+ The Role of. Physiotherapy in Promoting Sustainable Fitness Opportunities for Individuals with Cerebral Palsy

Transcription

1 + The Role of Physiotherapy in Promoting Sustainable Fitness Opportunities for Individuals with Cerebral Palsy Lesley Wiart PT, PhD Laura Brunton PT, PhD Physiotherapy Alberta Webinar December 15 th 2016

2 + The plan Rationale for Physical Activity Re-thinking the role of Physiotherapy Understanding Barriers, Facilitators and Priorities Connecting Families to Fitness Questions

3 + The Physical Activity Continuum Image from:

4 + Sedentary Behaviour Risk factor for CVD Independent relationship with morbidity and mortality even when physical activity is considered. Those who meet physical activity guidelines may still be at risk

5 + Why is Physical Activity Important?

6 + Long-term Health Implications Increased risk of cardiovascular risk factors in young adults with cerebral palsy (van der Slot et al., 2013) Increased risk of stroke as a young adult OR=7.9 ( ) (Noorduyn et al., 2014)

7 + Psychosocial Benefits Physical activity (positively), and sedentary behaviour (inversely) associated with psycho-social well-being in children (Hinkley, 2014). Relationship between low physical activity in adolescence and decreased adult mental health (Poulsen et al., 2016)

8 + Quality of Life Physical activity associated with physical quality of life (R2=0.64, p=.002), social quality of life (R2=0.28, p<.01) and happiness (R2=.08, p=.04) in adolescents with cerebral palsy (Maher et al., 2016) Quality of life is related to fit between personal interests/preferences and opportunities to participate (Shikako-Thomas, 2009)

9 + Fatigue Children with cerebral palsy report higher levels of fatigue (Mayer et al., 2015). Fatigue is negatively correlated with time spent in moderate to vigorous physical activity (McPhee et al., 2016). Physical activity may play a role in decreasing fatigue

10 + Functional Implications Physical fitness related to walking related physical fitness and fatigue in children with bilateral cerebral palsy (Balemans et al., 2015). Fatigue Physical Fitness Walking related Activity

11 + In unilateral cerebral palsy Association between muscle strength and fatigue (Balemans, 2015). Could strengthening decrease fatigue for children with unilateral cerebral palsy?

12 + Establish Early Habits Physical activity habits track into adulthood (Telama, 2009) Many opportunities for children to explore a variety of physical activities

13 + We know that Fitness levels and physical activity are reduced in children with cerebral palsy and both are correlated with GMFCS levels.

14 + Physical Activity Levels Children with cerebral palsy have reduced physical activity levels (Bjornson et al., 2014)

15 + and Increased Sedentary Behaviour 30 Children with cerebral palsy spend more time sedentary (Ryan et al., 2015) % 18% Cerebral Palsy Typical Development 5 0

16 + Cardiorespiratory Fitness Decreased cardiorespiratory fitness compared to peers. (Verschuren, 2010)

17 + Anaerobic Fitness Children with cerebral palsy have anaerobic fitness compared to their peers;

18 + Re-Thinking Physiotherapy Assessment and Intervention When considering facilitating lifelong/sustainable physical activity we need to assess differently using a holistic approach encompassing many individual aspects: Fitness Testing Fatigue Self-efficacy Personal Factors

19 + Fitness Testing in Cerebral Palsy Why? Fitness testing can quantify improvements or declines in exercise capacity over time or in response to an intervention Fitness testing can help guide exercise prescription and ensure achievable goals

20 Energy Cost (J/kg/m) + Fitness Testing in Cerebral Palsy Why? Energy Cost of Walking TD GMFCS 1 GMFCS II GMFCS III (Bolster et al., submitted)

21 + Fitness Testing in Cerebral Palsy (Balemens et al., submitted)

22 + Fitness Testing in Cerebral Palsy What Measures Do I Use? Core Set of Exercise Tests (Verschuren et al., 2011; Verschuren & Balemans, 2015)

23 + Fitness Testing in Cerebral Palsy Submaximal Testing (6MWT) Pros: Simple, easy, inexpensive, corresponds to functional activities, test of endurance Cons: Only outcome is distance covered, no monitoring of physiological state

24 + Fitness Testing in Cerebral Palsy Maximal Exercise Testing (Shuttle Run/Ride Tests) Pros: Multiple stages for different ability levels, little equipment, external pacing, can use physiological monitoring, reference values available for CP Cons: Some children require a pacer, need to ensure maximal test criteria met (HR>180bpm)

25 + Fitness Testing in Cerebral Palsy (Verschuren et al., 2010a)

26 + Fitness Testing in Cerebral Palsy (Verschuren et al., 2010a)

27 + Fitness Testing in Cerebral Palsy Anaerobic Exercise Testing (Muscle Power Sprint Test, Verschuren, 2014) Pros: Inexpensive, short duration, reference values available Cons: Depends on individual s motivation

28 + Fitness Testing in Cerebral Palsy (Verschuren et al., 2010b)

29 + Fitness Testing in Cerebral Palsy (Verschuren et al., 2010b)

30 + What Training Intensity is Walking? Near Max/Maximal Vigorous Moderate Light Very Light (Balemens et al., submitted)

31 + Fitness Testing in Cerebral Palsy Other Measures? Early Activity Scale for Endurance (EASE) (McCoy et al., 2012) Parent-completed measure Children under the age of 6 years 11-items, use a total score Download a copy of the measure (short/long version)

32 + Fitness Testing in Cerebral Palsy Other Measures: OMNI-Rating of Perceived Exertion Pros: Validated against physiological indices of VO 2 and heart rate using an estimation protocol during real-life activities of varying intensities, can be used to monitor exercise intensity in GMFCS levels I to III Cons: Evidence for use of the OMNI-RPE to prescribe exercise intensity is not yet available may still need to use HR models

33 + OMNI-RPE (Fragala-Pinkham et al., 2015)

34 + Other Assessment Considerations Fatigue Impact and Severity Self- Assessment Pros: Validated in CP, Self-management tool, PArelated items, moderate-to-vigorous physical activity shown to be a significant predictor of having less fatigue Cons: Self-report scale limited to subjective experience, no normative values yet laura.brunton@ucalgary.ca for copy of the scale

35 + What Does it Mean? Need to determine if someone has a decreased aerobic capacity (something you might train with physical activity) or has a decreased walking economy (something better treated with other interventions such as AFOs, reduce spasticity, surgical procedure, etc)

36 + Other Assessment Considerations Self-efficacy Attitude Subjective Norm Intention Behaviour Perceived Behavioural Control Self Efficacy (Task) (Behaviour) (Foley et al., 2008)

37 + Other Assessment Considerations Self-efficacy Self-Efficacy for Exercise Scale (SEE) (Resnick & Jenkins, 2000) Self-Efficacy for Physical Activity Scale (Campbell, 2012) Pros: In other populations self-efficacy has been shown to predict exercise, more information about self-perceived abilities Cons: Not explicitly validated for use in populations with CP Find the scales here: ext=etd (Appendix G)

38 + Self-Efficacy Scale Example (Campbell, 2012)

39 + Self-Efficacy Alternative Approach: Interview How confident or sure do you feel about carrying out your plan (on a scale from 0 to 10)? What would it take for you to move up even one point on that scale? Consider both the task and the behaviour as being things that influence change Asking about self-efficacy as an intervention

40 + Other Assessment Considerations Personal Factors Motivation Preferences Family dynamics and priorities Individualized barriers/facilitators Shields et al., 2012 Wiart et al., 2015 Personal Social Program & Policy Environmental

41 + 24 Hour Movement Guidelines ParticipACTION Report Card, 2016

42 + Connecting Families to Fitness Ascertain family resources, activity preferences, current physical activity level and readiness for change. APTA Section on Pediatrics Fact Sheet Opportunities to connect with other families Finding the best fit (Wiart et al., 2015) Many factors including age of child, preference for inclusion or specialized program, opportunities for social interaction

43 + There s an app for that

44 + Connecting Families to Fitness Integrate health and fitness into rehabilitation goals Connect with community based programs Be knowledgeable about available supports Transitional programs Exploration of physical activities Increase self-efficacy for physical activity Adapt activities

45 + Igniting Fitness Possibilities Long-term Athlete Development Framework Two phases QuickStart (8 weeks, twice weekly, after school) Stage 2 FUNdamentals Give it a Try (community based activity) Stage 3 Learning to Train Igniting Fitness Possibilities (Nicitopoulos, Wright, Nicolopoulos, Boross-Harmer, Faulkner)

46 + Partnership between pediatric physical therapists, occupational therapists and Edmonton bike commuters society. Adapted bike workshops, loaner bikes

47 + Thank you! Lesley Wiart Laura Brunton