Progressive strength-training in ambulant children and teenagers with cerebral palsy: a retrospective service evaluation Margaret Mockford, MSc, MCSP, SRP; Children s Physiotherapy Service
Overview The change of progressive strength training (PST) protocol The progressive strength-training programme we delivered The outcome measures we used The service evaluation Findings of this evaluation Implications for clinical practice
The most effective 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 stimulus (Shortland 2009).
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, sit stand Progressive backpack load, start weight calculated: initial 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-ordination, soft tissues
Outcome measures Routinely used, relevant to children and parents, and able to do in most settings 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)
The service evaluation Objective: 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 Retrospective gathering of data from children s physiotherapy records, August 2015 onwards Questionnaires to children and parents/carers Discussion with physiotherapy staff team R&D approval from SSOTP NHS Trust
Parent and child satisfaction questionnaires Do you feel you have improved your walking? Stamina? Posture? Stairs? Any particular activities? Did you have any difficulties 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?
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 difficulties in carrying out the programme and doing the outcome measures.
Findings of the evaluation 13 children aged 70-175m GMFCS 1 n=8; GMFCS 2 n=1; GMFCS 3 n=4 Compliance mean 92.3% (range 62-100%) of all planned sessions 8 children completed 100% of sessions 6 children participated in groups; 6 did 1:1 activities 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
Parent and child satisfaction 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 positive and wanted more! Difficulties: time to do home sessions; motivating child at home; tripping over the step; weights getting heavy Positives: opportunity to spend time with my child ; the whole programme was very helpful.
Staff discussion Staff found PST efficient use of time Weights sometimes a problem? Engaging children who attend special schools? Difficulties of group hard work initially group size children were tired, some distracted, some behaviour issues Benefits of group valuable networking for children and families from mainstream schools motivating, competitive, mutual learning, variety of activities. One-to-one modified group opportunity to work on quality, individual goals; but missed the competition with others
Time to walk 12m (secs) Time to walk 12m (secs) Walk time over 12 m: those who progressed weights by <100% vs >100% Greater weights progression: individual walk time 4 35.00 Lesser weight progression: individual walk time 3 25.00 25.00 15.00 15.00 5.00 5.00 Baseline 12 weeks 24 weeks Baseline 12 weeks 24 weeks Child 12 Child 7 Child 11 Child 2 Child 8 Child 1 Child 6 Child 13
Time to climb 12 stairs (secs) Time to climb 12 stairs (secs) 6 5 Lesser weights progression: timed stairs Stair-climbing time: weights progressed by <100% vs by >100% 4 25.00 Greater weights progression: timed stairs 3 15.00 5.00 Baseline 12 weeks 24 weeks Baseline 12 weeks 24 weeks Child 9 Child 12 Child 7 Child 2 Child 4 Chiild 8 Child 5 Child 3 Child 6 Child 10 Child 13
Time to walk 12 m (secs) Time to walk 12m (secs) 4 35.00 3 Younger children: timed walk Children <10 yrs compared to children 10yrs: time to walk 12m 25.00 15.00 18.00 17.50 17.00 16.50 16.00 15.50 15.00 14.50 14.00 Older children: timed walk Baseline 12 weeks 24 weeks 5.00 Child 4 Child 13 Baseline 12 weeks 24 weeks Child 1 Child 2 Child 6 Child 7 Child 8 child 12
time to climb 12 stairs Time to climb 12 stairs 6 5 Younger children: timed stairs Children <10 yrs vs children 10yrs: time to climb 12 stairs 4 3 Older children: timed stairs 25.00 15.00 5.00 Baseline 12 weeks 24 weeks Child 5 Child 2 Child 6 Child 7 1 2 3 Baseline 12 weeks 24 weeks Child 8 Child 3 Child 12 Child 4 Child 10 Child 9 Child 13
time to walk 12 m (secs) time to walk 12m (secs) Time to walk 12m: GMFCS 1,2 compared to GMFCS 3 4 35.00 GMFCS 3: timed walk GMFCS 1+2: timed walk 3 18.00 25.00 16.00 14.00 12.00 15.00 8.00 6.00 4.00 5.00 2.00 Baseline 1 122 weeks 324 weeks Baseline 12 weeks 24 weeks Child 1 Child 2 Child 12 Child 4 child 6 Child 7 Child 8 Child 13
Time to climb 12 stairs (secs) Time to climb 12 stairs (secs) Time to climb 12 stairs: GMFCS 1,2 compared to GMFCS 3 6 5 GMFCS 3: timed stairs 4 GMFCS 1+2: timed stairs 18.00 3 16.00 14.00 12.00 8.00 6.00 4.00 2.00 Baseline 12 weeks 24 weeks Baseline 12 weeks 24 weeks child 3 Child 4 Child 6 Child 7 Child 2 Child 10 Child 12 Child 8 Child 9 Child 13 Child 5
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)
Implications for practice PST can be achieved, with minimal equipment, in almost any setting BUT requires engagement from child and family / school PST can be an efficient use of staff time PST can be enjoyable for children and parents PST appears to improve gait-related skills More than doubling the weights appears to result in better outcomes, with retention 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.
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
Key references Behm et al 2008 Canadian society for exercise physiology position paper: resistance training in children and adolescents. Appl Physiol Nutr Metab 33:547-61 Council on Sports Medicine and Fitness (USA) 2008. Pediatrics 121(4):835-40 Gillett et al 2016 The impact of strength training on skeletal muscle morphology and architecture in children and adolescents with spastic cerebral palsy: systematic review. Res Dev Disab 56:183-96 McNee et al 2009 Increases in muscle volume after plantarflexor strength training in children with CP. Dev Med Ch Neuro 51:429-35 Mockford and Caulton 2008 Systematic review of progressive strength training in children and adolescents with CP who are ambulant. Ped Phy Ther 20:318-333 Mockford and Caulton 2010 The pathophysiological basis of weakness in children with CP. Ped Phy Ther 22:222-33 Moreau et al 2013 Differential adaptations of muscle architecture to high-velocity versus traditional strength training in CP. Neurorehab Neuro Repair 27(4):325-34 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 spastic 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 spastic CP: considerations for future resistance training protocols. Phy Ther 91(7):1130-9