PEDALS

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PEDALS

• Pediatric Endurance Development and Limb
  Strengthening for
• Children with Cerebral Palsy

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Standardized Exercise Regimen for PEDALS

• A protocol to promote fitness and strength for
  children with disability

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Investigators

• Eileen Fowler PT, PhD UCLA
• Loretta Knutson, PT, PhD SMSU
• Sharon DeMuth, DPT USC

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Investigators

• Eileen Fowler PT, PhD UCLA
• Loretta Knutson, PT, PhD SMSU
• Sharon DeMuth, DPT USC
• Research Coordinator
• Kara Siebert, MEd,DPT UCP Fellow

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Multi-site Multi-institution
Visit us at http//pt.usc.edu/clinresnet
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Why Cycling ??

• Children with CP
• exhibit weakness (Damiano et al., 1995)
• are not physically fit (Rimmer, 2001)
• Adults with CP
• cardiorespiratory fitness 23-45 lower than
  controls
• (Fernandez et al., 1990)
• 12 improvement with a cycling intervention
  (Pitetti et al., 1991)

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Why Cycling ??

• Strengthening Intervention
• Muscle recruitment patterns are similar to
  walking
• Can progressively increase resistance similar to
  the use of weights
• Fitness Intervention
• Task does not require a high level of motor
  control or balance
• - allows a focus on the goal of increasing
  heart rate

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Why Cycling ??

• Developmental disability need a life long
  exercise program. Our goal is to optimize and
  maintain function despite their lifelong
  disability.
• Form of recreation and mobility and fun !
• Overall Intent to develop optimal strength and
  endurance in PT using a stationary bicycle and
  discharge to a home or community based cycling or
  other type of fitness/sport activity

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• Lack of evidence that cycling is an effective
  physical therapy intervention for children with
  CP

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SUBJECTS

• Spastic diplegia
• Common form of CP
• GMFCS classification I-III
• Can walk independently with or without assistive
  devices
• Age 7 18 years
• Developmentally appropriate cooperation and
  physiology
• Can fit on a stationary bike may require
  additional
• adaptations

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Intervention Design

• Stationary Bike for clinic use
• Requirements
• bike needed to fit children
• safety features
• adaptations to secure feet to the pedals
• low resistance capability
• progress resistance in an objective manner

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Intervention Design

• Biodex Cyclocentric semi-recumbent bike
• David Brown, PI STEPS developed protocol for
  stroke
• Ability to compare rehabilitation protocols
  within PTClinResNet
• Increase resistance by engaging cords 10-100 lbs

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Not a Typical Pediatric PT Intervention

• Phase 1 - Strengthening
• engage rubber cords to provide resistance 10 to
  100 lbs
• Phase 2 - Cardiorespiratory training
• heart rate goal 70 - 80 maximum (Karvonen
  Method)
• 15-30 minutes
• American College of Sports Medicine, 2000

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Intervention

• Community Pediatric PT practices
• 30 sessions within 12 weeks
• A sufficient of sessions to see an effect
• Learning curve unknown, novel task

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Strengthening Phase Considerations

• Injury Prevention
• Patella alta common in CP
• Shifted cycling range into less flexion than
  normal for cycling
• Knee angle of 15-20 degrees when maximally
  extended
• Proper biomechanical alignment may require
  assist to maintain
• Motor learning
• Most subjects could master the cycling task with
  resistance during the first session
• Others took 1 - 3 sessions to perform revolutions
  with 1 cord
• One 7 y.o. subject took over 20 sessions
  increased the resistance on the bike using
  typical resistance settings as an alternative
  method

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Strengthening Phase

• Progression
• 10 revolutions without difficulty to add 1 more
  cord
• Some subjects reached 10 cords within 1st month
• Needed an alternate method to add more resistance
• Increased resistance by decreasing the isokinetic
  setting on bike from the recommended 60 cycles
  per minute

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Phase1 Strengthening
Subject 004
Resistance (lbs.)
30
Session
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Phase 1 Strengthening
Subject 010
Resistance (lbs.)
30

Session
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Cardiorespiratory Phase

• Literature to support cycling as an
  intervention?
• Studies for testing e.g. VO2
• Intervention study for adults with CP does not
  describe
• Intervention study for children none found
• Reason to believe that there is a primary
  impairment of cardiorespiratory system in CP?
  No
• UCP Research Education Exercise Guidelines,
  1998
• APTA Pediatric Research Summit, 2004
• Medical clearance required for each child

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Cardiorespiratory Phase

• Heart rate (HR) monitor ear lobe
• Goal of 70 80 max HR target HR
• Baseline HR must be after a rest period for
  accuracy
• Verified accuracy with manual pulse
• Excessive trunk motion during cycling chest
  monitor
• Visual feedback to increase HR
• Children Effort Rating Table
• Subjects provided feedback for perception of
  effort
• Williams et al. Perceptual Motor Skills, 1994

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Cardiorespiratory Phase

• Motivation biggest challenge !!!!!!
• Boring to some subjects
• Coaching and rewards important especially for
  younger subjects
• One young subject would not produce the effort
  required to reach his target HR despite MUCH
  encouragement
• Other subjects enjoyed the challenge felt
  athletic

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Intervention Cardiorespiratory Phase
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Phase 2 Cardiorespiratory Training
Subject 004
Target HR Zone
Maximum HR
Heart Rate (HR) (bpm)
Typical HR for Session
Baseline HR
30
Session
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Phase 2 Cardiorespiratory Training

Subject 011
Target HR Zone
Heart Rate (HR) (bpm)
Maximum HR
Typical HR for Session
Baseline HR
30
Session
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Education Program for Intervention PTs

• Intervention Manual
• - Manual of procedures, Standards, Flyers,
  Consent Forms, Contacts, HIPAA, Adverse Event
  Reporting
• In-service with demonstration of the intervention
  protocol
• One-on-one educational sessions with intervention
  PTs
• Email or phone communications to answer questions

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Intervention Standardization

• Set of standards created
• All potential intervention PTs were videotaped
• Criteria 90 score to pass
• Videos 1. Another PT 2. Child with CP
• Good videotaping procedures - important!

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Community PT practices

• Research Partnership
• Intervention PTs assisted in the refinement of
  the intervention
• Advantages
• Real life as opposed to research lab setting
• Immediate translation of research into practice
• Assistance with recruitment
• Disadvantages
• Challenge to standardize everyone! BOTH for
  investigators and intervention PTs
• Time (financial) constraints

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Outcomes - Primary

• 600 yard walk-run, 30 sec walk
• Knee extensor and flexor torque 0, 60, 120?/sec
• Gross Motor Function Measure (GMFM-66)
• POSNA (PODCI) function questionnaire
• PedsQL quality of life questionnaire

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Sites

• Southern California
• Orthopaedic Hospital, Downtown LA
• Pediatric Therapy Network, Torrance
• Therapy West, Culver City
• The Childrens Therapy Center, Garden Grove

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Sites

• Missouri
• Cox South Hospital, Springfield
• Capable Kids, Rolla
• St. Johns Mercy Hospital, Lebanon

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Free Adapted Bicycles !!!!
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Thank you !!!
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References

• American College of Sports Medicine, 2000.
  Guidelines for Exercise Testing and Prescription
  (6th Edition), Philadelphia Lippincott Williams
  Wilkins.
• Damiano DL, Vaughn CL, Abel MF. Muscle response
  to heavy resistance exercise in children with
  spastic cerebral palsy. Dev Med Child Neurol
  199537731-739.
• Fernandez J, Pitetti K, Betzen M. Physiological
  capabilities of individuals with cerebral palsy.
  Human Factors 19904457-466.
• Rimmer J. Physical fitness levels of persons with
  cerebral palsy. Dev Med Child Neurol
  200143208-212.
• Williams JG, Etson R, Furlong B. CERT A
  perceived exertion scale for young children.
  Perceptual Motor Skills 1994791451-1458.