Hemda Rotem

The effects of a `home-based' task-oriented exercise programme on motor and balance performance in children with spastic cerebral palsy and severe traumatic brain injury

Objectives: To evaluate the feasibility and the ability to recruit and retain children with severe traumatic brain injury or cerebral palsy, and their families, to a simple home-based exercise programme and to assess the immediate and short-term effects of such intervention on reducing impairment and improving function. Study design: Randomized clinical trial. Participants: Twenty children aged 7—13 years, with traumatic brain injury (N = 10) or cerebral palsy (N = 10) who were independent ambulators. Five children from each group were randomly assigned to a control group — regular daily activities, or to an experimental group — regular daily activities plus a home-based task-oriented exercise programme of sit-to-stand and step-up exercise, for six weeks. Outcome measures: Feasibility: The number of participants who completed the programme protocol. Efficacy: Timed Up and Go Test and Functional Reach Test were used as functional balance tests. Maximal isometric strength was assessed by using a hand-held dynamometer; walking performance was assessed by the 10 m walk test, 2-minute walk test and Energy Expenditure Index. Results: Nine children completed all parts of the training programme. At the end of the intervention period an increase of 3—4 cm in the mean Functional Reach Test and a reduction of 1.6 ± 2.1 seconds in the Timed Up and Go Test were noted (P<0.01) in the experimental group while no changes were noted in the control group. In all other outcomes assessed no significant differences were noted between groups. The positive change in balance performance in the experimental group was maintained during a six-week follow-up period. Conclusions: A home-based task-oriented exercise programme can improve balance performance in children with spastic cerebral palsy or severe traumatic brain injury.

Relationship between balance abilities and gait characteristics in children with post-traumatic brain injury.

Objectives: To quantify the differences in gait variability and balance performance between typically developed (TD) children and children with post-traumatic brain injury (TBI) and to determine the association between gait variability and functional balance in both groups. Design: Cross-sectional study. Setting: Physical therapy department of a paediatric and adolescent rehabilitation hospital. Participants: A convenience sample of 24 children post-TBI and 24 TD age and sex matched controls. Intervention: Not applicable. Main outcome measure: Step length, step time and base width variability measured with an electronic walkway; timed up and go (TUG) test and functional reach test (FRT) as a functional balance test. Results: Base width and step time variability showed no significant difference between the groups. However, children post-TBI had significantly greater variability in step length in comparison to healthy controls. The functional balance abilities of children post-TBI were significantly limited compared to TD children. A significant linear inverse correlation was found between balance performance and step length variability only among children with a TBI. Conclusion: Ambulatory children post-severe TBI had decreased balance performance, decreased gait speed and increased step length variability as compared to age-matched healthy controls.

Balance abilities and gait characteristics in post-traumatic brain injury, cerebral palsy and typically developed children

Objectives: To quantify the differences in gait variability and balance performance between children with cerebral palsy (CP), children with post-traumatic brain injury (TBI) and typically developed (TD) children and to determine the association between gait variability and functional balance in these groups. Design: Cross-sectional study. Setting: Physical therapy department of a paediatric and adolescent rehabilitation hospital. Participants: A convenience sample of 15 children post-TBI, 15 children with CP and 30 TD age- and sex-matched controls. Intervention: Not applicable. Main outcome measure: Step length and step time variability measured by an electronic walkway; timed up and go (TUG) test and functional reach test (FRT) were used as functional balance tests. Results: The functional balance abilities of children post-TBI and children with CP were significantly limited compared to TD children. Children post-TBI had significantly greater variability in step length in comparison to healthy controls. A significant linear inverse correlation between balance performance and step length variability was found only among children with TBI. Conclusion: Brain damage is associated with restricted balance performance and increased step variability. It might be that in a child born with brain damage, as opposed to acquired damage, the developmental process has a restraining effect on gait variability.

Functional balance tests for children with traumatic brain injury: within-session reliability.

Purpose: To assess the within-session reliability of the Modified Functional Reach Test (MFRT) and the Timed Up and Go (TUG) test in children with traumatic brain injury (TBI) and children with typical development (TD). Methods: A convenience sample of 24 children with TBI and 24 children with TD matched for age and sex were tested. Following 1 practice trial, 3 trials of the MFRT and TUG were completed and recorded for each child. Results: Within-session reliability for the MFRT was excellent [children with TBI (intraclass correlation coefficient, ICC (1,1) = 0.92–0.97), children with TD (ICC (1,1) = 0.94–0.95)]. Within-session reliability for the TUG test was good [children with TBI (ICC (1,1) = 0.86), children with TD (ICC (1,1) = 0.85)]. The average of the first and second trials showed the least measurement error for the TUG test. Conclusion: Within-session reliability values are excellent for the MFRT and good for the TUG test in children with TBI.

Heart rate and heart rate variability at rest and during exercise in boys who suffered a severe traumatic brain injury and typically-developed controls

Objectives: To measure heart rate (HR) and heart rate variability (HRV) at rest and during exercise in children with post-severe traumatic brain injury as compared to age-matched typically-developed controls. Design: Comparative study. Setting: Out-patient rehabilitation department. Participants: Twelve boys post-severe traumatic brain injury (TBI) (aged 7–13 years) and 18 typically-developed (TD) boys matched for age. Interventions: HR and HRV were determined at rest and at a steady functional walking rate on the treadmill. Main outcome measures: HR and HRV parameters include: time domain parameters: standard deviation of the R-R interval, square root of the mean squared differences of successive R-R differences at rest and during steady-state exercise. Results: Children post-TBI demonstrated higher mean HR values at rest (TBI 91.8 ± 7.0 beats per minute vs 72.0 ± 7.1 beats per minute in controls, p < 0.05) and during exercise (TBI 123.4 ± 15.5 beats per minute vs 113.0 ± 9.1 beats per minute in controls, p < 0.05). At rest, the time domain measures of HRV were significantly lower in the TBI group (p < 0.05). Time domain mean values decreased significantly during exercise only among the TD children. Conclusions: The findings of this study suggest that among children post-severe TBI, the cardiac autonomic mechanism is less efficient at rest and less adaptive to exercise and activity as compared to TD children.

The effect of combining daily restraint with bimanual intensive therapy in children with hemiparetic cerebral palsy: A self-control study

AIM To examine the influence of combining restraint therapy with bimanual intensive therapy on the unimanual and bimanual function among children with hemiparetic cerebral palsy (CP). Included were nine children (ages 6-9 yr), with Manual Ability Classification System scores of 2-3, Gross Motor Functional Classification System 1-2; INTERVENTION 10 days, six hours per day including one hour of restraint followed by five hours of bimanual activities. EVALUATIONS One month and immediately prior to the intervention (as the control period), immediately, two months and six months post-intervention. The Assisting Hand Assessment was the primary outcome measure, along with the Jebsen-Taylor Test of Hand Function, the Jamar pinch gauge for grip and pinch, and the Pediatric Evaluation of Disability Inventory (PEDI). RESULTS No significant change was observed during the pre-intervention control period in any of the outcome measures; a significant improvement in all outcome parameters was noted after the intervention as compared to the control period. These achievements were still significantly higher than baseline values at six months post-intervention. CONCLUSION Children with hemiparetic CP at this level of impairment might benefit from a short daily intervention program of combining restraint with bimanual training in order to improve unimanual and bimanual function.

Recreational physical activities among children with a history of severe traumatic brain injury

Objective: To describe leisure time physical activity (LTPA) and physical capabilities such as balance, muscle strength and walking performance and to evaluate the associations between physical capabilities and LTPA among children post-traumatic brain injury (TBI) as compared to a peer group of typically-developed (TD) controls. Participants: Convenience sample of 15 children, 1.5–7 years post-severe TBI and 15 age- and sex-matched controls. Main outcome measures: LTPA by the Godin and Shephard (G&S) questionnaire. Balance tests—the Timed Up and Go test (TUG) and functional reach test (FRT). Maximal isometric strength was assessed by using a hand-held dynamometer; walking dynamics were recorded by an electronic mat and the 6 minute walk test and energy expenditure index (EEI). Perceived exertion was rated by the OMNI scale. Results: Children post-severe TBI participate significantly less in LTPA as compared to TD controls (p < 0.01). Walking performance was comparable between groups except for step length which was significantly shorter among children post-TBI. Hip extensor strength and balance performance were significantly lower among children post-TBI. Balance performance was positively associated with LTPA. Conclusions: This study suggests that attention should be directed towards improving balance performance as part of the training repertoire of children and adolescents with post-severe TBI. The efficacy of such a training programme, in particular its contribution to LTPA participation, should then be further assessed.

Effect of concurrent cognitive tasks on gait features among children post-severe traumatic brain injury and typically-developed controls

Aim: To investigate and compare the influence of concurrent cognitive tasks on gait characteristics in children post-traumatic brain injury (TBI) and typically-developed (TD) controls. Methods: Fifteen children post-TBI (aged 9.5 ± 2.2 years) and 15 TD controls (aged 9.9 ± 1.3 years) were included in the study. The children were asked to walk under three conditions: (1) walking at a self-selected speed, (2) walking at a self-selected speed while memorizing and recalling a series of three random numbers and (3) walking at a self-selected speed while listening and identifying commonly experienced sounds. Gait parameters include walking speed, step time and length and step time and length variability as measured with the GAITRite® system. Results: Introduction of a concurrent task led to decreased walking speed and step length and increased step time and step length variability in both groups, but with a significantly prominent effect in children post-TBI. The results also showed that the effect of a concurrent cognitive task on walking depended on the complexity level of the task. Conclusion: When children were asked to perform an additional task while they were walking, this had a negative effect on their gait. One may deduce from these results that control of the rhythmic stepping mechanism at a self-selected walking speed in children is dependant to an extent on their ability to focus attention on their gait. In children post-TBI who usually have an attention deficit anyway, this ability is severely disturbed.

The relationship between step variability, muscle strength and functional walking performance in children with post-traumatic brain injury.

The objective of this study was to investigate the association between step variability, muscle strength and functional walking performance in children post-traumatic brain injury (TBI) and typically developed (TD) children. A convenience sample of 16 children post-TBI and 16 TD age and sex matched controls participated in this cross sectional study. The main outcome measures included step length and step time variability, measured with an electronic walkway, strength of four lower-extremity muscle groups, tested bilaterally with a hand held dynamometer, walking performance as assessed by the 2-min walk test, energy expenditure index (EEI) and rating of perceived exertion (OMNI scale). Significant differences were found in walking parameters between the groups (e.g., 2-min walk test: TBI 109+/-31 compared to TD 168+/-19 m). Children post-TBI had significantly greater variability in step time and step length in comparison to TD controls (e.g., step length variability: TBI 16.3+/-13.6 compared to TD 4.9+/-2.0). TD children had significantly higher mean strength values than children post-TBI in the knee extensor and hip abductor muscle groups (p<0.05). The 2-min walk test correlated inversely with the step time and length variability only among children post-TBI while muscle strength values correlated positively with the 2-min walk test only in TD children. This study found that step time and length variability and lower-extremity muscle strength correlated differently to distance covered during the 2-min walk test among children post-TBI and among TD children.

Effect of concurrent cognitive tasks on temporo-spatial parameters of gait among children with cerebral palsy and typically developed controls.

Abstract Objective: To assess the influence of different concurrent cognitive tasks on gait characteristics in children with cerebral palsy (CP) and typically developed (TD) controls. Methods: Eleven children with CP and eleven TD controls walked under three conditions: at a self-selected speed, at a self-selected speed while memorizing and recalling a series of three random numbers, at a self-selected speed while listening and identifying commonly experienced sounds. Gait parameters were measured with the GAITRite® system. Results: Children with CP walked slower in both assignments as compared to baseline walking; TD controls reduce walking velocity only during the sounds assignment. Step length was constantly reduced and step time and length variability were constantly increased among children with CP as compared to TD controls, throughout assignments. Conclusion: It might be advisable for clinicians when assessing walking performance in children with CP, to assess it during both single and dual-task conditions.