Paul J. M. Helders

Effectiveness of exercise therapy: A best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinsons disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Exercise Training Program in Children and Adolescents With Cerebral Palsy: A Randomized Controlled Trial

OBJECTIVES To delineate the natural history of pityriasis rosea in black children and to compare our findings with those of the American, European, and African literature on pityriasis rosea. Textbook and journal article descriptions of pityriasis rosea usually offer information about the presentation and clinical course of this condition in white patients. DESIGN Prospective observational study. SETTING The general pediatric clinic, adolescent clinic, and emergency department of Childrens Hospital of Michigan, Detroit, from June 2003 through May 2005. PATIENTS We followed up 50 black children with pityriasis rosea from the time of diagnosis through follow-up visits at 1, 2, and 4 weeks. Detailed observations were made and digital photographs taken at each visit. MAIN OUTCOME MEASURES Duration of illness and pigmentary sequelae. RESULTS Similarities with the medical literature were found regarding season of onset and prevalence of pruritus and of a herald patch. Our patients had more frequent facial involvement (30%) and more scalp lesions (8%) than usually described in white populations. One third had papular lesions. The disease resolved in nearly one half of patients within 2 weeks. Residual hyperpigmentation was seen in 48% of patients. Hypopigmentation developed in 29% of patients with purely papular or papulovesicular lesions. CONCLUSIONS Pityriasis rosea in black children differs in several ways from textbook descriptions. Physicians may use this information to better counsel patients about the course and potential sequelae of this condition.

The six‐minute walking test in children with cystic fibrosis: Reliability and validity

There is a need to judge general exercise tolerance in children with cystic fibrosis (CF) under normal daily activity conditions and—when more extensive testing is required—in an exercise laboratory in a specialized center. We investigated the reproducibility, validity, and criterion for a 6‐minute walking test, which simulates normal childhood activities. In Part A, we evaluated the reproducibility of a 6‐minute walking test in 23 children (12 girls and 11 boys; ages 11.1 ± 2.2 years; range, 8.2 15.6 years) with mild symptoms of CF [forced expiratory volume in 1 second (FEV1) 94.4 ± 16.5% of predicted values (range, 60.6–129.7); body weight Z‐score −0.71 ± 0.81 (range, −1.73–0.93)]. The subjects performed two standardized 6‐minute walking tests with 1 week between tests. There was no significant difference between the two walking distances reached (737 ± 85 versus 742 ± 90 meters; P = 0.56), and there was a strong correlation between the two walking distances reached by the individuals (r = 0.90, P < 0.0001).

Functional motor abilities of children with cerebral palsy: a systematic literature review of assessment measures

Objective: To provide an overview of functional assessment measures for children with cerebral palsy, supporting the selection of measures and the interpretation of results from measures. Methods: Instruments were selected on the basis of a literature search of the Medline, Sportdisk and PsychLIT databases. Issues reviewed: Instruments were reviewed with respect to target group, purpose, nature, type and psychometric properties. Results: In the literature 17 instruments that are used in paediatric rehabilitation and paediatric physical therapy to assess the functional motor abilities of children with cerebral palsy were found. While there is an urgent need for measures that can evaluate change in functional abilities, it was found that most measures are developed and validated for discriminative purposes. Conclusions: Although instruments developed within the lastdecade meet psychometric criteria more adequately than those developed previously, it is concluded that only two evaluative assessment measures, the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI), fulfil the criteria of reliability and validity with respect to responsiveness to change.

Exercise programs for children with cerebral palsy: a systematic review of the literature.

Verschuren O, Ketelaar M, Takken T, Helders PJM, Gorter JW: Exercise programs for children with cerebral palsy: a systematic review of the literature. Am J Phys Med Rehabil 2008;87:404–417.The purpose of this literature review, regarding all types of exercise programs focusing on cardiovascular fitness (aerobic and anaerobic capacity) and/or lower-extremity muscle strength in children with cerebral palsy (CP), was to address the following questions: (1) what exercise programs focusing on muscle strength, cardiovascular fitness, or a combination are studied, and what are the effects of these exercise programs in children with CP? (2) What are the outcome measures that were used to assess the effects of the exercise programs? (3) What is the methodological quality of the studies?We systematically searched the literature in electronic databases up to October 2006 and included a total of 20 studies that were evaluated. The methodological quality of the included trials was low. However, it seems that children with CP may benefit from improved exercise programs that focused on lower-extremity muscle strength, cardiovascular fitness, or a combination. The outcome measures used in most studies were not intervention specific and often only focused on the International Classification of Function, Disability and Health body function and activity level. There is a need to determine the efficacy of exercise programs to improve the daily activity and participation level of children with CP and increase their self-competence or quality of life.

Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study.

OBJECTIVE. The purpose of this work was to identify risk factors for deformational plagiocephaly within 48 hours of birth and at 7 weeks of age. PATIENTS AND METHODS. This was a prospective cohort study in which 380 healthy neonates born at term in Bernhoven Hospital in Veghel were followed at birth and at 7 weeks of age. Data regarding obstetrics, sociodemographics, asymmetry of the skull, anthropometrics, motor development, positioning, and care factors related to potentially provoking deformational plagiocephaly were gathered, with special interest for putative risk factors. The main outcome measure at birth and at 7 weeks of age was deformational plagiocephaly, assessed using the plagiocephalometry parameter oblique diameter difference index, a ratio variable, calculated as the longest divided by the shortest oblique diameter of the skull × 100%. A cutoff point of ≥104% was used to indicate severe deformational plagiocephaly. RESULTS. Only in 9 of 23 children who presented deformational plagiocephaly at birth was deformational plagiocephaly present at follow-up, whereas in 75 other children, deformational plagiocephaly developed between birth and follow-up. At birth, 3 of 14 putative risk factors were associated with severe flattening of the skull: gender, birth rank, and brachycephaly. At 7 weeks of age, 8 of 28 putative risk factors were associated with severe flattening: gender, birth rank, head position when sleeping, position on chest of drawers, method of feeding, positioning during bottle-feeding, and tummy time when awake. Early achievement of motor milestones was a protective factor for developing deformational plagiocephaly. Deformational plagiocephaly at birth was not a predictor for deformational plagiocephaly at 7 weeks of age. There was no significant relation between supine sleeping and deformational plagiocephaly. CONCLUSIONS. Three determinants were associated with an increased risk of deformational plagiocephaly at birth: male gender, first-born birth rank, and brachycephaly. Eight factors were associated with an increased risk of deformational plagiocephaly at 7 weeks of age: male gender, first-born birth rank, positional preference when sleeping, head to the same side on chest of drawers, only bottle feeding, positioning to the same side during bottle feeding, tummy time when awake <3 times per day, and slow achievement of motor milestones. This study supports the hypothesis that specific nursing habits, as well as motor development and positional preference, are primarily associated with the development of deformational plagiocephaly. Earlier achievement of motor milestones probably protects the child from developing deformational plagiocephaly. Implementation of practices based on this new evidence of preventing and diminishing deformational plagiocephaly in child health care centers is very important.

Exercise training improves functional recovery and motor nerve conduction velocity after sciatic nerve crush lesion in the rat

OBJECTIVE To observe the effects of exercise training on recuperation of sensorimotor function in the early phase of regeneration, and to monitor the long-term effects of exercise on electrophysiological aspects of the regenerating nerve. DESIGN After sciatic nerve crush in 20 male Wistar rats, one random selected group was subjected to 24 days of exercise training, whereas the other group served as sedentary controls. INTERVENTIONS Exercise training was induced for 24 days, starting the first postoperation day, by placing bottles of water at such a height that the exercising rats had to maximally erect on both hindpaws to drink. MAIN OUTCOME MEASURES Recovery of motor and sensory function in the early phase was monitored by analysis of the free walking pattern and the foot reflex withdrawal test, respectively. Electrophysiological measurements on postoperation days 50, 75, 100, 125, and 150 were used to evaluate the late phase of recovery of nerve conduction velocity. RESULTS During the early phase of the recovery period, exercise training enhanced functional recovery. The motor nerve conduction velocity (MNCV), as measured in the late phase of recovery, was significantly better in the trained group than in the control group (p < .01). CONCLUSIONS We conclude that exercise training enhances the return of sensomotoric function in the early phase of recovery from peripheral nerve lesion. Furthermore, these results suggest that the beneficial effects of 24 days of exercise training after crush persist in the late phase of peripheral nerve recovery.

Decreasing Incidence and Severity of Cerebral Palsy in Prematurely Born Children

OBJECTIVE To examine incidence and severity of cerebral palsy (CP), and associated factors among preterm survivors (gestational age <34 weeks), admitted to a neonatal intensive care unit from 1990-2005. STUDY DESIGN Eighteen antenatal, perinatal and postnatal factors were analyzed. The cohort was divided in four birth periods: 1990-1993 (n=661), 1994-1997 (n=726), 1998-2001 (n=723), and 2002-2005 (n=850). The Gross Motor Function Classification System was used as primary outcome measure (mean age: 32.9 ± 5.3 months). Logistic regression analyses were used. RESULTS CP incidence decreased from 6.5% in period I, to 2.6%, 2.9% and 2.2% (P<.001) in period II-IV, respectively. Simultaneously, cystic periventricular leukomalacia (c-PVL) decreased from 3.3% in period I to 1.3% in period IV (P=.004). Within the total cohort (n=3287), c-PVL grade III decreased from 2.3% in period I to 0.2% in period IV (P=.003). The number of children with Gross Motor Function Classification System levels III-V decreased from period I to IV (P=.035). Independent risk factors for CP were c-PVL and severe intraventricular hemorrhage, whereas antenatal antibiotics, presence of an arterial line, Caesarean section, and gestational age were independent protective factors. CONCLUSION CP incidence and severity decreased from 1990-1993 onward, which could be attributed to a reduction of 93% in severe c-PVL.

Reliability of hand-held dynamometry and functional strength tests for the lower extremity in children with Cerebral Palsy

Purpose. To evaluate the intertester reliability of two methods for measuring lower-limb strength in children with cerebral palsy (CP). Method. Twenty-five subjects with CP (7 – 17 years of age) participated in this study. Lower-limb muscle strength was measured on 2 occasions using a Hand-held Dynamometer (HHD; break-method and make-method) and a 30-sec Repetition Maximum (RM) during three functional strength tests for the lower extremities. Reliability was measured using the intraclass correlation coefficients (ICCs), the standard error of measurement (SEM) and the coefficient of variation (CV). Results. The intertester reliability of strength measurement using a HHD was questionable with ICC values ranging from 0.42 – 0.73 for the break-method, and from 0.49 – 0.82 for the make-method. The SEM and CV (%) values ranged from 27.9 – 58.9 and 22.2 – 35.3% for the break-method, and from 30.6 – 52.7 and 16.2 – 56.2% for make-method. The intertester reliability of strength measurement using the 30-sec RM was acceptable with ICC values ranging from 0.91 – 0.96, and SEM and CV (%) values ranging from 1.1 – 2.6 and 10.9 – 39.9% for the functional exercises. Conclusion. The intertester reliability of measuring muscle strength of the lower extremities using a hand-held dynamometer is questionable. The intertester reliability of the 30-sec RM for the lower extremity is acceptable.

Measuring patients' perceptions on their functional abilities: validation of the Haemophilia Activities List

Summary.  Recently, the Haemophilia Activities List (HAL), a haemophilia‐specific self‐assessment questionnaire to assess a patients self‐perceived functional ability, was introduced and a limited pilot study warranted its further development. The present study finalizes the HAL and assesses the convergent and construct validity, as well as the internal consistency of its definitive version. Three questionnaires (HAL, Dutch‐Arthritis Impact Measurement Scales 2 and the Impact on Participation and Autonomy questionnaire) were completed by 127 patients with severe haemophilia (<1% clotting activity), as well as four performance tests (button test, 50 metre walking test, timed‐up‐and‐go test and figure‐8 walking test). After removal of 15 non‐informative items from the provisional HAL, three components within the questionnaire were identified (upper extremity activities, basic lower extremity activities and complex lower extremity activities). The internal consistency of these components was high (Cronbachs α = 0.93–0.95), as was internal consistency for the seven domains of the HAL (α = 0.61–0.96). The convergent validity of the HAL when compared to the other two questionnaires was good (r = 0.47–0.84). The construct validity of the HAL when compared to the four performance tests was generally lower (r = 0.23–0.77). The final version of the HAL has good internal consistency and convergent validity and gives the clinician insight into a patients self‐perceived ability to perform activities of daily life. It is likely that self‐assessment instruments (questionnaires) and performance tests consider different concepts of functional health status and it is therefore recommended that both types are included when clinicians assess a patients functional abilities.