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Critically Appraised Topic

Phelps, Rose V. PT, DPT; Wong, Rita EdD, DPT; Brady, Rachel PT, DPT, MS

doi: 10.1097/PEP.0b013e3181b13581
Departments: Critically Appraised Topic

Falls Church, VA (Phelps)

Marymount University, Arlington, VA (Wong)

Georgetown University Center for Child Human Development, Washington, DC (Brady)

QUESTION: Does fitness training improve physical performance and activity level of children with cerebral palsy (CP)?

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Clinical Bottom Line:

  1. The results of a case report corroborated the results from the 2 randomized, controlled trials.
    1. Fitness programs for children and adolescents ranging in age from 5 to 20 years old that include strength training and aerobic fitness improve gross motor and aerobic function.
    2. Fitness programs for children with CP need to be ongoing for benefits to continue.
    3. Children with CP can participate in fitness programs with no ill effects.
    4. Group exercise provided more consistent benefits than did individual exercise.
  2. The results of 2 randomized, controlled trials indicated improved quality of life, and the case report indicated improved self-perception even after the training was completed.
  3. More randomized, controlled trials of aerobic and strength training for children with CP need to be done to determine frequency and dose parameters.

Our clinical bottom line is consistent with the information reported in Verschuren O, Ketelaar M, Takken T, et al. Exercise programs for children with cerebral palsy: a systematic review of the literature. Am J Phys Med Rehabil. 2008;87:404–417. It is an excellent resource for more information on the topic of fitness training for the population of children with CP. Our review includes more recent literature and a case report.

Citation: Fragala-Pinkham MA, Haley SM, Rabin J, et al. A fitness program for children with disabilities. Phys Ther. 2005;85:1182–1200.

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Clinical Bottom Line:

Children in the group exercise period participated more fully and had improvements in walking efficiency, strength, and function compared with children in the home program period.

The children in this report were able to safely participate in a group fitness program.

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Summary of Key Evidence:

  1. Study Design: A case report with 9 subjects aged 5 to 9 years and 4 subjects with CP.
  2. Sample: The Gross Motor Function Classification System (GMFCS) was used to classify the 4 children with CP as follows: 1 child at level 1, 2 children at level 2, and 1 child at level 3.
  3. Procedure: Intervention 1 consisted of 60–70 minutes of aerobic and strengthening exercises, individualized to accommodate participants’ abilities, 2 times per week for 14 weeks. Aerobic activities and strengthening exercises were begun at an easy level and advanced to a moderate level of intensity. Intervention 2 was a 12-week home program with a video tape, written exercises, and a journal.
  4. Outcome Measures: The energy expenditure index (EEI), muscle strength obtained with a hand-held dynamometer, the self-perception profile (SPP) for children, the Gross Motor Function Measure (GMFM-66), the Presidential Fitness Test. Safety was measured by parent questionnaire.
  5. Results: Minimal detectable change (MDC) was calculated to determine whether each child improved or declined. Three of the 4 children with CP exceeded the MDC for EEI, all 4 subjects exceeded the MDC for GMFM; 3 of the 4 exceeded MDC for walking speed. Strength gains occurred during the exercise phase for 3 children and during the home program phase for 1 child; self-perception did not change for any of the subjects. There were 5 segments to the Presidential Fitness Test; 1 subject showed improvements in 4 areas and 2 showed improvements in the sit and reach portion during the exercise phase only. Improvements in 3 of the 4 children were achieved only in the group setting.
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Appraisal and Application:

Internal Validity. Threats: (1) Nonexperimental descriptive case report; did not have a comparison group, subjects were not randomly put into exercise/nonexercise groups, and the study had small number of subjects with CP. (2) Changes in the children could have been due to maturation, learning the outcome measures, or outside therapy in which the child was involved. (3) The exercises were individualized, so that no set exercise regimen was followed. (4) The SPP has been used in other studies with children with CP but has not been validated with this population. (5) The Presidential Fitness Test has descriptors for use with children with special needs but does not have reliability data for this population. Strengths: (1) The EEI and GMFM-66 are valid for this population. (2) The dynamometer was used under standard protocol with high test-retest reliability. (3) The remaining measures have been used in other research with the population with CP, and a protocol was followed to standardize the measurements.

External Validity. Strengths: (1) The subjects, children with CP, are well focused on the question. Threats: (1) Subjects were homogeneous: white boys between 5.5 and 7.5 years of age from 1 area in Boston, MA.

Statistical Validity. Strengths: (1) Use of test-retest data to support outcome measures for tools that are not validated for this population. (2) Use of MDC for outcomes to ensure change was not just measurement error.

Citation: Unnithan VB, Katsimanis G, Evangelinou C, et al. Effect of strength and aerobic training in children with cerebral palsy. Med Sci Sports Exerc. 2007;39:1902–1909.

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Clinical Bottom Line:

Adolescents with CP in a 12-week aerobic interval and strength training program demonstrated improved arm cranking economy and a significant increase in peak Vo2.

The subjects showed an improvement in GMFM scores for the standing and walking sections at the end of a 12-week training period.

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Summary of Key Evidence:

  1. Study Design: Randomized, controlled trial.
  2. Sample: Thirteen adolescents (9 girls, 4 boys) aged 14–18 years were recruited from a local rehabilitation center. Inclusion criteria were diagnosis of spastic diplegia, ability to ambulate with or without device, no orthopedic surgery or Botox injections for spasticity in the previous year, physical therapy that did not include aerobic or strength training.
  3. Procedure: Subjects were randomized to training and control groups over a 6-month period. Both groups had 2 measurements performed at baseline and at 12 weeks. The training group exercised 3 times per week for 70 minutes for each of the 12 weeks. Core and general strengthening exercises were also performed. Aerobic training was 20 minutes with 60-m uphill walking repetitions. The control group received their usual care ranging from no treatment to various therapeutic interventions: care was documented by the caregiver.
  4. Outcome Measures: Submaximal and peak exercise testing was performed on an arm crank. Vo2 was determined with open-circuit spirometry. The GMFM was used to assess motor status.
  5. Results: Submaximal exercise intensity: the exercise group showed an increase (+3.9%) in arm-cranking economy and an increase (+20%) in peak Vo2, demonstrating that the exercise group used their oxygen better during exercise than the control group. Motor status: the exercise group significantly (p < 0.05) increased their GMFM standing and walking scores compared with the control group (+3.5%).
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Appraisal and Application:

Internal Validity. Strengths: (1) Control and training groups were similar at baseline. (2) The study was moderately rigorous with a PEDro scale score of 6/10. Threats: (1) Researcher, who was aware of group allocation, performed pre- and posttests of the GMFM, allowing for the possibility of scoring bias toward a beneficial outcome and skewing the effect size.

External Validity. Strengths: (1) Eligibility criteria were well defined: allow readers to accurately determine whether their population is similar to the treatment population. (2) Between-group outcome measurements are reported on all key outcomes, giving the reader confidence that differences are due to treatment, not individual differences. Threats: (1) Adolescent age group does not specifically address the question of children’s responses to fitness training. (2) Small sample size impairs generalizability.

Statistical Validity. Strengths: (1) Nonparametric statistics were applied to data rigorously with tests used to examine the effects of time and group on each dependent variable, giving the reader confidence that these factors are sufficiently accounted for in the results.

Citation: Verschuren O, Ketelaar M, Gorter JW, et al. Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial. Arch Pediatr Adolesc Med. 2007;161:1075–1081.

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Clinical Bottom Line:

The study demonstrated significant training effect for aerobic and anaerobic capacities, agility, muscle strength, and athletic competence after an 8-month program of aerobic and anaerobic exercises.

The study demonstrated improvements in quality-of-life measures and skill-based activities.

A follow-up after 4 months of no exercise noted regression to pretraining levels for the training group in all domains, indicating the need for ongoing fitness training to maintain improvements.

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Summary of Key Evidence:

  1. Study Design: Randomized, controlled trial.
  2. Sample: Eighty-six children and adolescents between 7 and 20 years of age with CP were recruited from 4 special education schools in the Netherlands. Inclusion criteria included diagnosis of spastic CP with a GMFCS level I or II and capacity to follow simple verbal commands. All participants were currently receiving rehabilitation services. Exclusion criteria included surgery and Botox injections within the previous 6 months. The participants could not have cardiac or respiratory conditions that would interfere with exercising.
  3. Procedures: The students were divided into 2 groups according to their GMFCS, level I or II. Each school had its own group of participants, from each block and group, and every participant was randomly assigned to the training group or the control group. The training group performed 8 standardized aerobic and 8 standardized anaerobic exercises. Each session took place 2 times per week and was 45 minutes long. The entire exercise program lasted 8 months; the first 4 months focused on improving aerobic fitness, and the focus for the last 4 months was anaerobic capacity, with a postexercise follow-up at 12 months. The training group underwent their usual physical therapy regimen in addition to the exercise; the control group underwent their usual physical therapy regimen only.
  4. Outcome Measures: SPP for children, GMFM, 10-m shuttle run test from the Presidential Fitness Test, Muscle Power Sprint Test: The Netherlands Organization for Applied Scientific Research Academic Medical Centre (TNO-AZL), Child Quality of Life Questionnaire for Children’s Health-Related Quality of Life (TAQOL).
  5. Results: Strength and aerobic training improved strength (+20%), aerobic fitness (+38%), anaerobic capacity (+25%), and self-perception (+11%) in children and adolescents with CP. There were no negative effects reported.
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Appraisal and Application:

Internal Validity. Threats: (1) No blinding to group of therapists or participants, thus risking potential bias in the treatment group to work extra hard for good results. Strengths: (1) The study was rigorous, with a score of 8/10 on the PEDro scale for randomized, controlled trials that included specific inclusion and exclusion criteria, random and concealed allocation to groups, and blinding of assessors of outcome measures.

External Validity. Strengths: (1) Well-defined population to be able to generalize results to children with CP.

Statistical Validity. Strength: (1) Intent-to-treat analysis of data, meaning statistics were analyzed for all subjects according to the group to which they were assigned, assuming the worst outcome, and computed in. This statistical analysis greatly reduces the possible biasing effects of subjects who drop out.

Rose V. Phelps, PT, DPT

Falls Church, VA

Rita Wong, EdD, DPT

Marymount University, Arlington, VA

Rachel Brady, PT, DPT, MS

Georgetown University Center for Child Human Development, Washington, DC

© 2009 Lippincott Williams & Wilkins, Inc.