PowerPoint Presentation. We will not discuss ... Individual case reports have demonstrated functional improvements ... Programs: neuro, foot management, ortho/sports, rehab

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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 use.

Objectives

Upon completion, participants will be able to demonstrate understanding of the role of muscular strength in determining functional independence in youth with cerebral palsy.

Upon completion, participants will be able to complete a clinical assessment to select the most ideal training parameters to achieve a patient's specific functional goals.

Upon completion, participants will be able to design a resistance and functional skill training program using appropriate dosing and outcomes assessment to address individualized goals for youth with cerebral palsy.

Upon completion, participants will be able to develop a plan to initiate a resistance training program for youth with cerebral palsy at their institution.

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Impact Video

Impact Video

Impact Video

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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

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

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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

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

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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

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?

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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

Train specifically for function

Moreau 2013, Hedgecock 2015, Kenyon 2010

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

Fundamentals of Strength Training

Functional and Participation

ImprovementsOutcomes

Training Specificity

Individualization

Periodicity

Frequency

Volume

Progression

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

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

Complete the Intervention

Guarding/spotting

Assistance?

Verbal cuing

Concentric and Eccentric Control

Encouragement

Rest Periods

Sheppard 2015

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

Figure adapted from: Sheppard 2015, Robertson 2015

Our Hospital:CHCO

Large hospital based system in Denver metro area – inpatient and outpatient

6 locations for outpatient neurodevelopmental ~ 90 Miles between sites.

Total PT Staff: ~ 86 (1/3 of our staff participating in intensive programs)

Work closely with rehabilitation and orthopedic physicians

6 years ago added program coordinators in specialty areas Decreased case load to allow for program development

Programs: neuro, foot management, ortho/sports, rehab

To allow for program development and advancing specialty care areas

Department management dedicated to providing exceptional care

New Ideas:

CSM 2013 pre-con Kolobe and Moreau

Therapeutic threshold

Training specificity:

brain, bone, muscle

Kids with CP are WEAK

POWER

MotivationChange emphasis:

Decreased emphasis on movement patterns

Heathcock 2013

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Intensive Programs at CHCO:

HISTORY

Big Ideas• Beth Hutchinson (manager) gives a thumbs

up • Katie Hodapp, DPT is willing co-worker

• Review literature

Establish Program

• 3 times per week x 6 weeks

• Strength (no 1 rep max test) and “power”

• Functional activities

• Outcome measures

RE-evaluate

• Great results!

• Update program in 2015


GROWTH

• 2 years with same PTs and only 3-4 kids. Summer only

• Continued good results

• Sharing results with PT department and physicians

Maintain

• 2015 Program updated and included interested PTs at 2 other sites and added a site each summer

• Improving documentation of outcomes and data tracking

• Trialing other diagnoses

Expansion

• Lunch and learns with process and outcome measure updates before summer

• Updates at all staff training days

• On-site assistance

• 2017: 4 hour training for 30 therapists on theory, implementation and outcome measure reliability

Staff Training


Current State

Offered throughout the year at 5 out-patient sites

Tracking outcomes

Consistency:

with varied equipment and PTs

Referrals : PT, community, rehab and ortho

departments

AACPDM Transformative Practice Award:

Glenrose Rehab Hospital/University of

Alberta

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Intensive Periods of Treatment

Benedetto et al. 2012

Intensive Programs at CHCO: Options

Individualized episode of care targeting muscular weakness through well dosed resistance training program and intensive functional skill practice.

3 times per week for 8-10 weeks

Resistance Training

(RTI)

Brief and intense episode of ambulatory and balance skill practice, targeted strengthening, and gait training (FES, TM, OG, Lite-gait) 3 times per week for 3 -4 weeks

Gait and Balance

Intensive episode of care specifically targeting a small number of goals and tasks with a high degree of focus on skill transfer to patients and caregivers. 3 times per week for 3 weeks, 3 week break, 3 times per week for 3 weeks

Neurofunctional (NFTI)

Intensive episode of care using mixed discipline individual and co-treatment focusing on a small number of functionally based goals and caregiver practice using NDT based treatment principles.

NDT Based Mixed Discipline


No recipe for program design

Individualized to patient goals and situation

DosingWhat impairment needs

improvement?

Is it the beginning or the

end?Avoid Burnout

Patient and Family Characteristics

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Resistance Training Intensive (RTI):

What are we doing?

Model:• Brief episodes of intense

intervention• Periodic follow-up for progress

monitoring, orthotic/contracture management

Patients:

• Children with neurological impairments with ability to volitionally contract LE muscles

• Able to maintain attention and follow directions for safety

Muscle Groups:

• gastrocnemius, gluteus maximus, gluteus medius, quadriceps, hip flexor, dorsiflexion

Time Frame:

• 8-12 weeks, 2-3 sessions per week

Dosing:

• Typically power training: 6 sets, 6 repetitions, 40-80% 1 rep max

• Occasionally strength training: 3 sets of 6-10 reps, 85% 1 rep max

• Intensive functional skill practice

Outcomes:

Functional Strength Test, 10 meter gait speed (SS and fast), 1 minute walk, GMFM 66, Muscle Power Sprint Test, Patient Specific Functional Scale

• Optional: 4-square step test, functional reach, timed up and down stairs

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

Who Else?

Andersen 2016, Baque 2016, Bye 2017, Harvey 2016, Madsen 2015, Lewelt 2015, de Groot 2011

Individualization &Assessment :

How do we do it?

Set collaborative goals with the patient and

family

Measure current performance

Trial intervention before committing to

it if unsure

Determine Targeted muscles:

How are they used?

Pick your lifting movement(s)

Single joint or closed chain

Plan specific functional skill practice

and progress that too!

Sheppard 2015

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RTI Evaluation

Schedule an RTI evaluation separate from the first treatment session

Interview and establish goals (PSFS)

Outcome measures: with or without orthotics?

30” Functional Strength Tests (Verschuren ) Sit-to-stand

Lateral step-ups

½ kneel to stand

10 meter gait speed (SS and fast)

1 minute walk

GMFM 66

Muscle Power Sprint Test (MPST)

Patient Specific Functional Scale (PSFS)

1 rep max testing: can do at first intensive session if you run out of time

Qualitative gait assessment (if that is a goal)

RTI:Complete the Intervention

Your first session wasn’t perfect or the child had an adverse reaction?

Adjustment

Progressive resistance exercise means there needs to be change.

Progression

Vary the order and environment in which you do things

Variability

Increased strength/power generation is needed AND the skill must be practiced!

Functional Skill Practice

Resistance training is hard and sometimes involves failure.

Frustration

Post-Intervention:

Assessment

Periodicity

Further Planning

Re-assess the child/family goals

Re-assess the outcome measures

Transition to community based

activities, if possible

New model of therapy?

Address ongoing needs through consultative

periodic visits

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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

RTIProgram evaluation

Strengths

• Consistently good outcomes!

• Slow controlled growth ~ consistent quality, increased referrals from physicians

• Incorporating ortho and neuro based PTs, and PTAs has created a well-rounded program

• Increased ownership and decision making from families

• Increased motivation from patients as they see results for themselves

Weaknesses

• GROUPS: improved motivation and community

• Community transition resources

• Participation outcome measures:

• Better equipment/ consistency across sites

• How can it be more fun?

• Increase referrals form community physicians, PTs, schools

• Increased education needed on appropriate referrals to different intensive programs

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Take Home

Weakness has significant impact of function for children with CP

Specificity of training is the key to functional goal achievement

RTI is a specific evidence based model of therapy to increase strength in children with CP

FOCUS: Intensive programs are designed to help the clinician, patient, and family focus on a narrow set of impairments and goals

Avoid underestimating capabilities: Surprised by what these young people can accomplish and achieve

Don’t water down your intervention!

Don’t strive for perfection, but for progression!

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

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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 interjointcoordination 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;35:154-158.12. Ross S a, 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, TsuboyamaT, HarutaT, 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.

References

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. VerschurenO, 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.20100356.23. 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-PottenYJ, 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.

References

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.Pescatello LS, American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription. 9th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2014.31. 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; 2015:439-4369.32. 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-2013-092952.33. 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. doi:10.1097/00001577-199801030-00004.34. 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:10.1097/00005768-199905001-00223.35. 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.36. 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. 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, 2017.40. 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. doi:10.1080/09638280701639873.

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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.45. Andersen JL, Jørgensen JR, Zeeman P, et al. Effects of high-intensity physical training on muscle fiber characteristics in post-stroke patients. Muscle Nerve. 2016:1-9. doi:10.1002/mus.25514. 46. Baque E, SakzewskiL, Barber L, Boyd RN. Systematic review of physiotherapy interventions to improve gross motor capacity and performance in children and adolescents with an acquired brain injury. Brain Inj. 2016;30(8):948-959. doi:10.3109/02699052.2016.1147079.47. Bye EA, Harvey LA, Gambhir A, et al. Strength training for partially paralysed muscles in people with recent spinal cord injury: a within-participant randomised controlled trial. Spinal Cord. 2016;55(5):460-465. doi:10.1038/sc.2016.162.48. Harvey LA, Glinsky J V, Bowden JL. The effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injury: a systematic review. Spinal Cord. 2016;54(11):914-923. doi:10.1038/sc.2016.95.49. Madsen KL, Hansen RS, Preisler N, Thøgersen F, Berthelsen MP, VissingJ. Training improves oxidative capacity, but not function, in spinal muscular atrophy type III. Muscle Nerve. 2015;52(2):240-244. doi:10.1002/mus.24527.50. Lewelt A, Krosschell KJ, Stoddard GJ, et al. Resistance strength training exercise in children with spinal muscular atrophy. Muscle Nerve. 2015;52(4):559-567. doi:10.1002/mus.24568.51. de Groot JF, Takken T, Gooskens RHJM, et al. Reproducibility of Maximal and Submaximal Exercise Testing in “Normal Ambulatory” and “Community Ambulatory” Children and Adolescents With Spina Bifida: Which Is Best for the Evaluation and Application of Exercise Training? Phys Ther. 2011;91(2):267-276. doi:10.2522/ptj.20100069.52. Hedgecock JB, Harris N. Resistance training improves function and participation in children with cerebral palsy. 2016.

Documents

PowerPoint Presentation. We will not discuss ... Individual case reports have demonstrated functional improvements ... Programs: neuro, foot management, ortho/sports, rehab