Karen J Dodd

A randomized clinical trial of strength training in young people with cerebral palsy

This randomized clinical trial evaluated the effects of a home-based, six-week strength-training programme on lower limb strength and physical activity of 21 young people (11 females, 10 males; mean age 13 years 1 month, SD 3 years 1 month; range 8 to 18 years) with spastic diplegic cerebral palsy (CP) with independent ambulation, with or without gait aids; (Gross Motor Function Classification System levels I to III). Compared with the 10 controls, the 11 participants in the strength-training programme increased their lower limb strength (combined ankle plantarflexor and knee extensor strength as measured by a hand-held dynamometer) at 6 weeks (F(1,19)=4.58, p=0.046) and at a follow-up 12 weeks later (F(1,18)=6.25, p=0.041). At 6 weeks, trends were also evident for improved scores in Gross Motor Function Measure dimensions D and E for standing, running and jumping, and faster stair climbing. A relatively short clinically feasible home-based training programme can lead to lasting changes in the strength of key lower-limb muscles that may impact on the daily function of young people with CP.

Outcomes of progressive resistance strength training following stroke: a systematic review

Objective: To determine whether progressive resistance strength training reduces impairments, activity limitations and participation restrictions after stroke. Methods: Electronic databases were searched to find trials conducted from 1966 to 2002. Articles were assessed independently by two reviewers according to the following inclusion criteria: (1) population: adults with stroke, (2) intervention: progressive resistive strength training in isolation, and (3) outcomes: changes in body function, physical activity or societal participation. Results: From the 350 articles initially identified, eight met the criteria for detailed review. Three were randomized controlled trials, with the remainder being single-case time-series analyses or pre–post trials. The five trials that measured impairments of muscle strength showed positive outcomes for progressive resistance strength training, with large effect sizes (d = 1.2–4.5). Few negative effects of strength training were reported, and these were minor. Only three of the eight trials that measured activity limitations reported improvements in activities such as walking and stair climbing. The effects of strength training on societal participation could not be determined due to insufficient data. Conclusions: There is preliminary evidence that progressive resistance strength training programmes reduce musculoskeletal impairment after stroke. Whether strengthening enhances the performance of functional activities or participation in societal roles remains unknown.

Diversity of participation in children with cerebral palsy

The aim of this study was to investigate the participation of children with cerebral palsy (CP) in activities outside school and to compare their participation with a large representative sample of children. A population‐based survey was conducted of children with CP born in Victoria, Australia in 1994 and 1995. Of 219 living children identified, 114 (52.1%) returned completed surveys. The children (65 males, 49 females) were aged between 10 years 9 months and 12 years 9 months (mean age 11y 9mo, SD 6mo). Thirty‐eight per cent had hemiplegia, 23% diplegia, 4% triplegia, 34% quadriplegia, and 1% was of unknown topography. Distribution according to the Gross Motor Function Classification System (GMFCS) was 22.8% Level I, 36% Level II, 10.5% Level III, 8.8% Level IV, and 21.9% Level V. Distribution according to the Manual Ability Classification System (MACS) was: 19.3% Level I, 38.6% Level II, 14.0% Level III, 8.8% Level IV, and 19.3% Level V. Participation was measured using the Childrens Assessment of Participation and Enjoyment. Participation in selected sport, cultural, and quiet leisure activities was compared with population‐based data for 11‐year‐olds from the Australian Bureau of Statistics. Children with CP undertook a median of 26.5 activities (interquartile range 10) in 4 months which were commonly informal rather than formal. Intensity of participation was low. Diversity and intensity of participation was similar for children in each level of the MACS and the GMFCS, except for participants in Level V. More children with CP participated in organized sports (p<0.001) compared with other Australian children, although with lower frequency (p<0.001). Participation diversity and level of intensity of Australian children with CP were similar to those reported in a Canadian study.

Falls and injury prevention should be part of every stroke rehabilitation plan

Objective: To evaluate falls incidence, circumstances and consequences in people who return home after stroke rehabilitation, so that appropriate falls and injury prevention strategies can be developed. Design: Prospective cohort study. Setting: Community. Subjects: Fifty-six subjects with stroke who were participating in a rehabilitation programme and returning to live in a community setting completed the study. Main measures: Subjects completed a prospective falls diary for six months after discharge from rehabilitation, and were interviewed after falls. Physical function was measured by the Berg Balance Scale (BBS) and the Functional Independence Measure (FIM). Results: Forty-six per cent of people (26/56) fell, with most falls (63/103 falls) occurring in the two months after discharge from rehabilitation. One subject had 37 similar falls and these falls were excluded from further analysis. Falls occurred more often indoors (50/66), during the day (46/66) and towards the paretic side (25/66). People required assistance to get up after 25 falls (38%) and 36 falls (55%) resulted in an injury. People sought professional health care after only 16 falls, and activity was restricted after 29 falls (44%). The Berg Balance Scale and Functional Independence Measure scores were lower in people who had longer lies after a fall, and who restricted their activity after a fall (p < 0.05). Lower physical function scores were also associated with falling in the morning, wearing multifocal glasses at the time of a fall, and injurious falls (p < 0.05). Conclusion: Falls are common when people return home after stroke. Of concern are the small number seeking health professionals’ assistance after a fall, the high proportion restricting their activity as a result of a fall and the number of falls occurring towards the paretic side.

Therapeutic exercise in physiotherapy practice is beneficial : a summary of systematic reviews 2002-2005.

QUESTION Is therapeutic exercise of benefit? DESIGN A summary of systematic reviews on therapeutic exercise published from 2002 to September 2005. PARTICIPANTS People with neurological, musculoskeletal, cardiopulmonary, and other conditions who would be expected to consult a physiotherapist. INTERVENTION Therapeutic exercise was defined as the prescription of a physical activity program that involves the client undertaking voluntary muscle contraction and/or body movement with the aim of relieving symptoms, improving function or improving, retaining or slowing deterioration of health. OUTCOME MEASURES Effect of therapeutic exercise in terms of impairment, activity limitations, or participation restriction. RESULTS The search yielded 38 systematic reviews of reasonable or good quality. The results provided high level evidence that therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice, including people with conditions such as multiple sclerosis, osteoarthritis of the knee, chronic low back pain, coronary heart disease, chronic heart failure, and chronic obstructive pulmonary disease. Therapeutic exercise was more likely to be effective if it was relatively intense and there were indications that more targeted and individualised exercise programs might be more beneficial than standardised programs. There were few adverse events reported. However, in many areas of practice there was no evidence that one type of exercise was more beneficial than another. CONCLUSION Therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice. Further high quality research is required to determine the effectiveness of therapeutic exercise in emerging areas of practice.

Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial.

This matched‐pairs, clinical controlled trial evaluated the effects of a school‐based, partial body‐weight‐supported treadmill training (PBWSTT) programme, conducted twice a week for 6 weeks, on the walking speed and endurance of children with cerebral palsy (CP). Pairs of children (10 males, four females; mean age 8y 10mo [SD 2y 6mo], range 5–14y) matched for sex, age, type of CP (athetoid quadriplegia, n=6; spastic quadriplegia, n=6; spastic diplegia, n=2), and Gross Motor Function Classification System level (10 at Level I V, four at Level III) were allocated to the experimental or control group. Compared with the control group, the seven treadmill‐training participants increased their self‐selected walking speed over 10 metres (Mann‐Whitney U=9.00, z=−1.98, p=0.048; mean difference 4.21m/min). A trend was also found for increased distance walked over ground in 10 minutes (t[12]=1.88, p=0.083; mean difference 19.81m). A relatively short PBWSTT programme can improve the walking speed of children with CP and moderate to severe disabilities. Walking endurance might also improve in some children. Treadmill training seems to be a useful gait training option for children with C P, and it seems feasible to conduct such a programme within a school environment.

Should we be testing and training muscle strength in cerebral palsy

Cerebral palsy (CP) is a collection of disorders characterized by an insult to the developing brain that produces a physical disability as the primary or distinguishing feature. The spastic form of CP is most common and in those patients, additional clinical signs may include muscle shortening, diminished selective control, and weakness. The recognition of weakness as a component of CP has been longstanding as evidenced by the names given to this disorder and its subtypes. ‘Cerebral palsy’ means weakness originating from the brain, and the use of the suffixes ‘plegia’ or ‘paresis’ also indicate that weakness is a prominent feature. More than 50 years ago, Phelps contended that resisted exercise ‘to develop strength or skill in a weakened muscle or an impaired muscle group’ was an integral part of treatment in CP. (p 59) Since that time, physical educators have also advocated strengthening. Yet for years, conventional clinical wisdom in physical therapy argued against the use of strength testing and training in children with CP and, indeed, in all persons with CNS disorders. The rationale for this exclusion appears to be multifaceted. First, therapists were discouraged by the relatively meager functional responses to strength training in patients with spasticity compared with those with polio. Clinicians also feared that strong near maximal effort would exacerbate spasticity and muscle tightness in those who were already ‘stiffer’ than normal. Many also attested that impaired selective control in CP essentially prohibited performance of strengthening activities. Consequently, this approach was discarded in favor of a more direct focus on the brain. Only recently has strength testing and training experienced a resurgence in habilitation and rehabilitation programs for this population and for other spastic motor disorders. However, hesitation and even resistance to their incorporation are still encountered despite the lack of evidence to suggest that strengthening is detrimental in the presence of spasticity and accumulating evidence to support this type of exercise. The purpose of this annotation is to summarize existing research on strength testing and training, primarily focusing on CP and address the following clinical questions: (1) Can strength be measured reliably and in a valid way in cerebral palsy? (2) Is weakness a significant impairment in CP? (3) Is strength training effective in increasing force production and improving motor function and disability in CP? (4) Is strength training safe in the presence of spasticity and for children and adolescents, regardless of health status, who have an immature musculoskeletal system?

Single-event multilevel surgery in children with spastic diplegia: a pilot randomized controlled trial.

BACKGROUND Single-event multilevel surgery is considered the standard of care to improve gait and functioning of children with spastic diplegic cerebral palsy. However, the evidence base is limited. This pilot study is the first randomized controlled trial of single-event multilevel surgery, to our knowledge. METHODS Nineteen children (twelve boys and seven girls with a mean age of nine years and eight months) with spastic diplegia were enrolled. Eleven children were randomized to the surgical group and eight, to the control group. The control group underwent a program of progressive resistance strength training. The randomized phase of the trial concluded at twelve months. The control group then exited the study and progressed to surgery, whereas the surgical group continued to be followed in a prospective cohort study. The primary outcome measures were the Gait Profile Score (GPS) and the Gillette Gait Index (GGI). Secondary outcome measures were gross motor function (Gross Motor Function Measure-66 [GMFM-66]), functional mobility (Functional Mobility Scale [FMS]), time spent in the upright position, and health-related quality of life (Child Health Questionnaire [CHQ]). RESULTS A total of eighty-five surgical procedures were performed, with a mean of eight procedures per child (standard deviation, four). The surgical group had a 34% improvement in the GPS and a 57% improvement in the GGI at twelve months. The control group had a small nonsignificant deterioration in both indices. The between-group differences for the change in the GPS (-5.5; 95% confidence interval, -7.6 to -3.4) and the GGI (-218; 95% confidence interval, -299 to -136) were highly significant. The differences between the groups with regard to the secondary outcome measures were not significant at twelve months. At twenty-four months after surgery, there was a 4.9% increase in the GMFM-66 score and improvements in the FMS score, time spent in the upright position, and the physical functioning domain of the CHQ in the surgical group. CONCLUSIONS This study provides Level-II evidence that single-event multilevel surgery improves the gait of children with spastic diplegic cerebral palsy twelve months after surgery. Improvements in other domains, including gross motor function and quality of life, were not observed until twenty-four months after surgery.

Progressive resistance exercise for people with multiple sclerosis

Purpose. This study aimed to determine if participation in a progressive resistance exercise (PRE) programme can: (1) increase the ability to generate maximal muscle force, (2) increase muscle endurance, (3) increase functional activity, and (4) improve overall psychological function of people with multiple sclerosis (MS). Methods. A pre-post single group research design with a 4-week baseline familiarisation phase was used. Nine people (mean age 45.6 years, SD 10.7) with MS attended a gymnasium three times over 4 weeks for familiarization. Participants then completed a twice-weekly 10-week PRE programme, with two sets of 10 – 12 repetitions of each exercise. Outcome measures of muscle strength (1RM for arms and legs), muscle endurance (repetitions at half 1RM), walking speed, the 2-min walk test (2MWT), a timed stairs test, and the impact of MS on physical and psychological function were taken at weeks 2, 4, and 14. Results. Participants attended 94.3% (SD 8.2%) of the training sessions, with no adverse events. After accounting for baseline stability, significant improvements (P < 0.05) were found in arm strength (14.4%), leg endurance (170.9%), fast walking speed (6.1%), and there was a trend for increased distance in the 2MWT (P = 0.06). The perceived impact of MS on physical function was reduced (P = 0.02). Conclusions. Adults with MS benefited from a PRE programme by improving muscle performance and physical activities, without adverse events. These findings suggest that PRE may be a feasible and useful fitness alternative for people with mild to moderate disability due to MS.

Outcomes of the Bobath concept on upper limb recovery following stroke

Objective: To determine the effectiveness of the Bobath concept at reducing upper limb impairments, activity limitations and participation restrictions after stroke. Methods: Electronic databases were searched to identify relevant trials published between 1966 and 2003. Two reviewers independently assessed articles for the following inclusion criteria: population of adults with upper limb disability after stroke; stated use of the Bobath concept aimed at improving upper limb disability in isolation from other approaches; outcomes reflecting changes in upper limb impairment, activity limitation or participation restriction. Results: Of the 688 articles initially identified, eight met the inclusion criteria. Five were randomized controlled trials, one used a single-group crossover design and two were single-case design studies. Five studies measured impairments including shoulder pain, tone, muscle strength and motor control. The Bobath concept was found to reduce shoulder pain better than cryotherapy, and to reduce tone compared to no intervention and compared to proprioceptive neuromuscular facilitation (PNF). However, no difference was detected for changes in tone between the Bobath concept and a functional approach. Differences did not reach significance for measures of muscle strength and motor control. Six studies measured activity limitations, none of these found the Bobath concept was superior to other therapy approaches. Two studies measured changes in participation restriction and both found equivocal results. Conclusions: Comparisons of the Bobath concept with other approaches do not demonstrate superiority of one approach over the other at improving upper limb impairment, activity or participation. However, study limitations relating to methodological quality, the outcome measures used and contextual factors investigated limit the ability to draw conclusions. Future research should use sensitive upper limb measures, trained Bobath therapists and homogeneous samples to identify the influence of patient factors on the response to therapy approaches.