Cerebral Palsy, Spastic, Diplegic Clinical Trial
Official title:
Stretching and Strength Training for Children With Cerebral Palsy -an Intervention Study
The purpose of this randomized and controlled intervention study is to explore the effect of
a physiotherapy intervention targeting contract and spastic hamstring muscles in children
having bilateral spastic cerebral palsy (CP), GMFCS I-III: A stretching routine targeting
hamstrings (and psoas if short), and a progressive strengthening program on the muscles
extending then lower extremities (quadriceps, gluteus maximus and triceps surae)
Study hypothesis: Stretching of hamstrings and strength training of the extending muscles in
the lower extremities in children with bilateral spastic cerebral palsy will increase
popliteal angle, active knee extension, and gait function.
The key intervention: 16 weeks with three treatment sessions each week. Minimum pause
between two treatment sessions is one day. Week 1 and 2: To assure the correct dosage in
each exercise and a satisfactory education of the session done at home, all three sessions
will be implemented with the physiotherapist the first two weeks. From week 3: Two
treatment/training sessions with the physiotherapist and one shorter training session at
home.
Maintenance intervention: From week 17 to week nr 32.; One session pr. week will be
performed at home, together with an assistant in school or with the physiotherapist. How
this is accomplished will depend on what is feasible for the child and the parents.
The physiotherapy sessions: 2 sessions pr week. 5-10 min. warm up on a treadmill or a bike.
A stretching exercise on the hamstrings (and psoas if shortened; ≤ 5º hip extension) and 3
strength exercises targeting the muscles extending the hip, knee and ankle.
The intervention is expected to last 30 min. and it is an extra session on top of the usual
physiotherapy intervention given the child.
Home session: One session pr. week, lasting 10-15 min. No need of warm up. The session is
contending one stretching exercise on hamstrings and one strength exercise. The exercises
will be modified individually so the children are able to do them at home.
Exercise registration: The physiotherapist will be asked to register the sessions performed
each week. The reason why a session is not performed should be registered (a scheme is
attached).
The stretching (exercise schema p.3): Two stretching exercises will be performed on
hamstrings, and if the psoas muscle is short (≤ 5º hip extension) there should also be a
stretch performed on psoas. The stretching shall not be painful for the child.
The strength training exercises (exercises schema p.4 and 5): The strength training will be
performed following the principles of "Progressive Resistance Exercise" (PRE) and the
recommendations from The National Strength and Conditioning Association (NSCA) concerning
strength training for children12. The recommended weight resistance for children who are
familiar with strength training are 60-80% of 1RM (Repetition Maximum = maximum weight when
lifting one repetition), 2- 3 sets and 8-12 repetitions, 2 -3 times per week. Verscuhen and
collegues13 recommendations concerning a strength training protocol for children with CP are
taken into account: not only multi -joint exercises, but also singe - joint exercises,
extended rest between exercises (min 2-3 minute), minimum 12 weeks of intervention and the
children should be over 7 years of age. The standing exercises shall be performed with a
back pack (everyone in the intervention group will get one) which is possible to load with
weights/bottles of water.
Customization of weight resistance
Children having CP are likely to be diverse and according to physical conditions and because
of that 1 Repetition Maximum (1RM) will most likely be to difficult to perform. For
estimation of the optimal and individualized resistance throughout the period of
intervention a modified test shall be performed.
The test will be performed after the child have understood and completed the exercises
correct, during the first two weeks. Until that the physiotherapist will do a mapping of the
child's strength skills in order to recognize the wright amount of weight for the child for
12 repetitions and 2 series. As of week 3 there are 3 series per exercises. Recommendations
from the study done by Sholtes et all14 are used for guiding of optimal weight dosage. In
this study they found that for 8 RM in a sit- to stand exercise, for those having CP GMFCS
I-III the weight should be 35%, 30% and 25% respectively of body weight.
Performance of the RM test: Starting out with 3 repetitions without any resistance
throughout the range of moment. Every repetition shall be performed as correct and
controlled as passible throughout the range of moment and the speed is 2-3 sec. per
extension/flexion movement. If one repetition is carried out incorrectly with respect to
speed and movement quality it shall not be counted.
The RM test shall be conducted the first time in the end of the second week (12 RM x 3
series), then next time in week 5. (10 RM x 3 series), week 8. (8 RM x 3 series), and
finally in week 14. (8 RM x 3 series). When the child can do more than 12, 10 or 8
repetitions respectively, there shall be added more weight. The weight changes shall be
registered in a registration form.
RM test shall be performed in exercise nr 1),2) and 3). Exercise nr 4) is mostly an
awareness exercise where the focus is on quality and the ability to activate m.vastus
medialis by doing a max extension in the knee in a prone position.
;
Allocation: Randomized, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Treatment
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