Strength training in bimanual tasks for children with cerebral palsy

Rationale: Based on the latest research and clinical insights, we recently developed a promising and innovative approach to increase manual performance of daily activities in children with spastic Cerebral Palsy (CP), namely Task-Oriented Arm Strength Training (TOAST-CP).

Objective: To compare the effectiveness of TOAST-CP with manual skill learning in improving the performance of manual daily activities in children with spastic CP.

Methods/Design: This multicenter randomized controlled trial will investigate the effectiveness of TOAST-CP in children with spastic CP, involving 50 participants aged 8-18 years. Participants will be recruited from rehabilitation centers and outpatient physiotherapy clinics. Eligible participants will be randomly allocated to either TOAST-CP or usual care related to manual skill learning.

Intervention: The participants of the intervention group will perform a TOAST-CP program, based on individual goals and guided by an algorithm. The control group will receive usual care related to manual skill learning program. The contrast between both groups is based on the training according to strength training guidelines in a task oriented concept versus practicing manual skills without any strength training involved. TOAST-CP consists of an individual-based 30 minute session, three times a week over a 16 week period. Control group will receive usual care without any strength related training.

Outcome: Outcome will be measured at baseline at eight, 16 (end of training), three and six months after training.

Primary aim of the training is to improve the level of performance of both hands in manual daily activities and primary outcome will be measured at the level of activity. As a primary outcome the Assisting Hand Assessment (AHA) will be used. The AHA measures the performance and capacity of use of the affected hand in bimanual play in standardized way by video. Other secondary outcome measures, at the level of activity, are the Observation and Scoring of Arm Hand Skills (OSAS) (performance and amount of use of both hands), the ABILHAND (-Kids) (manual ability questionnaire) and the Jebsen Taylor test (speed of hand use). At the activity and participation level (ICF-CY), the most important goals for the child and his/her parents will be scored by Goal Attainment Scaling (GAS). The Children's Assessment of Participation and Enjoyment (CAPE) will be used to document change in how children and youth participate in the community. At the body function/body structure level measurements of passive and active range of movement and spasticity (Spasticity Test (SPAT)) will be used. Task-oriented strength, muscle related strength and isometric grip task will be measured.

Discussion: This is the first randomized controlled trial comparing TOAST-CP with usual care related to manual skill learning. Using high-quality methodology, this trial will add evidence to the gap in knowledge about the effect of strength training in children with CP.

6-10 Rehabilitation center in the Netherlands will participate in this multicenter trial.

Children with CP experience limitations in motor activities and participation in the community, predominantly caused by impairments in muscle function. Aside from abnormal posturing due to spasticity, muscle weakness can significantly contribute to impaired muscle function and there is increasing evidence that muscle weakness significantly impairs upper limb motor function and ability to perform manual tasks in children with CP.
Studies in the last decade have shown that muscle weakness, not spasticity, is the greatest limiting factor of motor function in children with CP. This has shifted the focus from spasticity management towards strength training in children with CP. Consequently, strength training is expected to reduce limitations in activities of children with CP.
Based on the latest research and clinical insights, we recently developed a promising and innovative approach to increase manual performance of daily activities in children with spastic Cerebral Palsy (CP), namely Task-Oriented Arm Strength Training (TOAST-CP).
Objective: To compare the effectiveness of TOAST-CP with manual skill learning in improving the performance of manual daily activities in children with spastic CP.
Both programs will improve everyday activities and the use of both hands, but the TOAST-CP program will possibly lead to a faster improvement in the performance of everyday activities. This effect can decrease the period of upper limb treatment. Furthermore, the increased strength after the TOAST-CP will ensure that everyday activities will be more easily executed compared to solely manual skill learning, increasing the long lasting independent use of both hands in everyday activities.

Participants are assessed by blinded testers at baseline, after eight weeks of training, after completion of the intervention period at 16 weeks, and at three and six months after the treatment, to assess the long term outcome of the intervention. Tests will be performed at the same location the child receives the training.

Each measurement session will take 90 minutes. These measurement sessions will be performed in several shorter periods of measurement during one week, in order to fit easily into a regular program for the children and their parents. The tests will be performed in random order to prevent fatigue. The tests are easy to perform and fun to execute for the children.

Participants assigned to the experimental group will perform an individualized TOAST-CP program. The exercises in TOAST-CP will be based on 1) the three defined goals, 2) the outcome of the analysis of the task performance and 3) a specific strength analysis will be performed based on the chosen exercises.
The Repetition Maximum (RM) model will be used to determine the load. All exercises based on the task analysis will be loaded with weight to determine the 8-12 RM. According to the nature of task-oriented strength exercises, a set of muscles required to perform the functional task will be trained and targeted. Examples of these tasks are lifting a bucket, carrying a tray, making a sandwich, fastening a belt and lifting a mug.

The training method is Progressive Resistance Exercise (PRE). This method of strength training has previously demonstrated efficacy in children with CP without injury or problems with compliance during a 12-week program8. Using the NSCA guidelines, a training load of 8-12 RM, three sets with a 90-second rest period will be used.

The PRE training lasts 16 weeks. The first two weeks consist of unloaded task-oriented exercises, with the focus on the quality of the performance of the task. To determine the load of 8-12 RM, measurement will take place at conclusion of the second week. In the third and fourth week the load of the task-oriented exercises will be increased up to the level of their individual 8-12 RM. At the start of week five, the 8-12 RM training will be started and at conclusion of each week the load will be re-measured and adapted.

From week five to week 16 (12 weeks) the load will be increased 10-20% per week, if a block of three sets of 8-12 RM is possible.

A detailed program has been developed by the investigators. In this program examples of exercises, based on the most frequently chosen goals are described. This program will guide the therapists. The principles of training will be taught beforehand in a one day program.

This method has been shown to be very useful for therapists to perform strength training.Usual Care (Manual Skill Learning)



Participants assigned to the control group will receive usual care (manual skill learning).
The exercises in the control group will be based on the three defined goals. Based on the three main goals individualized manual skill learning will be performed, without any strength training.