developmental disabilities (DD), and (3) to determine the association between motor coordination variables and functional fine motor skills. Twenty-four children with ASD were compared to 30 children with typical development (TD) and 11 children with DD. A precision grip task was used to quantify and analyze motor coordination. The motor coordination variables were two temporal variables (grip to load force onset latency and time to peak grip force) and two force variables (grip force at onset of load force and peak grip force). Functional motor skills were assessed using the Fine Motor Age Equivalents of the Vineland Adaptive Behavior Scale and the Mullen Scales of Early Learning. Mixed regression models were used for all analyses. Children with ASD presented with significant motor coordination deficits only on the two temporal variables, and these variables differentiated children with ASD from the children with TD, but not from children with DD. Fine motor functional skills had no statistically significant associations with any of the motor coordination variables. These findings suggest that subtle problems in the timing of motor actions, possibly related to maturational delays in anticipatory feed-forward mechanisms, may underlie some motor deficits reported in children with ASD, but that these issues are not unique to this population. Further research is needed to investigate how children with ASD or DD compensate for motor control deficits to establish functional skills.

Gross motor abilities in children with Hurler syndrome

Hurler syndrome is the most severe form of mucopolysaccharidosis type I. There is a paucity of literature reporting the gross motor abilities of children with untreated Hurler syndrome. The purpose of this case series is to describe the gross motor abilities of one male and three female children (mean age 11.4mo [SD 3.1]; range 9.5-16mo) diagnosed with Hurler syndrome. The children were assessed using the Peabody Developmental Motor Scales, 2nd edition. Gross motor delays were present in all four children at the time of assessment, and were most evident in locomotor abilities for three of the children. All four children had range of motion limitations at multiple joints. This case series provides evidence for early gross motor delays in this population, as well as evidence for specific gross motor abilities of children with untreated Hurler syndrome. It is recommended that children diagnosed with Hurler syndrome be referred to physical therapy services upon diagnosis and that physical therapists be part of the interdisciplinary team involved in the care of children with Hurler syndrome.

Gross Motor Development of Children With Hurler Syndrome After Umbilical Cord Blood Transplantation

Background and Purpose: Little is known about the gross motor development of children with Hurler syndrome who have undergone umbilical cord blood transplantation (UCBT). The purpose of this study was to provide a description of gross motor development in children with Hurler syndrome after UCBT. Subjects and Method: Longitudinal changes in gross motor abilities were documented on the gross motor subtests of the Peabody Developmental Motor Scales, second edition (PDMS-2) for 21 children with Hurler syndrome. Each child was assessed between 1 and 6 times after UCBT. The participants had a mean age (±SD) of 32.2±16.0 months at the time of the first assessment. The mean time (±SD) between UCBT and the first assessment was 16.2±16.5 months. Results: The participants had marked gross motor delays, with a mean gross motor quotient 2 standard deviations below the mean for children who were developing typically. The rate of development differed between the subtests of the PDMS-2. The participants gained abilities at the slowest rate on the stationary subtest and at the fastest rate on the locomotor subtest. Discussion and Conclusion: The participants had varying degrees of delay in different gross motor domains. While gaining new gross motor abilities over time, these children continued to have delays up to 48 months after UCBT. Physical therapists treating children with Hurler syndrome after UCBT should use assessment tools that will capture these differences and should individualize treatment plans accordingly. Additional research is needed to document the efficacy of physical therapy intervention with this population.