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Purpose: To evaluate whether changes in lower-limb muscle strength explain changes in walking capacity during 14-week periods of usual care, power training and follow-up for children with spastic cerebral palsy., Methods: Secondary analysis of a previously conducted double-baseline controlled trial of 22 children with spastic cerebral palsy. Generalized estimating equations were used to evaluate the relationships between within-subject changes in isometric muscle strength and walking capacity over 3 periods., Results: Changes in hip abductor strength were associated with changes in the Muscle Power Sprint Test, changes in gastrocnemius and hip abductor strength were associated with changes in the Shuttle Run Test, and changes in gastrocnemius strength were associated with changes in the 1-minute walk test. All associations supported better walking capacity with increased strength., Conclusion: Walking capacity, especially sprint capacity, can be improved by increasing strength by functional power training in this population., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.)

Background: In children with cerebral palsy (CP), strength training programs to improve walking capacity and participation in activities of daily living are commonly used in clinical practice, despite lacking evidence of its effectiveness. It has been suggested that strength training with high movement velocity could be more effective than traditional resistance training to improve functional abilities such as walking. In a recently published study, we have demonstrated the positive effects of functional high-velocity resistance (power) training on muscle strength and walking capacity in young children with CP. Whether this type of training is also effective in achieving individual predefined goals in daily activities and self-reported mobility limitations, has not yet been described however., Aim: To evaluate the effect of functional power-training on parent-reported mobility and achievement of individual goals on activity and participation level in young children with CP., Design: A double-baseline design was used to compare a 14-week period usual care with a 14-week period of functional power-training (3 times a week) and a follow-up period of 14 weeks., Setting: A rehabilitation center, two special needs schools for children with physical disabilities, and a university medical center outpatient clinic., Population: Twenty-two children with spastic CP (13 bilateral, GMFCS level I [N.=10] and level II [N.=12], mean age 7.5 years [SD 1.8, range 4-10 years]) and their parents participated., Methods: Outcome measures were goal attainment scaling (GAS) of individual daily activity related treatment goals, mobility performance as measured using the Functional Mobility Scale (FMS-5 m, 50 m and 500 m), and the parent-reported Mobility Questionnaire (MobQues)., Results: After power-training, 86% of children achieved or exceeded their goal, compared with 14% in the usual care period (P<.001). The probability of improvement by one point or more on the FMS-500 meter after functional power-training was 10 times higher, compared with the usual care period (Relative Risk=10.0 with 95% CI 1.4 - 71.3). No changes were found in the FMS-5m and FMS-50m categories. Improvement on the MobQues was significantly greater after power-training compared with usual care (7.9% (95% CI 2.7 - 13.0, P=.005)). The improvement in performance in the activities defined in the treatment goals continued during the follow-up period., Conclusions and Clinical Rehabilitation Impact: The results indicated that functional power-training is an effective training to achieve personalized treatment goals for activities in daily life and parent-reported mobility performance in young children with cerebral palsy.

Background: Strength training programs for children with cerebral palsy (CP) showed inconclusive evidence for improving walking, despite improvements in strength. Recent studies have suggested that strength training with high movement velocity is more effective for improving walking than traditional resistance training., Objective: The purpose of this study was to evaluate the effect of functional high-velocity resistance training (power-training) to improve muscle strength and walking capacity of children with CP., Method: Twenty-two children with spastic CP participated (13 bilateral, Gross Motor Function Classification System [GMFCS] level I [n = 10] and II [n = 12], 7.5 years [SD 1.8, range 4-10 years]). Within-subjects changes in a 14-weeks usual care period were compared with changes in a 14-week functional power-training period (in groups, 3×/wk). Outcome measures were the muscle power sprint test (MPST), 1-minute walk test (1MWT), 10-m shuttle run test (SRT), gross motor function (GMFM-66), isometric strength of lower-limb muscles and dynamic ankle plantar flexor strength., Results: Changes during the training period were significantly larger than changes in the usual care period for all outcome measures ( P < .05). Large improvements were found during the training period for walking capacity (ΔMPST [mean]: 27.6 W [95%CI 15.84-39.46, 83% increase], Δ1MWT: 9.4 m [95% CI 4.17-14.68, 13%], ΔSRT: 4.2 [95%CI 2.57-5.83, 56%], ΔGMFM-66: 5.5 [95% CI 3.33-7.74, 7%]) and muscle strength (18%-128%), while outcomes remained stable in the usual care period., Conclusions: The results indicate that functional power-training is an effective training for improving walking capacity in young children with cerebral palsy.

Purpose: To evaluate the effect of functional high-velocity resistance (power) training to improve walking ability of young children with cerebral palsy., Methods: Twenty-two children with bi- or unilateral spastic cerebral palsy, Gross Motor Function Classification System levels I and II, aged 4 to 10 years will be recruited. A double-baseline design will be used to compare a 14-week functional power training (3 times a week) program with a 14-week usual care period and a 14-week follow-up period. The power exercises will be loaded and performed at 50% to 70% of the maximum unloaded speed. Load will be increased when exercises are performed faster than 70% of the unloaded speed. Primary outcomes will be sprinting capacity (15-m Muscle Power Sprint Test) and goal attainment scaling score of walking-related treatment goals. Secondary outcomes will be walking speed (1-min walk test), endurance (10-m shuttle run test), gross motor function, lower-limb strength, and parent-reported mobility.

Ankle-Foot Orthoses (AFOs) are commonly prescribed to promote gait in children with cerebral palsy (CP). The AFO prescription process is however largely dependent on clinical experience, resulting in confusing results regarding treatment efficacy. To maximize efficacy, the AFO's mechanical properties should be tuned to the patient's underlying impairments. This study aimed to investigate whether the efficacy of a ventral shell AFO (vAFO) to reduce knee flexion and walking energy cost could be improved by individually optimizing AFO stiffness in children with CP walking with excessive knee flexion. Secondarily, the effect of the optimized vAFO on daily walking activity was investigated. Fifteen children with spastic CP were prescribed with a hinged vAFO with adjustable stiffness. Effects of a rigid, stiff, and flexible setting on knee angle and the net energy cost (EC) [Jkg(-1)m(-1)] were assessed to individually select the optimal stiffness. After three months, net EC, daily walking activity [stridesmin(-1)] and knee angle [deg] while walking with the optimized vAFO were compared to walking with shoes-only. A near significant 9% (p=0.077) decrease in net EC (-0.5Jkg(-1)m(-1)) was found for walking with the optimized vAFO compared to shoes-only. Daily activity remained unchanged. Knee flexion in stance was reduced by 2.4° (p=0.006). These results show that children with CP who walk with excessive knee flexion show a small, but significant reduction of knee flexion in stance as a result of wearing individually optimized vAFOs. Data suggest that this also improves gait efficiency for which an individual approach to AFO prescription is emphasized., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Introduction: Rigid Ankle-Foot Orthoses (AFOs) are commonly prescribed to counteract excessive knee flexion during the stance phase of gait in children with cerebral palsy (CP). While rigid AFOs may normalize knee kinematics and kinetics effectively, it has the disadvantage of impeding push-off power. A spring-like AFO may enhance push-off power, which may come at the cost of reducing the knee flexion less effectively. Optimizing this trade-off between enhancing push-off power and normalizing knee flexion in stance is expected to maximize gait efficiency. This study investigated the effects of varying AFO stiffness on gait biomechanics and efficiency in children with CP who walk with excessive knee flexion in stance. Fifteen children with spastic CP (11 boys, 10±2 years) were prescribed with a ventral shell spring-hinged AFO (vAFO). The hinge was set into a rigid, or spring-like setting, using both a stiff and flexible performance. At baseline (i.e. shoes-only) and for each vAFO, a 3D-gait analysis and 6-minute walk test with breath-gas analysis were performed at comfortable speed. Lower limb joint kinematics and kinetics were calculated. From the 6-minute walk test, walking speed and the net energy cost were determined. A generalized estimation equation (p<0.05) was used to analyze the effects of different conditions. Compared to shoes-only, all vAFOs improved the knee angle and net moment similarly. Ankle power generation and work were preserved only by the spring-like vAFOs. All vAFOs decreased the net energy cost compared to shoes-only, but no differences were found between vAFOs, showing that the effects of spring-like vAFOs to promote push-off power did not lead to greater reductions in walking energy cost. These findings suggest that, in this specific group of children with spastic CP, the vAFO stiffness that maximizes gait efficiency is primarily determined by its effect on knee kinematics and kinetics rather than by its effect on push-off power., Trial Registration: Dutch Trial Register NTR3418.

Background: A vicious circle of decreased physical fitness, early fatigue, and low physical activity levels (PAL) is thought to affect children with cerebral palsy (CP). However, the relationship of changes in physical fitness to changes in PAL and fatigue is unclear., Objective: The objective of this study was to investigate the associations among changes in physical fitness, walking-related PAL, and fatigue in children with CP., Design: This study was a secondary analysis of a randomized controlled trial with measurements at baseline, 6 months (after the intervention period), and 12 months., Methods: Twenty-four children with bilateral spastic CP and 22 with unilateral spastic CP, aged 7 to 13 years, all walking, participated in this study. Physical fitness was measured by aerobic capacity, anaerobic threshold, anaerobic capacity, and isometric and functional muscle strength. Walking-related PAL was measured using an ankle-worn activity monitor for 1 week. Fatigue was determined with the Pediatric Quality of Life (PedsQL) Multidimensional Fatigue Scale. Longitudinal associations were analyzed by random coefficient regression analysis., Results: In children with bilateral CP, all fitness parameters showed a positive, significant association with walking-related PAL, whereas no associations between physical fitness and walking-related PAL were seen in children with unilateral CP. No clinically relevant association between physical fitness and fatigue was found., Limitations: Although random coefficient regression analysis can be used to investigate longitudinal associations between parameters, a causal relationship cannot be determined. The actual direction of the association between physical fitness and walking-related PAL, therefore, remains inconclusive., Conclusions: Children with bilateral spastic CP might benefit from improved physical fitness to increase their PAL or vice versa, although this is not the case in children with unilateral CP. There appears to be no relationship between physical fitness and self-reported fatigue in children with CP. Interventions aimed at improving PAL may be differently targeted in children with either bilateral or unilateral CP., (© 2015 American Physical Therapy Association.)

Purpose: To compare walking activity of children with and without cerebral palsy (CP) between the Netherlands and the United States., Methods: A cross-sectional analysis on walking activity data from an international retrospective comparison study including a convenience sample of 134 walking children aged 7-12 years with spastic CP, classified as Gross Motor Function Classification System (GMFCS) level I (N = 64), II (N = 49) or III (N = 21), and 223 typically developing children (TDC) from the Netherlands and the United States. Walking activity was assessed during a one-week period using a StepWatch™ activity monitor. Outcomes were the daily number of strides, daily time being inactive and spent at low (0-15 strides/min), moderate (16-30 strides/min) and high stride rate (31-60 strides/min). Walking activity was compared between countries using multiple linear regression analyses., Results: Walking activity of TDC was not significantly different between countries. Compared to their American counterparts, Dutch children in GMFCS level I and II showed less walking activity (p < 0.05), whereas Dutch children in GMFCS level III showed more walking activity (p < 0.05)., Conclusion: The absence of differences in walking activity between Dutch and American TDC, and the presence of differences in walking activity between Dutch and American children with CP suggest that between-country differences affect walking activity differently in children with CP., Implications for Rehabilitation: Physical activity of children with CP should be promoted in both the United States and the Netherlands. The between-country differences in walking activity illustrate that apart from the severity of the CP walking activity seems to be influenced by environmental aspects. In the promotion of physical activity, practitioners should pay attention to environmental barriers that families may experience for increasing physical activity.

Aim: To assess ambulatory activity of children with cerebral palsy (CP), aged 7 to 13 years, and identify associated characteristics., Method:   Sixty-two children with spastic CP (39 males, 23 females; mean age 10y 1mo, SD 1y 8mo; age range 7-13y), classified as Gross Motor Function Classification System (GMFCS) levels I to III, participated. Ambulatory activity was measured during 1 week with a StepWatch activity monitor as steps per day, and time spent at medium and high step rates. Multiple linear regression analyses were performed following a backward selection procedure until only independent variables with p<0.05 remained in the model. Ambulatory activity outcome parameters served as dependent variables, and disease, personal, and environmental characteristics as independent variables. Ambulatory activity was corrected for body height., Results: Children took more steps during school days (5169 steps, SD 1641) than during weekend days (4158 steps, SD 2048; p<0.001). Higher GMFCS level, bilateral CP, and higher age were associated with lower ambulatory activity on school days (R(2) ranged from 43-53%), whereas bilateral CP, higher age, and no sport club participation were associated with lower ambulatory activity in the weekend (R(2) ranged from 21-42%). Correcting for body height decreased the association with age., Interpretation: Interventions should focus at increasing physical activity at the weekend for children with bilateral spastic CP., (© The Authors. Developmental Medicine & Child Neurology © 2012 Mac Keith Press.)

Objective: To quantify dynamic spasticity, i.e. the coupling between muscle-tendon stretch velocity and muscle activity during gait, of the gastrocnemius and soleus muscles in children with spastic cerebral palsy., Design: Prospective, cross-sectional study., Subjects: Seventeen ambulatory children with cerebral palsy with spastic calf muscles, and 11 matched typically developing children., Methods: The children walked at 3 different speeds. Three-dimensional kinematic and electromyographic data were collected. Muscle-tendon velocities of the gastrocnemius medialis and soleus were calculated using musculoskeletal modelling., Results: In typically developing children, muscles were stretched fast in swing without subsequent muscle activity, while spastic muscles were stretched more slowly for the same walking speed, followed by an increase in muscle activity. The mean ratio between peak activity and peak stretch velocity in swing was approximately 4 times higher in spastic muscles, and increased with walking speed. In stance, the stretch of muscles in typically developing children was followed by an increase in muscle activity. Spastic muscles were stretched fast in loading response, but since muscle activity was already built up in swing, no clear dynamic spasticity effect was present., Conclusion: Spastic calf muscles showed increased coupling between muscle-tendon stretch velocity and muscle activity, especially during the swing phase of gait.

Background: The calf muscles of children with cerebral palsy are often spastic, which can lead to an equinus gait pattern. Although spasticity is defined as a velocity-dependent increase in muscle tone, very little is known about the effect of walking speed on muscle-tendon behavior of spastic muscles during gait. The aim of this study was to investigate gastrocnemius and soleus length and lengthening velocity during gait in spastic muscles with and without static contractures compared to non-spastic muscles, as well as the effect of walking speed, and the interacting effect of walking speed and spasticity on muscle-tendon length and lengthening velocity., Methods: Seventeen ambulatory children with spastic cerebral palsy and 11 typically developing children, aged 6-12, walked at comfortable, slow, and fast walking speeds. 3D kinematic data were collected and muscle-tendon lengths and velocities were calculated using musculoskeletal modeling. Spasticity and contractures of calf muscles were measured during standardized physical examination., Findings: Spastic calf muscles showed a deviating muscle-tendon length pattern with two peaks in stance, which was found to be irrespective of muscle contracture. This deviating pattern became more pronounced as walking speed increased. In swing, spastic calf muscles were stretched approximately one third slower than normal, while in stance, spastic calf muscles were stretched twice as fast as normal, with peak velocity occurring earlier in the gait cycle., Interpretation: The increasingly deviating muscle-tendon length pattern at faster walking speed indicates a velocity-dependent spasticity effect. This impairs walking especially at faster speeds, and may therefore limit comfortable walking speed.

The aim of the present study was to examine the effects of balance training with visual feedback on stance and gait in school-age children with hemiplegic cerebral palsy. Ten participants between 5 and 11 years of age were assigned to either the training or the control group according to an aged-stratified randomization. The training corresponded to three sessions per week during six weeks. Stance and gait parameters, based on force plate data, were assessed three times in both groups: (a) at the beginning of the study (before training); (b) after six weeks; (c) after ten weeks. Spatial and temporal parameters were calculated. The results for stance showed that the training improved the performances on the tasks that were trained. More interesting, the results for gait showed that the walking pattern became more symmetrical after the training. [ABSTRACT FROM AUTHOR]

Purpose: To determine the relationship between isometric leg muscle strength and mobility capacity in children with cerebral palsy (CP) compared to typically developing (TD) peers.Method: Participants were 62 children with CP (6–13 years), able to walk with (n = 10) or without (n = 52) walking aids, and 47 TD children. Isometric muscle strength of five muscle groups of the leg was measured using hand-held dynamometry. Mobility capacity was assessed with the 1-min walk, the 10-m walk, sit-to-stand, lateral-step-up and timed-stair tests.Results: Isometric strength of children with CP was reduced to 36–82% of TD. When adjusted for age and height, the percentage of variance in mobility capacity that was explained by isometric strength of the leg muscles was 21–24% (walking speed), 25% (sit-to-stand), 28% (lateral-step-up) and 35% (timed-stair) in children with CP. Hip abductors and knee flexors had the largest contribution to the explained variance, while knee extensors showed the weakest correlation. Weak or no associations were found between strength and mobility capacity in TD children.Conclusion: Isometric strength, especially hip abductor and knee flexor strength, is moderately related to mobility capacity in children with CP, but not in TD children. To what extent training of these muscle groups will lead to better mobility capacity needs further study.Implications for RehabilitationStrength training in children with cerebral palsy (CP) may be targeted more specifically at hip abductors and knee flexors.The moderate associations imply that large improvements in mobility capacity may not be expected when strength increases. [ABSTRACT FROM PUBLISHER]

Abstract: Question: 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] [Copyright &y& Elsevier]

Abstract: The objective of the study was to evaluate the effectiveness of functional progressive resistance exercise (PRE) training on walking ability in children with cerebral palsy (CP). Fifty-one ambulant children with spastic CP (mean age 10 years 5 months, 29 boys) were randomized to an intervention (n =26) or control group (n =25, receiving usual care). The intervention consisted of 12 weeks functional PRE circuit training, for 3 times a week. Main outcome measures were walking ability and participation. Secondary outcomes were muscle strength and anaerobic muscle power. Possible adverse outcomes were spasticity and passive range of motion (ROM). Muscle strength increased significantly in the training group compared to the control group, but walking ability, participation and anaerobic muscle power did not change. Spasticity and ROM remained unchanged, except for a significant decrease in rectus femoris length in the intervention group. It is concluded that twelve weeks of functional PRE-training does not improve walking ability, despite improved muscle strength. [Copyright &y& Elsevier]