Cerebral palsy is a group of permanent disorder that is caused by
non-progressive insult to the fetal brain leading to disorders of development
of movement and posture. The
overall pooled prevalence of cerebral palsy in India is around 2.95 per 1000
live births.
Spasticity, dystonia,
contractures, gait and balance disturbances, selective loss of motor control,
and muscular weakness are the impairments associated with cerebral palsy. The
four major subtypes of CP are spastic, athetoid, ataxic, and mixed CP, spastic
forms being the most common form. the most problems in children with spastic CP
are spasticity in extremity muscles. If physiotherapy
treatment is not started early motor impairment will lead to reduced physical
activity and associated complications in adult life. Physical activity
exercises which include the strengthening and endurance exercises were not
given to patients with spastic cerebral palsy due to the reason that these
exercises will increase the spasticity and abnormal movement patterns. Scientific evidence has
not supported this concern and currently the research implies that resistive
exercise is an effectual intervention to enhance strength and function in
children with CP. Due to the paucity of previous research that has critically
examined the effect of stationary cycling for children with CP the PEDALS
Project for children with CP was designed as a Phase I RCT. Pedals is the pediatric endurance and limb
strengthening protocol designed for cerebral palsy children where strengthening
and the endurance program both are carried out on a stationary cycle. Pedal Cycling is an effective
rehabilitation tool that can be added to the physical therapy program which
promotes high speed of movement by improving muscle control more than other
daily activities performed by most of CP children. Pedals intervention provides
progressive resistance exercise for lower extremity musculature. Cycle
ergometer can be used in children with CP to improve lower limb muscular
strength, endurance, balance, gait and upper limb function. It allows cyclic
rotations in passive, active, and endurance modes, promoting an activity that
is safe and fully adaptable to the disabilities of this population. motor
function has been improved post long-term ergometer exercise, they are easy to
perform and quantify the amount of load, these makes them suitable for upper
and lower extremity exercises. In neuro-rehabilitation promoting,
maintaining and enhancing gait function are the ultimate therapeutic goals. To
achieve these there are many other interventions used one of them is cycling.
The kinematics of walking and cycling are similar except that in cycling there
is greater minimum to maximum flexion at the knee, more posterior pelvic tilt,
more external rotation of hip, less ankle plantar flexion and less ankle
excursion than walking. Therefore, cycling is a simplified locomotor pattern. Cycling can improve
muscle strength, balance and gross motor function in children with cerebral
palsy. Cycling involves bilateral training which improves inter-
and intralimb timing parameters. These are major parameters for balanced
standing or walking. Repeated pedaling exercise can reduce the
hypersensitivity of the muscle spindle, leading to decrease spasticity. Also,
repeated pedaling exercise may activate upper motor neurons leading to recovery
of the balance between activation and inhibition of spinal reflexes. Because
pedaling facilitates selective muscle activation with less co-contraction of
antagonists, it can potentially be an effective mode of muscle re-education.
Cycling and walking is a shared neural circuitry as both require reciprocal motor
coordination. While cycling loading is decreased through the lower limbs
because of seated support. Also, simultaneous strengthening of hip, knee and
ankle musculature is seen as all the three joints are highly coupled and move
in unison. Movement speed and inertial properties of the limbs influences
muscular activity and coordination. During cycling for the major lower
extremity joint extensors and flexor the Normative adult data demonstrates that
there is a significant muscle recruitment, based on electromyography (EMG). During the propulsive phase (limb extension)
and during the recovery phase (limb flexion) there is mean recruitment of at
least 50% of maximum EMG for the soleus, gastrocnemius, hamstring, vastus
medialis/lateralis, rectus femoris, gluteus maximus muscles and tibialis
anterior muscle respectively. Prolonged periods of knee and ankle muscle
coactivation occurred in children with CP who underwent a single stationary
cycling intervention. Similar to reciprocal stepping, bipedal
cycling allows cerebral palsy children to practice accuracy in timing and
movement of lower limbs as well as to learn the effective muscle usage of the
affected leg during exercise. The positron emission tomography study during
cycling movement showed that active cycling significantly activated areas
bilaterally in the primary sensory cortex, primary motor cortex, and
supplementary motor cortex and in the anterior part of the cerebellum. After
lower limb cycling exercise there is seen a reduction in lower limb spasticity
especially in calf and hamstring muscles. increase in the range of knee
extension motion in children with Cerebral Palsy, also an improvement in the
antigravity muscles’ strength and lower limb joints range of motion is seen.
Child’s motor skills and independence improved post cycling intervention. Balance and walking performance improved post cycling training in
persons with chronic stroke. In Parkinson’s patients the
application of bicycling, improved gait-related parameters of balance, walking
speed and overall walking capacity. P.E.D.A.L.S which is the Pediatric Endurance and Limb
Strengthening, this intervention has a structured protocol where the exercise
intensity, duration and guidelines for the exercise progression is given, on
the other hand the conventional physiotherapy treatment as such does not follow
a set protocol while treating the children. This makes an important factor for
including the P.E.D.A.L.S protocol in Cerebral Palsy children’s treatment
program. P.E.D.A.L.S intervention was given to children with Cerebral Palsy
and results had a positive effect on gross motor function, quality of life and
aerobic responses. Limited studies have stated whether P.E.D.A.L.S intervention
on lower extremity muscular strength and endurance is having an effect or not
on gait speed and balance in children with spastic diplegic cerebral palsy,
making it a need for conducting this study. Control Group (Conventional
physiotherapy)
Balance training:
WEEK
1-3
1. Supine
lying position to standing exercise (Supine lying to side sitting to sitting to
standing with hand support).
2. Prone
lying position to standing exercise (Prone lying to quadruped to kneeling to
half kneeling to standing with hand support).
3. Sitting
position on chair to standing exercise with hand support.
4. Kneel
standing exercise.
5. Standing
alone exercise (1-2 mins).
6. Stride
standing exercise (1-2 mins).
7. Step
standing exercise One limb rested on ground and other limb rested on wooden
step (stable surface).
WEEK 4-6
1.
Supine lying position to standing exercise (Supine
lying to side sitting to sitting to standing with hand support).
2.
Prone lying position to standing exercise (Prone
lying to quadruped to kneeling to half kneeling to standing with hand support).
3.
Sitting position on chair to standing exercise
with hand support.
4.
Kneel standing exercise.
5.
Standing alone exercise (2-4 mins).
6.
Stride standing exercise (2-4 mins).
7.
Step standing exercise One limb rested on ground
and other limb rested on wooden step (stable surface).
WEEK
7-9
1.
Supine lying position to standing exercise
(Supine lying to side sitting to sitting to standing without hand support).
2.
Prone lying position to standing exercise (Prone
lying to quadruped to kneeling to half kneeling to standing without hand
support).
3.
Sitting position on chair to standing exercise
without hand support.
4.
Kneel standing exercise.
5.
Standing alone exercise (4-6 mins).
6.
Stride standing exercise (4-6 mins).
7.
Step standing exercise on uneven surface as on
small ball or small balance board.
8.
Standing exercise on the balance board.
9.
Equilibrium
reaction training exercises from standing position (Tilting different
directions using a balance board).
10.
Protective
reaction training exercises from standing position (Pushing the child forward,
backward or sideways).
WEEK 10-12
1.
Supine lying position to standing exercise
(Supine lying to side sitting to sitting to standing without hand support).
2.
Prone lying position to standing exercise (Prone
lying to quadruped to kneeling to half kneeling to standing without hand
support).
3.
Sitting position on chair to standing exercise
without hand support.
4.
Kneel standing exercise.
5.
Standing alone exercise (6-8mins).
6.
Stride standing exercise (6-8mins).
7.
Step standing exercise on uneven surface as on
small ball or small balance board).
8.
Standing exercise on the balance board.
9.
Equilibrium
reaction training exercises from standing position (Tilting different
directions using a balance board).
10.
Protective
reaction training exercises from standing position (Pushing the child forward,
backward or sideways).
Gait training:
WEEK 1-3
1-Walking exercise alone between parallel bars forward and backward
slowly with bilateral hand support.
2-Walking exercise between parallel bars on stepper with bilateral hand
support.
3-Walking exercise between parallel bars over balance board with
bilateral hand support.
4-Walking exercise in stepper outside parallel bars with hand support.
5-Side walking exercise outside parallel bars with hand support.
6-Backward walking exercise outside parallel bars with hand support.
7-Walking alone exercise in altered surface conditions, such as on
(firm, sand, carpets, ramps, grass, and gravel).
8-Zigzag walking exercise.
WEEK 4-6
1-Walking exercise alone between parallel bars forward and backward
slowly with bilateral hand support.
2-Walking exercise between parallel bars on stepper with bilateral hand
support.
3-Walking exercise between parallel bars over balance board with
bilateral hand support.
4-Walking exercise in stepper outside parallel bars with hand support.
5-Side walking exercise outside parallel bars with hand support.
6-Backward walking exercise outside parallel bars with hand support.
7-Walking alone exercise in altered surface conditions, such as on
(firm, sand, carpets, ramps, grass, and gravel).
8-Zigzag walking exercise.
WEEK 7-8
1-Walking exercise alone between parallel bars
forward and backward slowly without bilateral hand support.
2-Walking
exercise between parallel bars on stepper without bilateral hand support.
3-Walking
exercise between parallel bars over balance board without bilateral hand
support.
4-Walking
exercise in stepper outside parallel bars without hand support.
5-Side
walking exercise outside parallel bars without hand support.
6-Backward
walking exercise outside parallel bars without hand support.
7-Walking
alone exercise in altered surface conditions, such as on (firm, sand, carpets,
ramps, grass, and gravel).
8-Zigzag
walking exercise.
9-Walking
up low inclined ramp then walking down.
10-Climbing
up and down stairs exercise with bilateral hand support.
WEEK 9-12
1-Walking exercise alone between parallel bars forward and backward
slowly without bilateral hand support.
2-Walking exercise between parallel bars on stepper without bilateral
hand support.
3-Walking exercise between parallel bars over balance board without
bilateral hand support.
4-Walking exercise in stepper outside parallel bars without hand
support.
5-Side walking exercise outside parallel bars without hand support.
6-Backward walking exercise outside parallel bars without hand support.
7-Walking alone exercise in altered surface conditions, such as on
(firm, sand, carpets, ramps, grass, and gravel).
8-Zigzag walking exercise.
9-Walking up low inclined ramp then walking down.
10-Climbing up and down stairs exercise without bilateral hand support.
Experimental group (Conventional physiotherapy +P.E.D.A.L.S protocol)
• Conventional Physiotherapy (similar as mentioned above)
• P.E.D.A.L.S (Pediatric endurance and limb strengthening) protocol.
1.
5-10 mins
warm up (prior to cycling)
Passive manual stretching
will be applied to the muscles of lower limb that are tensed (bilateral hip
flexor, knee extensor, knee flexor, ankle plantar flexor).
2.
Cycling
intervention will be divided into 2 phases:
a.
Lower
extremity strengthening.
b.
Cardiorespiratory
endurance.
Lower extremity strengthening (10-15 mins)
• Lower extremity resistance training will begin with keeping the
resistance of cycle ergometer to 1.
• If participant is able to cycle in a smooth pattern without
difficulty for ten complete pedaling revolutions a resistance will be increased
to 2.
• The above protocol will be repeated until the subject cannot cycle
at the next higher level of resistance.
• In subsequent sessions subject will begin with a minimum of 20
revolutions.
• Further will progress to the maximum resistance level, gradually
increasing the number of revolutions.
• Cardio respiratory endurance training.
• During first intervention session, participant will be instructed
in the use of Children’s effort rating table (CERT)18 for perceived
exertion. • At the beginning of session resting heart rate will be recorded. • Target heart rate of 70 to 80% of HRmax will be calculated using
Karvonen formula [(HRmax - HRrest) * (0.70/0.80)] + HRrest]. • If child is able to cycle for 10 consecutive minutes within the
THR range. • Intensity of the resistance is increased with a setting of 60
cycles per minute for 2 minute period. • Initial session – 15 mins of cycling. • Child will be asked to describe their perceived exertion during
cycling session using the CERT18. • If HR is below target range but the participant is cycling at a
high rate, the constant level resistance will be increased. • Participants will be encouraged to gradually increase their
exercise to a maximum of 30 mins over the 30 sessions.
- Cool down period at the end of
intervention where participant pedals without resistance until HR
decreases to within 20 beats above baseline.
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