Progressive strength- training in ambulant children and teenagers with cerebral palsy: a retrospec9ve service evalua9on

Transcription

1 Progressive strength- training in ambulant children and teenagers with cerebral palsy: a retrospec9ve service evalua9on Margaret Mockford, MSc, MCSP, SRP; Children s Physiotherapy Service

2 Overview Background to the change of progressive strength training (PST) protocol The progressive strength- training programme we delivered The outcome measures we used The service evaluadon Findings of this evaluadon ImplicaDons for clinical pracdce

3 The most effecdve method of extending mobility in adulthood may be to develop a significant muscle reserve in childhood and adolescence, when muscles may be more adaptable to mechanical sdmulus (Shortland 2009).

4 The PST programme 12 weeks, 3 sessions per week, on alternate days Child- held logbook 2 x10 reps of 6 closed- chain exercises Forward step- ups R+L, lateral step- ups R+L, squats, sità stand Progressive backpack load, start weight calculated: inidal 1- RM = 30% of body weight (Jung et al 2013), and start weight is 20-50% of 1- RM Warm- up and cool- down: 10 step- ups with no load, plus stretches of 2- joint muscles Fortnightly group: to progress weights; monitor quality; address other impairments balance, co- ordinadon, so_ Dssues

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6 Outcome measures RouDnely used, relevant to children and parents, and able to do in most se`ngs without specialised equipment Timed walk over 12m Timed stair- climb up 12 stairs Timed 6- minute walk using a 22m corridor Wee Glasgow Gait index (WeeGGI) (Tennant et al 2012)

7 The service evalua9on ObjecDve: to evaluate the delivery of a progressive strength- training programme to ambulant children and teenagers with CP, using a protocol updated in the light of this recent evidence RetrospecDve gathering of data from children s physiotherapy records, August 2015 onwards QuesDonnaires to children and parents/carers Discussion with physiotherapy staff team R&D approval from SSOTP NHS Trust

8 Parent and child sa9sfac9on ques9onnaires Do you feel you have improved your walking? Stamina? Posture? Stairs? Any pardcular acdvides? Did you have any difficuldes or problems doing the programme? If you could do the programme again next year, would you go for it? Did you like doing the group sessions? Do you have any other comments about the programme?

9 Staff discussion Semi- structured discussion around: Engaging the family and the child Working with a teaching assistant Doing the expanded programme 2 sets instead of 1 set, 12 weeks instead of 6-8 weeks Running the groups Any other thoughts, advantages or difficuldes in carrying out the programme and doing the outcome measures.

10 Findings of the evalua9on 13 children aged 5y 10m 14y 7m GMFCS 1 n=8; GMFCS 2 n=1; GMFCS 3 n=4 Compliance mean 92.3% (range %) of all planned sessions 8 children completed 100% of sessions 6 children pardcipated in groups; 6 did 1:1 acdvides with PTA; one opted to work alone All did standard 6 exs; one also did heel dips 11 did 20 reps; 1 did 10 reps only; 1 teenager progressed himself to 30 reps for weeks 7-12

11 Parent and child sa9sfac9on 11/13 parents; 11/13 children All had enjoyed the programme All except one child would do it again All those who did groups were very posidve and wanted more! DifficulDes: Dme to do home sessions; modvadng child at home; tripping over the step; weights ge`ng heavy PosiDves: opportunity to spend Dme with my child ; the whole programme was very helpful.

12 Staff discussion Staff found PST efficient use of Dme Weights somedmes a problem? Engaging children who aqend special schools? DifficulDes of group hard work inidally group size children were Dred, some distracted, some behaviour issues Benefits of group valuable networking for children and families from mainstream schools modvadng, compeddve, mutual learning, variety of acdvides. One- to- one modified group opportunity to work on quality, individual goals; but missed the compeddon with others

13 % change at 12 weeks % change at 24 weeks Lesser weights progression: % change in walk ;me - 2 Lesser weights progression: % change in stairs ;me - 4 % change in walk Dme % change in stairs Dme Child Mean 2 Child Mean % change in walk Dme Greater weights progression: % change in walk ;me % change in stairs Dme Greater weights progression: % change in stairs ;me Child Mean Child Mean

14 % change in walk Dme % change at 12 weeks % change at 24 weeks GMFCS 1 and 2: % change in walk ;me Child: % change in stairs Dme GMFCS 1,2: % change in stairs ;me Child GMFCS 3: % change in walk ;me GMFCS 3: % change in stairs ;me % change in walk Dme Child % change in stairs Dme Child

15 Other gait outcomes Distance walked in 6 minutes using a 22m corridor: one GMFCS 1 child, improved by 22% at end of 12 week programme Wee Glasgow Gait Index: One GMFCS 2 child, 17/22 at baseline, 9/22 at end of 12 weeks (lower score indicates improved gait parameters)

16 Baseline- end Baseline- follow- up Younger children % change walk ;me - 6 Younger children: % change stairs ;me % change in walk Dme Child % change in stairs Dme Child % change in walk Dme Older children: % change in walk ;me Child 4 9 % change in stairs Dme Older children: % change in stairs ;me child

17 Implica9ons for prac9ce PST can be achieved, with minimal equipment, in almost any se`ng BUT requires engagement from child and family / school PST can be an efficient use of staff Dme PST can be enjoyable for children and parents PST appears to improve gait- related skills More than doubling the weights appears to result in beqer outcomes, with retendon at 24 weeks Both pre- adolescents and adolescents can improve gait skills GMFCS 1,2,3 all gained in some way but we need to choose outcome measures that challenge each group.

18 Acknowledgments The 13 children and their families, who worked so hard! The staff of the Children s Physiotherapy Service, SSOTP Research and Development Department, SSOTP Dr Sue Hunter, Academic Partner, Keele University

19 Key references Behm et al 2008 Canadian society for exercise physiology posidon paper: resistance training in children and adolescents. Appl Physiol Nutr Metab 33: Council on Sports Medicine and Fitness (USA) Pediatrics 121(4): Gilleq et al 2016 The impact of strength training on skeletal muscle morphology and architecture in children and adolescents with spasdc cerebral palsy: systemadc review. Res Dev Disab 56: McNee et al 2009 Increases in muscle volume a_er plantarflexor strength training in children with CP. Dev Med Ch Neuro 51: Mockford and Caulton 2008 SystemaDc review of progressive strength training in children and adolescents with CP who are ambulant. Ped Phy Ther 20: Mockford and Caulton 2010 The pathophysiological basis of weakness in children with CP. Ped Phy Ther 22: Moreau et al 2013 DifferenDal adaptadons of muscle architecture to high- velocity versus tradidonal strength training in CP. Neurorehab Neuro Repair 27(4): Shortland 2009 Muscle deficits in CP and early loss of mobility: can we learn something from our elders? Dev Med Child Neuro 51(suppl 4):59-63 Shortland 2013 Muscle deformity in the lower limbs of children and young adults with spasdc CP. APCP Journal 4(2):7-12 Tennant et al 2012 Wee Glasgow Gait Index: a gait screening tool. APCP Journal 3(2):39-48 Verschuren et al 2011 Muscle strengthening in children and adolescents with spasdc CP: consideradons for future resistance training protocols. Phy Ther 91(7):1130-9