PowerPoint Presentation€¦ · 9/15/2017 Copyright 2017: Hedgecock & Harris 15 References 1. Jeffries L, Fiss A, McCoy SW, Bartlett DJ. Description of Primary and Secondary Impairments

9/15/2017

Copyright 2017: Hedgecock & Harris 1

SEPTEMBER 16, 2017

AACPDM ANNUAL CONFERENCE –MONTRÉAL, QUÉBEC, CANADA

INCORPORATING RESISTANCE TRAINING INTO EPISODIC CARE IMPROVES FUNCTION AND PARTICIPATION IN YOUTH WITH CEREBRAL PALSY

James B. Hedgecock, PT, DPT, PCS

Nicole Harris, PT, PCS, BOCO

We have no conflicts of interest or relevant financial interests to report.

We will not discuss off label/investigational drug use.

Objectives

Understand the impact of muscular strength on function and participation in youth with CP

Complete a clinical assessment to select ideal training parameters to achieve a patient's specific goals.

Design a resistance and functional skill training program using appropriate dosing and outcomes assessment to address individualized goals

Develop a plan to initiate a resistance training program for youth with cerebral palsy at their institution.

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Appreciation

http://betamonkeys.co.uk/assistance/

Impact

Motor difficulties in people with CP are related to several factors

CEREBRAL PALSY

IMPAIRMENTS• Selective motor

control• Postural Control• ROM• Spasticity/Tone• Endurance• Strength

FUNCTIONAL LIMITATIONS

• Sitting• Transitional

movements• Walking• Stair negotiation• Higher level gross

motor tasks

PARTICIPATION RESTRICTIONS

• Environmental access• Peer related activities• Sports /Recreational

Activities• Family Routines

PERSONAL FACTORS• Cognitive, academic,

communication impairments

• Social stigma• Psychological

comorbidity• Equipment/brace use

ENVIRONMENTAL FACTORS

• Service availability• Community

accessibility

Jeffries 2016, Jensen 2004, Fowler 2009, Palisano 2017, Moreau 2010/2013

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Strength significantly impacts gross motor capability in young children with CP.

Bartlett 2014, Chiarello 2016

Muscular weakness occurs early in development in children with CP

Jeffries 2016

Measure Factor Loading

Tone (Ashworth) 0.68

Coordination (GMPM) 0.77

Balance/Postural Control (ECAB) 0.95

Strength (FST) 0.95

Endurance (EASE) 0.68

Range of Motion (SAROMM) 0.74

SecondaryImpairments

Primary Impairments

Strength and balance/postural control are the impairments that carry the most impact in young children with CP

Secondary impairments that impact function and participation already occur as young as 1.5-5 years

Strength impacts function in school-aged and adolescents with CP.

Dallmeijer 2011, Eek 2008, Moreau 2012, Ross 2007, Moreau 2010

Spasticity Strength

Measures of strength are more related to performance on measures of gross motor performance and gait measures

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Strength is associated with participation across the life span

Moreau 2010, Ross 2007, Ohata 2008

Several measures of participation are significantly associated with measures of strength

These relationships are more common and stronger than relationships to spasticity

Quad Ms Thickness Quad and Hamstring Tone

Ambulatory children with CP exhibit upwards of 50% strength deficit in key muscle for ambulation.

Eek 2008, Ross 2007, Moreau 2010, Nooijen 2017

% A

ge

Exp

ecte

d S

tren

gth

Hamstrings, dorsiflexors, plantar flexors and hip abductors are the most impacted

<50% age expected strength = walking with assistance

It isn’t all about how much you bench, bro.

Moreau 2012, Nooijen 2014, Yancy 2016

Rate of force development is diminished by upwards of 70% in children with CP compared to those with typical development

Power generation is related to function and participation as is maximal strength

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Muscle structure impacts organ function

Muscle structure in

Children with CP is

altered

Decreased: Muscle fascicle length

Speed of contraction

Muscle volume

Muscle belly length

Myofiber number

Diminished physiological cross sectional area

ACTIVITY LIMITATION AND PARTICIPATION RESTRICTION

Barrett 2010, Gao 2011, Moreau 2013

Reduced Force Production Capability

Do you even lift?

Conflict of Evidence

Taylor 2005, Mockford 2008, Scianni 2009, Kenyon 2010, Verschuren 2011, Scholtes 2011, Scholtes 2012, Novak 2013, Moreau 2013, Hedgecock 2015, Moreau 2016, Gannotti2015, Kirk 2016, van Vulpen 2017

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Train specifically for function

Moreau 2013, Hedgecock 2015, Kenyon 2010, van Vulpen 2017

Velocity dependent (AKA POWER) training positively alters function in children with CP, whereas maximal strength training did not

Individual case reports have demonstrated functional improvements with other strength training focuses, but they were targeted at a specific function

So, what should I do?

Fundamentals of Strength Training

Functional and Participation

Improvements

Outcomes: Measure Before, During, and After

Training Specificity: Train

for What You Want to Do

Individualization: Build a Plan for a

Person

Periodicity: Train in Phases

Frequency: Train Enough Over

Time

Volume: Do Enough in Your

Session

Progression: Make it Harder

Frequently

Pescatello 2014, Sheppard 2015

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Safety Concerns

Patient Selection

• >3 years of age

• Able to follow your instructions

• Volitional control of the selected joint

Precautions

• Communication impairment

• Heat sensitivity

• Cardiac precautions

• Recent, minor musculoskeletal injury

• Joint contracture or skeletal malformation

• Sensory impairment

Contra-inidcations

• Recent orthopedic surgery

• Unable to follow directions or complete action safely

• <3 years of age

• Unhealed wound around moving joint

Weight lifting, under supervision of a trained professional, has been found safe over, and over, and over again in

children as young as 3 years

Lloyd 2014, Faigenbaum 1998, Bauer 1999, Sheppard 2015

What do we do?

Exercise Selection

Mimics Targeted Function?

Complete with

minimal assist

Single vs. Multi-Joint

Repeatable

Adaptable

Prescription - 1 Repetition Maximum Testing

Continue Adjusting Weight

Child completes 1-5 repetitions, estimate 1RM

Child unable to complete repetition or completes >5 repetitions, then adjust

Adjust Weight

Child completed >5 repetitions of previous weight then increase weight

Child unable to complete a successful attempt then decrease weight

Select weight for movement

Guess a weight that you think a child can successfully complete <5 times

- 1-5 repetitions – http://www.exrx.net/Calculators/OneRepMax.html

Sheppard 2015, Faigenbaum 2012

http://www.exrx.net/Calculators/OneRepMax.html

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Dose it, do it, progress it

Training Goal Load (%1RM)

Goal Repetitions

Sets Rest Period

Strength >85% <6 2-6 2-5 min

Power 75-85% 3-5 3-5 2-5 min

Hypertrophy 67-85% 6-12 3-6 30 sec-1.5 min

Figures adapted from: Sheppard 2015, Robertson 2015; Moreau 2013, Verschuren 2008, van Vulpen 2017, Damiano 2010

*3x/week for 12 weeks*Work within above 1RM guides or 7-9/10 RPE (last reps of last 1-2 sets should be very hard to do*Advance weight 5-10% percent when efforts become easier

Dose it, do it, progress it

Training Goal Load (%1RM)

Goal Repetitions

Sets Rest Period

Strength >85% <6 2-6 2-5 min

Power 75-85% 3-5 3-5 2-5 min

Hypertrophy 67-85% 6-12 3-6 30 sec-1.5 min

Figures adapted from: Sheppard 2015, Robertson 2015; Moreau 2013, Verschuren 2008, van Vulpen 2017, Damiano 2010

Current recommendations state 3x/week for 12 weeks is required for strengthening, non-consecutive days

ADAPT

Moreau – 80% 1RM at 30 degrees/second movement, 6 sets, 5 reps, 24 session over 8-10 weeks (2-3 sessions/week); Quadriceps onlyVerschuren – Suggested 1-3 sets, 6-12 reps; 2-3x/week, 12 weeks, increased rest

periods (follows NSCA novice lifting guidelines); Noted most studies are not intense enoughvan Vulpen – 50-70% 1RM; Functionally based intervals (25” on, 35-60” rest x 6 reps, 10% load increase to progress, 4 exercises, 3x/week, 16 weeks); Plantar flexor focusedDamiano – Unknown intensity, 30 repetitions (3 sets, 8-10 reps), 3x/week, 8 weeks,

Complete the Intervention

Guarding/spotting

Assistance?

Verbal cuing

Concentric and Eccentric Control

Encouragement

Rest Periods

Sheppard 2015

Other Considerations

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Our Hospital:CHCO

New Ideas:

CSM 2013 pre-con Linking Structure to Function: Muscle, Bone, Brain

Therapeutic threshold

Training specificity:

brain, bone, muscle

WEAKNESS POWER

Motivation Change emphasis

Heathcock 2013

Intensive Programs at CHCO:

History

Big Ideas

Establish Program

Evaluate Educate

Expand

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Resistance Training

(RTI)

Gait and Balance

Neurofunctional (NFTI)

NDT Based Mixed Discipline

Core concepts of RTI:

No recipe book for program design

IndividualizedFamily, Goals and treatment

DosingWhat impairment needs

improvement?

FOCUS and BREAKS

Resistance Training Intensive (RTI):

What are we doing?

Model:• Brief episodes of intense

intervention• Periodic follow-up

Patients:

• Neuro impairment• Safe• Motivated

Muscle Groups:

• Typical – Gastroc-soleus, gluteus maximus, gluteus medius, quadriceps, hip flexor, dorsiflexion

Time Frame:

• 8-12 weeks, 2-3 sessions per week

Dosing:

• Typically - power training

• Occasionally - strength training

• Always- functional skill practice

Outcomes:

• consistent

• individual outcomes added as needed

Verschuren 2008, Verschuren 2011, Chrysagis 2014,Avery 2013, Fairbaim 2012; Sheppard 2015, Moreau 2013, Verschuren 2011

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Individualization &

Assessment :

How do we do it?

Goals

Assessment

Muscle groups

Lifting movements

Functional activities

Just do it…

RTIin Action!

Functional Activities

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Post-Intervention

Re-assess the child/family

goals

Re-assess the outcome measures

What’s next?Patient and

family are the drivers

Resistance Training:

It’s working

p=0.12

*

p<0.0001

* *

*

p<0.0001

*Change greater than MDC

Hedgecock & Harris 2016

Resistance Training:

It’s working

p=0.0001

D p=0.0003

E p=0.0006

**

*Change greater than MDC

Hedgecock & Harris 2016

0

20

40

60

80

100

Pre Post

Percen

t

Gross Motor Function Measure - 88

GMFM D

GMFM E

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What has changed?

RTIProgram Evaluation

Areas of Growth

•GROUPS

•Participation outcome measures

•Equipment

•Increase referrals

•Nutrition

Take Home

Weakness

Specificity of training

FOCUS

Be surprised

Don’t water down your intervention!

Don’t strive for perfection, but for PROGRESSION!

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Be Confident!

Case Discussions and Troubleshooting:

20 minutes

Review case examples. (10 minutes) Get in small groups (2-4 people)

Review 1-2 case presentations, patient goals, initial outcome assessment and intervention choices

Discuss why you may agree or disagree with the prescription, what might you have done differently?

Jim and Nickie will be available for questions

We will re-group to discuss next steps/barriers to implementation of an RTI at your site (10 minutes)

General questions

Contact Us: [email protected] [email protected]

Next Steps Needs Barriers

mailto:[email protected]

mailto:[email protected]

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References

1. Jeffries L, Fiss A, McCoy SW, Bartlett DJ. Description of Primary and Secondary Impairments in Young Children With Cerebral Palsy. Ped Phys Ther. 2016;28(1):7-14. doi:10.1097/PEP.0000000000000221.2. Jensen MP, Engel JM, Hoffman AJ, Schwartz L. Natural history of chronic pain and pain treatment in adults with cerebral palsy. Am J Phys Med Rehabil. 2004;83(6):439-445. http://www.ncbi.nlm.nih.gov/pubmed/15166688.3. Fowler EG, Goldberg EJ. The effect of lower extremity selective voluntary motor control on interjoint coordination during gait in children with spastic diplegic cerebral palsy. Gait Posture. 2009;29(1):102-107. doi:10.1016/j.gaitpost.2008.07.007.4. Palisano RJ, Di Rezze B, Stewart D, et al. Life course health development of individuals withneurodevelopmental conditions. Dev Med Child Neurol. 2017;59:470-476.5. Moreau NG, Holthaus K, Marlow N. Differential adaptations of muscle architecture to high-velocity versus traditional strength training in cerebral palsy. Neurorehabil Neural Repair. 2013;27(4):325-334. doi:10.1177/15459683124698346. Moreau N, Simpson K. Muscle architecture predicts maximum strength and is related to activity levels in cerebral palsy. Phys Ther. 2010;90(11):1619-1630. http://ptjournal.apta.org/content/90/11/1619.short. Accessed April 18, 2016.7. Bartlett DJ, Chiarello LA, McCoy SW, et al. Determinants of self-care participation of young children with cerebral palsy. Dev Neurorehabil. 2014;17(6):403-413. doi:10.3109/17518423.2014.897398.8. Chiarello LA, Bartlett DJ, Palisano RJ, et al. Determinants of participation in family and recreational activities of young children with cerebral palsy. Disabil Rehabil. 2016;38(25):2455-2468. doi:10.3109/09638288.2016.1138548.9. Dallmeijer a J, Baker R, Dodd KJ, Taylor NF. Association between isometric muscle strength and gait joint kinetics in adolescents and young adults with cerebral palsy. Gait Posture. 2011;33(3):326-332. doi:10.1016/j.gaitpost.2010.10.092.10. Eek MN, Beckung E. Walking ability is related to muscle strength in children with cerebral palsy. Gait Posture. 2008;28(3):366-371. doi:10.1016/j.gaitpost.2008.05.004.11. Moreau NG, Falvo MJ, Damiano DL. Rapid force generation is impaired in cerebral palsy and is related to muscle size and functional mobility. Gait Posture. 2012;35:154-158.

References

12. Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007;88(9):1114-1120. doi:10.1016/j.apmr.2007.06.011.13. Ohata K, Tsuboyama T, Haruta T, Ichihashi N, Kato T, Nakamura T. Relation between muscle thickness, spasticity, and activity limitations in children and adolescents with cerebral palsy. Dev Med Child Neurol. 2008;50(2):152-156. doi:10.1111/j.1469-8749.2007.02018.x.14. Nooijen C, Siaman J, van der Slot W, Starm HJ, Roebroeck ME, et al. Health related physical fitness of ambulatory adolescents and young adults with spastic cerebral palsy. J Rehabil Med. 2014;46:642-647.15. Yanci J, Castagna C, Los Arcos A, Santalla A, Grande I, et al. Muscle strength and anaerobic performance in football players with cerebral palsy. Disabil Health J. 2016;9:313-319. 16. Barrett RS, Lichtwark G a. Gross muscle morphology and structure in spastic cerebral palsy: a systematic review. Dev Med Child Neurol. 2010;52(9):794-804. doi:10.1111/j.1469-8749.2010.03686.x.17. Gao F, Zhao H, Gaebler-Spira D, Zhang L-Q. In vivo evaluations of morphologic changes of gastrocnemius muscle fascicles and achilles tendon in children with cerebral palsy. Am J Phys Med Rehabil. 2011;90(5):364-371. doi:10.1097/PHM.0b013e318214f699.18. Taylor NF, Dodd KJ, Damiano DL. Progressive resistance exercise in physical therapy: a summary of systematic reviews. Phys Ther. 2005;85:1208-1223.19. Mockford M, Caulton JM. Systematic review of progressive strength training in children and adolescents with cerebral palsy who are ambulatory. Pediatr Phys Ther. 2008;20(4):318-333. doi:10.1097/PEP.0b013e31818b7ccd.20. Scianni A, Butler J. Muscle strengthening is not effective in children and adolescents with cerebral palsy: a systematic review. Aust J Physiother. 2009;55:81-87. http://members.physiotherapy.asn.au/scriptcontent/getajp.cfm?dirname=55-2&filename=austjphysiotherv/55/2/scianni.pdf. Accessed October 17, 2012.21. Kenyon LK, Sleeper MD, Tovin MM. Sport-specific fitness testing and intervention for an adolescent with cerebral palsy: a case report. Pediatr Phys Ther. 2010;22(2):234-240. doi:10.1097/PEP.0b013e3181dba5e5.22. Verschuren O, Ada L, Maltais DB, Gorter W, Scianni A, Ketelaar M. Muscle strengthening in children and adolescents with spastic cerebral palsy: considerations for future resistance training protocols. Phys Ther. 2011;91:1130-1139. doi:10.2522/ptj.20100356.

References

23. Scholtes VA, Becher JG, Comuth A, Dkkers H, Van Dijk L, et al. Effectiveness of functional progressive resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: a randomized controlled trial. Dev Med Child Neurol. 2010; 52:e107-13.24. Scholtes VA, Becher JG, Janssen-Potten YJ, Dekkers H, Smallenbroek L, Dallmeijer AJ. Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: a randomized controlled trial. Res Dev Disabil. 2012;33(1):181-188. doi:10.1016/j.ridd.2011.08.026.25. Novak I, Mcintyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy : state of the evidence study design. Dev Med Child Neurol. 2013;55(10):885-910. doi:10.1111/dmcn.12246.26. Hedgecock JB, Rapport MJ, Sutphin AR. Functional movement, strength, and intervention for an adolescent with cerebral palsy. Pediatr Phys Ther. 2015;27(2):207-214. doi:10.1097/PEP.0000000000000143.

27. Moreau NG, Bodkin AW, Bjornson K, Hobbs A, Soileau M, Lahasky K. Effectiveness of Rehabilitation Interventions to Improve Gait Speed in Children With Cerebral Palsy: Systematic Review and Meta-analysis. Phys Ther. 2016;96:E-pub ahead of print. doi:10.2522/ptj.20150401.28. Gannotti ME, Fuchs RK, Roberts DE, Hobbs N, Cannon IM. Health benefits of seated speed, resistance, and power training for an individual with spasticc quadriplegic cerebral palsy: A case report. J Ped Rehabil Med. 2015;8:251-25729. Kirk H, Geertsen SS, Lorentzen J, Krarup KB, Bandholm T, et al. Explosive resistance training increase rate of force development in ankle dorsiflexors and gait function in adults with cerebral palsy. J Strength Cond Res. 2016;30:2749-2760.30. van Vulpen LF, de Groot SF, Rameckers E, Becher JG, Dallmeijer AJ. Improved walking capacity and muscle strength after functional power training in young children with cerebral palsy. Neurorab Neur Rep. 2017;ePub ahead of print: https://doi.org/10.1177/1545968317723.31.Pescatello LS, American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription. 9th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2014.32. Sheppard J, Triplett N. Program design for resistance training. In: Haff G, Triplett N, eds. Essentials of Strength Training and Conditioning. 4th ed. Champaign, IL: Human Kinetics; 2015:439-4369.33. Lloyd RS, Faigenbaum AD, Stone MH, et al. Position statement on youth resistance training: the 2014 International Consensus. Br J Sport Med. 2014;48:498-505. doi:10.1136/bjsports-2013-092952.

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References

34. Faigenbaum AD, Westcott WL, Long C, Loud RL, Delmonico M, Micheli LJ. Relationship Between Repetitions and Selected Percentages of the One Repetition Maximum in Healthy Children. Ped Phys Ther. 1998;10(3):110-113.35. Bauer G, Carson J, Tziallas M, Westcott W, Faigenbaum A. One Repetition Maximum Strength Testing in 5 To 11 Year Old Children. Med Sci Sport Exerc. 1999;17(1):162-166. doi:10.1097/00005768-199905001-00223.36. Faigenbaum AD, McFarland JE, Herman RE, et al. Reliability of the One-Repetition-Maximum Power Clean Test in Adolescent Athletes. J Strength Cond Res. 2012;26(2):432-437. doi:10.1519/JSC.0b013e318220db2c.37. Robertson RJ, Goss FL, Dube AJJ, Rutkowski JJ, Frazee KM, et al. Validation of children’s OMNI-Reisistanceexercise scale of perceived exertion. Med Sci Sports Exerc. 2005;37:819-26.38. Damiano DL, Arnold AS, Steele KM, Delp SL. Can strength training predictably improve gait kinematics? A pilot study on the effects of hip and knee extensor strengthening on lower extremity alignment in cerebral palsy. Phys Ther. 2010;90:269-27938. Heathcock J, Fuchs R, Moreau NG, Prosser L, Gannotti M, et al. Linking structure to function: Muscle, bone and brain. 2013. APTA Combined Sections Meeting, San Diego, CA.39. Benedetto M, Bailes A, Pandya S, Edwards P, Booker-Feister C. Intensity of service in an outpatient setting for children with chronic conditions. Section on Pediatrics Fact Sheet. https://pediatricapta.org/includes/fact-sheets/pdfs/12 Intensity of Service.pdf. Published 2012. Accessed June 4, 2017.doi:10.1080/09638280701639873.40. Verschuren O, Ketelaar M, Takken T, van Brussel M, Helders PJM, Gorter JW. Reliability of hand-held dynamometry and functional strength tests for the lower extremity in children with cerebral palsy. DisabilRehabil. 2008;30:1358-1366.41. Chrysagis N, Skordilis EK, Koutsouki D. Validity and clinical utility of functional assessments in children with cerebral palsy. Arch Phys Med Rehabil. 2014;95(2):369-374. doi:10.1016/j.apmr.2013.10.025.42. Avery LM, Russell DJ, Rosenbaum PL. Criterion validity of the GMFM-66 item set and the GMFM-66 basal and ceiling approaches for estimating GMFM-66 scores. Dev Med Child Neurol. 2013;55(6):534-538. doi:10.1111/dmcn.12120.43. Fairbairn K, May K, Yang Y, Balasundar S, Hefford C, Abbott JH. Mapping Patient-Specific Functional Scale (PSFS) Items to the International Classification of Functioning, Disability and Health (ICF). Phys Ther. 2012;92(2):310-317. doi:10.2522/ptj.20090382.44. Verschuren O, Takken T, Ketelaar M, Gorter JW, Helders PJM. Reliability for running tests for measuring agility and anaerobic muscle power in children and adolescents with cerebal palsy. Pediatr Phys Ther. 2007;19:108-115. doi:10.1097/pep.0b013e318036bfce.55. Hedgecock JB, Harris N. Resistance training improves function and participation in children with cerebral palsy. 2016.

Documents

PowerPoint Presentation€¦ · 9/15/2017 Copyright 2017: Hedgecock & Harris 15 References 1. Jeffries L, Fiss A, McCoy SW, Bartlett DJ. Description of Primary and Secondary Impairments