Six Months Guided Exercise Therapy Improves Original Article Motor .
Original ArticleSubmitted: 23 Jan 2020Accepted: 23 Jul 2020Online: 27 Oct 2020Six Months Guided Exercise Therapy ImprovesMotor Abilities and White Matter Connectivityin Children with Cerebral PalsyMd Safwan Samsir1,2, Rahimah Zakaria1, Salmi Abdul Razak3,6,Mohamed Saat Ismail4, Mohd Zulkifli Abdul Rahim4, Chia-ShuLin5, Nik Mohammad Faez Nik Osman1, Mohammad Afiq Asri1,Nor Haslina Mohd4, Asma Hayati Ahmad11Department of Physiology, School of Medical Sciences, Universiti SainsMalaysia, Kubang Kerian, Kelantan, Malaysia2Faculty of Psychology and Education, Universiti Malaysia Sabah, Malaysia3Department of Paediatrics, School of Medical Sciences, Universiti SainsMalaysia, Kubang Kerian, Kelantan, Malaysia4School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian,Kelantan, Malaysia5Department of Dentistry, School of Dentistry, National Yang-Ming University,Taipei, Taiwan6Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, MalaysiaTo cite this article: Samsir MS, Zakaria R, Abdul Razak S, IsmaiL MS, Abdul Rahim MZ, Lin CS, Nik Osman NMF,Asri MA, Mohd NH, Ahmad AH. Six months guided exercise therapy improves motor abilities and white matterconnectivity in children with cerebral palsy. Malays J Med Sci. 2020;27(5):90–100. https://doi.org/10.21315/mjms2020.27.5.9To link to this article: ckground: Diffusion magnetic resonance imaging (dMRI) provides the state of putativeconnectivity from lesioned areas to other brain areas and is potentially beneficial to monitorintervention outcomes. This study assessed the effect of a 6 months guided exercise therapy onmotor abilities and white matter diffusivity in the brains of cerebral palsy (CP) children.Methods: This is a single arm pre- and post-test research design involving 10 spastic CPchildren, aged 8–18 years and whose Gross Motor Function Classification System Expanded andRevised (GMFCS-E & R) at least Level 21 with the ability to ambulate independently. They wererecruited from Paediatric Neurology Clinic, Hospital Universiti Sains Malaysia (HUSM) fromDecember 2015–December 2016. All participants underwent 6 months of therapist-guided exercisesession comprising progressive strength training at a frequency of twice a week, 1 h duration persession. The effect of exercise on motor abilities was assessed using the Gross Motor FunctionMeasures (GMFM)-88. Six out of the 10 children consented for dMRI. Probabilistic tractography ofthe corticospinal tract (CST) was performed to determine the connectivity index of the tracts preand post-intervention.Results: All the participants displayed statistically significant increment in GMFM88 scores pre- to post-exercise intervention. This improvement was concurrent with increasedconnectivity index in the CST of upper limbs and lower limbs in the brain of these children.Malays J Med Sci. 2020;27(5):90–10090www.mjms.usm.my Penerbit Universiti Sains Malaysia, 2020This work is licensed under the terms of the Creative Commons Attribution (CC BY)(http://creativecommons.org/licenses/by/4.0/).
Original Article Guided exercise therapy in cerebral palsyConclusion: Our findings demonstrated that 6 months guided exercise therapy improvesmotor abilities of CP children concurrent with strengthening the connectivities of the motorpathways in the brain.Keywords: cerebral palsy, exercise therapy, diffusion MRIIntroductionCerebral palsy (CP) patients experience avariety of muscle dysfunctions such as musclespasticity, loss of selective muscle control andmuscle weakness (1). Exercise has been shownto reduce muscle spasticity and increase musclestrength. Even though motor skills of mostCP patients eventually improve as they grow,adults with CP are at risk of decreased mobilityand health complications if left untreated. Anexercise therapy may consist of several typesof training such as strength training, fitnesstraining, static weight bearing and passivestretching (2). Though it has been proven tohave its effect on muscular strength, volume andsignificantly increase motor ability of patientswith CP, the type and duration of exercisetherapy programme that should be prescribed tothese patients remain unclear (3).There have been several diffusion magneticresonance imaging (dMRI) studies in CP patientsdemonstrating damage to white matter tractsthroughout the brain (4), differences in the whitematter tract damage comparable to the typesof CP (5), as well as diffuse connectivity deficitsassociated with severity of functional impairment(6, 7) in cross sectional studies. Furthermore,CP is a heterogeneous disorder with multiplecauses and clinical manifestations, meaning thatthe specific structural changes that may underlieimproved function are likely to be unique toeach patient. Brain structural connectivityhas been shown to increase concurrent withfunctional improvement in CP children receivingautologous cord blood transfusions (with orderrandomised with a placebo administered over2 years) in conjunction with standard physicaland occupational therapies (8). Constraintinduced movement therapy has also been shownto potentially induce changes in corticospinaltract (CST) in CP children under the age of 2 (9).Recently our group reported that dMRI withprobabilistic tractography provides the state ofconnectivity from lesioned areas to other parts ofthe brain and is potentially beneficial to be usedas a means to monitor intervention outcomesand as an adjunct to the clinical managementof CP (10). Thus, the present study aimed toexamine the effect of a 6-month exercise therapyon motor abilities of CP children using the GrossMotor Function Measures (GMFM) and on whitematter diffusivity using dMRI with probabilistictractography.MethodsThis study was conducted from December2015–December 2016. A within-subjects,single arm pre- and post-test research designwas employed. The effect of exercise on motorabilities was assessed using the GMFM-88administered pre- and post-exercise therapy,while the effects on white matter diffusivitywere assessed using dMRI and probabilistictractography. The modified ConsolidatedStandards of Reporting Trials (CONSORT)flowchart is provided in Figure 1.ParticipantsTen spastic CP children with age rangingbetween 8 and 18 years old (mean age SD 13.4 3.307, six males) were recruited(Table 1). Six of the children had bilateral andfour had unilateral CP. All potential participantshad been evaluated and diagnosed as CP bya pediatric neurologist. All participants wereon follow-up in Paediatric Neurology Clinic,Hospital Universiti Sains Malaysia (HUSM).A total of 39 CP children data were retrievedfrom the Record Department of HUSM withinthe given age range. Thirteen children withquadriplegia were excluded from this study.Out of the remaining potential participants,only 10 (n 10) children fulfilled the inclusion/exclusion criteria and their parents or guardianagreed to participate in the exercise therapyprogramme. Out of the 10 participants, 6 parentsor guardian consented to undergo two sessions ofdiffusion tensor imaging (DTI) before and afterintervention. Exercise sessions were performedin the participants’ houses while scanning wasdone in the Department of Radiology HUSM.www.mjms.usm.my91
Malays J Med Sci. 2020;27(5):90–100Figure 1. Modified CONSORT flowchart for a single-arm non-randomised, own-control study of guided exercisetherapy in children with CPTable 1. Patients’ demographicsseizures 6 months prior to exercise intervention,had received botulinum toxin injections withinthe past 6 months and had marked intellectualdisability and inability to follow instructions.Physically, presence of muscle or tendoncontracture, presence of dystonia or athetoidwere also criteria for exclusion. Additionalexclusion criteria for magnetic resonanceimaging (MRI) scanning was having metalimplants in the body.SubjectAgeSexType of ral714MaleUnilateralStudy aleBilateralParticipants underwent individually-guidedexercise therapy by a well-trained exerciseinstructor who came to each child’s home orschool to conduct the exercise therapy sessions.The structured programme was implementedand conducted as after-school exercise sessions.The children underwent 6 months of exercisetherapy at a frequency of twice a week, andduration of 1 h each session.A session consisted of 5 min warm-up,45 min workout session and another 5 min ofcool-down session in a circuit training way. Eachwork station was set up for intensive repetitivepractice of an exercise practising. Children weremoved between stations, practicing functionalbased exercise such as step-ups, sit-to-standand some other exercise movement. ResistanceInclusion criteria included age between8 and 18 years old, medical follow-up of atleast 6 months, written informed consentfrom parents/guardian, and presence ofhand function, at least able to grasp object.Meanwhile, in terms of mobility, children shouldat least be Level 2 (children could walk andrun independently, despite reduced balance,speed and coordination) in GMFM, and able toambulate independently without assistive device.Children were excluded if they have history oforthopaedic surgery or neurosurgery, presence ofany diagnosed genetic syndrome or having active92www.mjms.usm.my
Original Article Guided exercise therapy in cerebral palsyor load was increased progressively as strengthincreased.Participants had GMFM scoring as baselineprior to exercise therapy and after completion of6 months exercise therapy. Six participants whoprovided informed consent also, additionally,underwent MRI scans of the brain prior and postexercise therapy.Exercise TherapyThe exercise regime was developedaccording to the needs of the CP children andadministered in accordance with the child’sstrength and ability. Nevertheless, the trainingprogramme was standardised in terms ofprotocol and duration (11). This regime includedexercise regime that mainly focused on musclestrength. Exercises were administered usingthe periodisation as well as the reversibilityprinciples (Table 2).Strength training exercises were prescribedindividually and by referring to the periodisationtable (Table 2). During the early phase oftraining (anatomical adaptation), the volumeof exercise was high while the intensity waslow. For example, in the initial phase of step-upexercise, the children may step-up on the stepwithout any weight but the number of repetitionwas high. Later in the exercise phase, they weregradually made to wear weights (wearing weightvest or ankle strap weight) while doing theexercise. They were started with 30% of theirmaximum capacity as recommended by previousstudies (1, 12). In the maximum strength phase,the volume of exercise was reduced by reducingthe number of repetition per set of exercise. TheTable 2. Periodisation tableintensity of exercise was increased to 50%–65%of their capacity and gradually increased withtime.The reversibility principle of training wasapplied during the exercise therapy wherebythe amount of load or intensity of training weredecreased according to the children’s capacity.For example, if the child skipped the exercisebecause of sickness, their capabilities woulddecrease. Thus, the intensity of training alsoneeded to be decreased (1).Functional Outcome MeasuresThe GMFM consists of 88 items that aregrouped into five dimensions of gross motorfunction; i) lying and rolling (17 items); ii) sitting(20 items); iii) crawling and kneeling (14 items);iv) standing (13 items); and v) walking, runningand jumping (24 items). Each item from thefive dimensions is scored based on a 4-pointLikert scale. A percentage is calculated for eachdimension as described by Ketelaar et al. (13).To minimise research bias, GMFM wasadministered by researchers who were notdirectly related to this study. Researchers wereamong exercise’s instructors that recruitedand provided with a scoring manual book toensure the scores were given objectively and theexamination session was video recorded. GMFMtest was administered before commencementof exercise therapy and 6 months after therapyhad been completed. The tests were done at theparticipants’ homes or schools.DTIwasMRI scanning of the brain for DTIperformed pre- and post-interventionwww.mjms.usm.my93
Malays J Med Sci. 2020;27(5):90–100on six participants who provided informedconsent. Before proceeding with the DTIscanning, sedation was given to minimisevigorous head motion during the scanningprocess. Sedation was administered by amedical officer and they were not allowedto consume food 5 h–6 h prior to sedation.Initially, oral chloral hydrate (50 mg/kg/dose–75 mg/kg/dose) was given. If the children did notshow positive reaction, intravenous midazolam(0.1 mg/kg/dose) or intravenous ketamine(1 mg/kg/dose) was used. Intravenous atropine(0.01 mg/kg/dose) was given to decreasesecretion for those who were given ketamine.To ensure children safety and minimising othercomplication during the sedation, they werewarded and continuously monitored using SpO2and cardiac monitoring until permitted to bedischarged.dMRI scan was obtained using PhilipsAchieva 3.0T system with 32-channel SENSEhead coil. Imaging parameters were as follows:matrix 128 128, field of view 221 mm 221 mm, repetition time/echo time 10,726/76ms, SENSE factor 2; EPI factor 67 andb 1000 mm2 s 1, NEX 1 and thickness 2.3 mm for each of the 32 non-colinear diffusionsensitising gradients. Raw imaging data in HDRform was converted to 4D NIfTi form using theMRIcron dcm2nii dicom to niftii convertersoftware to render it ready for further processing.Drawing of Regions of Interest MasksDrawing of regions of interest (ROI) maskswere hand-drawn, starting in one view anddouble-checked in multiplanar views usingFSLview in FMRIB Software Library (FSL, www.fmrib.ox.ac.uk/fsl). Seed masks were the motorarea for upper extremities in the pre-centralknob and the mediodorsal part of the precentralgyrus for the motor area for lower extremities.Mask for the target region was drawn in thelower pons. Seed and target masks were chosento trace the CST pathway from the upperlimb and lower limb area in the motor cortexdescending to the pons.Probabilistic TractographyDiffusion data were pre-processed usingFMRIB’s Diffusion Toolbox (FDT, http://fsl.fmrib.ox.ac.uk/fsl/fdt) (14, 15) in FSL. Headmotion effect and image distortion due to eddycurrents were corrected using eddy correct.Bayesian Estimation of Diffusion s.usm.my(BEDPOSTX) in FDT was then run on imagingdata that have been eddy-corrected. BEDPOSTXruns Markov Chain Monte Carlo sampling tobuild up distributions on diffusion parameters ateach voxel.Probabilistic tractography was performedon diffusion-weighted bedpostx datasets usingprobtrackx in FDT according to previouslydescribed methods (14, 16). Using Bayesianprinciple, a probability diffusion functionwas estimated for every voxel to determinethe principal fiber direction. Five thousandstreamline samples were generated from eachseed voxel to build up a connectivity distributionin diffusion space. The number of these samplespassing through each brain voxel is proportionalto the connection probability of the seed voxel.For each subject, probabilistic connectivitydistribution from all voxels in each seed regionto the target area was quantified. This gave themean number of samples per voxel in the seedarea with positive connection probability to thetarget area. The mean per voxel multiplied bythe volume (number of voxels) with positiveconnection probability gives the connectivityindex.Statistical AnalysisA priori sample size calculation indicatedthat six participants were needed to detecta clinically significant difference of trainingeffect on white matter integrity. Power wasset at 90%, significance level at 5% and thestandard deviation of the difference was set at0.03 (11). To allow for loss to follow-up andconsent for DTI, 10 children were included inthis study. Results were analysed using IBMSPSS version 22. Comparison of overall GMFMscores between pre- and post-intervention wascalculated using one-tailed paired t-test. GMFMscores for each dimension and connectivityindex output from tractography were analysedusing repeated-measures ANOVA. For GMFM,within-subject factors TYPE (five levels: Lying,Sitting, Crawling, Standing and Walking) andTIME (two levels: pre- and post-intervention)were used; while for connectivity index, withinsubject factors were AREA (four levels: left lowerlimb, left upper limb, right lower limb and leftupper limb) and TIME (two levels: pre- and postintervention). Greenhouse-Geisser correctionswere applied when assumption of sphericity wasnot met in Mauchly’s test. Post-hoc tests wereperformed using one-tailed paired t-tests withBonferroni corrected for multiple comparisons.
Original Article Guided exercise therapy in cerebral palsyResultsAll the CP children displayed improvementin their abilities to perform the GMFM afterundergoing exercise therapy for 6 months.During the first 2 weeks of therapy, some of theyounger children were not really committed withtheir exercise regime. But as time went on, withmotivation and support from the instructor,friends and family, they started to focus and hadpositive progress of their exercise therapy.GMFMThe results of one tailed paired t-testfor GMFM scores are shown in Table 3.Overall, the GMFM score showed significantlyhigher postintervention scores comparedto preintervention, t(9) –11.7, P 0.001,r 0.97 (Figure 2). Repeated measures ANOVAfor the different dimensions of GMFM showedsignificant main effect of TYPE, F(4, 36) 126.6,P 0.001, indicating significantly differentscores among the types of dimensions. Therewas also significant main effect of TIME, F(1, 9) 129.8, P 0.001.Post-hoc paired t-test, one tailed, adjustedfor multiple comparisons at significance level0.01 showed post-intervention GMFM werehigher for all dimensions (Figure 3); Lying andRolling, t(9) –6.5, P 0.001, r 0.91; Sitting,t(9) –6.3, P 0.001, r 0.9; Crawling, t(9) –5.9, P 0.001, r 0.89; Standing, t(9) –3.8, P 0.002, r 0.78; and Walking, Runningand Jumping, t(9) –4.1, P 0.001, r 0.81.Lying and Rolling dimension had the highestimprovement rate at 5.1% followed by Standing(4.9%), Sitting (4.8%), Crawling and Kneeling(3.1%) and lastly, Walking, Running andJumping (3.1%).Table 3. Pre- and post-GMFM-88 scoresPrePostP-valueLying and rolling60.2 1.6665.4 1.970.001Sitting62.9 1.2267.8 1.440.001Crawling and kneeling75.1 1.1378.2 0.980.001Standing52.1 1.2957.2 1.670.002Walking, running and jumping44.4 1.0547.6 1.070.001DimensionNotes: Post-hoc paired t-test, one-tailed, adjusted for multiple comparisons at significance level 0.01. Value ismean SEMFigure 2. Overall GMFM scores measured pre- andpost-exercise therapy interventionFigure 3. GMFM dimensions measured pre- andpost-exercise therapy interventionNotes: Data are mean SEM. *P 0.05, **P 0.01, ***P 0.005Notes: Data are mean SEM. *P 0.05, **P 0.01, ***P 0.005www.mjms.usm.my95
Malays J Med Sci. 2020;27(5):90–100TractographyRepeated measures ANOVA showedsignificant main effects of AREA, F(3, 15) 7.6, P 0.003 indicating that the connectivityindex was different among the CST of the upperlimb and lower limb bilaterally. There was alsosignificant main effect of TIME, F(1, 5) 16.9,P 0.009 indicating differences between preand post-intervention connectivity indices.Significant interaction was also found betweenAREA and TIME, F(3, 15) 5.6, P 0.009.Post-hoc comparison using Bonferronitest adjusted for multiple comparisons revealedthat the post-intervention connectivity indexwas higher than pre-intervention (P 0.009),while the significant difference in connectivityindex among the four tracts were between leftlower limb and right upper limb (P 0.03).To determine the CST of which area wassignificantly increased post-intervention, weperformed post-hoc paired t-tests correctedfor multiple comparisons (significance levelP 0.01); this showed that the increase wassignificant at the right upper limb, t(5) –3.8,P 0.007, r 0.86 (Figure 4). Figure 5 showsthe representation of probabilistic waterdiffusivity in the CST pre- and post-intervention.DiscussionThe present study utilised a full spectrumof strength training aimed at improving strengthof the majority of muscle groups. Our resultsFigure 4.Connectivity index pre- and post-intervention in the leftand right upper limbs and lower limbsNotes: *P 0.05, **P 0.01, ***P 0.00596www.mjms.usm.myshow that 6 months guided exercise therapyusing minimal equipment could increasemuscle strength of CP children and improvetheir movement abilities in all the GMFMdimensions. These findings were consistent withprevious studies. Verschuren et al. (17) showedthat 6 weeks training of 3–4 sessions per weekimproved CP children’s aerobic capacity andmuscle performance of the lower extremities.Similarly, a 6 weeks randomised controlled trialof exercise intervention showed improvement ingross motor function for non-ambulant childrenwith CP (18). These researchers demonstratedthat 6 weeks exercise intervention led tosignificant short-term improvement in motorfunction compared to standard physiotherapycare. Six weeks is the minimum time that isgenerally agreed to have minimal improvementin terms of performance for both normalperson and CP patients (19, 20). Nevertheless,to see meaningful or significant improvementin strength among children with CP, sufficientintensity with longer interventions may beneeded (21).The recommended duration of therapyto have better effect remain unknown. Mostresearchers recommend that exercise therapy isstudied for a longer period of time, for example12 weeks (21, 22). The National Strength andConditioning Association (NSCA) guidelinesrecommended 2–3 sessions per week for 8–20weeks of exercise intervention (19, 20) to allowfor adequate recovery between sessions (23).Thus, in the present study the exercise therapy
Original Article Guided exercise therapy in cerebral palsyFigure 5. Diffusion images of the CST for upper limb and lower limb overlaid on each subject’s diffusionweighted brain images. Brain image on the left shows representation of probabilistic water diffusivityin the CST preintervention while images on the right side were acquired after 6 months of exercisetherapy intervention. Blue: right CST for left upper limb; Yellow: right CST for left lower limb; Red:left CST for right upper limb; Green: left CST for right lower limbwas conducted twice per week for 6 months,under the guidance of a trained instructor.Previous researchers who aimed to improvemotor abilities of CP commonly focus on lowerextremities using simple and small number ofexercise regime (12, 19), for example, multijoint exercises such as front and lateral step-ups,half squats and sit-to-stand. Nevertheless, someresearchers suggest to start with single-jointresistance exercise such as leg press and heelraises because it is more effective for CP patientscompared to multi-joint exercise (21).Similar to the findings by Englanderet al. (8), our study shows that the improvementin motor abilities is accompanied by increasedconnectivity in the CST, motor pathways fromthe primary motor area in the precentral gyrusdescending down to pons and spinal cord tosupply the peripheral limbs. However, thechildren in Englander et al. (8) study alsoreceived autologous cord blood transfusionsin conjunction with standard physical andoccupationaltherapies.Theconnectivitychanges are evident of neuplasticity, the abilityof neurons to change their function, structureor chemical profile such as quantities and typesof neurotransmitters produced (24). There arethree main mechanisms of neuroplasticity i.e.habituation, experience-dependent plasticity andcellular recovery after injury (25). Experience-dependent plasticity or sometimes called usedependent or activity-dependent plasticityinvolves learning and memory (23). Themechanism process is complex and requirespersistent, long-lasting changes in the strength ofsynapses between neurons and also within neuralnetworks (26).Previous imaging studies have shownvariable abnormal patterns of sensory andmotor tracts in CP (27). Damage or injury towhite matter is usually related to spastic diplegiaand quadriplegia (28). CST and somatosensoryradiation tracts are very prone to injury becauseboth tracts mature faster than other white mattertracts (11). Injury to upper motor neurons maydecrease cortical input to the reticulospinal andCST that decrease motor unit effectiveness andmotor control, causing muscle weakness andabnormal muscle control (29). Abnormalities ofmuscle tone, spasticity and motor abilities areclosely related to the loss of CST.In our study, 6 months of guided exercisetherapy was able to modulate the brain’sconnectivity and manifesting as improvementin the execution of movement, as evidenced bythe significantly improved GMFM scores. Theseresults were obtained in a sample of unilateraland bilateral CP children with varying age,gender, as well as variable type and extent ofbrain lesions. Utilising a within-subjects design,www.mjms.usm.my97
Malays J Med Sci. 2020;27(5):90–100each subject was his or her own control and ourresults showed improvement in GMFM andbrain connectivity across all subjects.Plasticity and brain reorganisation of theyoung human brain after unilateral injurieshave been shown to be occur whereby ipsilateralprojections from the non-insulted hemispherereplace the contralateral projections fromthe lesioned side (30). While this is seen onlywhen the insult to the brain occurs early indevelopment, it opens up the possibility of thethe restorative capacity of the brain to reorganiseitself. In the adult brain, genetic factor may affectneural plasticity and motor learning progress,for example, polymophisms of the gene forbrain-derived neurotrophic factor (BDNF)(31). Synthesis of new proteins, growth of newsynapse or modification of existing synapses areprerequisites of activity-dependent plasticity(32). This can be achieved by repetitive brainstimulation such as by transcranial magneticstimulation (33) or deep brain stimulation(34). Our study shows that exercise therapy is apotential stimulus deemed capable of triggeringits reorganisation.Limitations of this study include smallsample size and single arm study design. Furtherstudies with larger population are required toconfirm the effects of this relatively affordableand accessible rehabilitation in children withmore advanced disabilities.ConclusionThis study, although conducted in a limitedsample size, gives initial scientific evidence onthe benefit of guided exercise therapy to improvemotor abilities in CP children concurrent withimprovement in white matter connectivity.The exercise therapy is affordable and canbe implemented as a home-based trainingthat could bring a lot of benefits not only tostrengthen the muscles, but also to maintain it.AcknowledgementsThis work was supported by UniversitiSains Malaysia RUI grant 1001/PPSP/812130.The authors would like to thank the children,their parents and schools for their participationand support of this research.98www.mjms.usm.myEthics of StudyNone.Conflict of InterestNone.FundsNone.Authors’ ContributionsConception and design: AHAAnalysis and interpretation of the data: SSDrafting of the article: AHACritical revision of the article for importantintellectual content: RZ, CSLFinal approval of the article: SAR, MSI, MZARStatistical expertise: CSLAdministrative, technical, or logistic support:NHMCollection and assembly of data: SS, NMFNO,MAACorrespondenceDr Asma Hayati AhmadMBBS (Universiti Malaya), MSc (USM), DPhil(Oxon)Department of Physiology,School of Medical Sciences, Universiti SainsMalaysia,16150 Kubang Kerian, Kelantan, Malaysia.Tel: 609 7676163Fax: 609 7653370E-mail: asmakck@usm.myReferences1.Scholtes VA, Becher JG, Comuth A, Dekkers H,Dijk LV, Dallmeijer AJ. Effectiveness of functionalprogressive resistance exercise strength trainingon muscle strength and mobility in childrenwith cerebral palsy: a randomized controlledtrial. Dev Med Child Neurol. 2010;52(6):e107–e113. https://doi.org/10.1111/j.1469-8749.2009.03604.x
Original Article Guided exercise therapy in cerebral palsy2.Papavasiliou AS. Management of motorproblems in cerebral palsy: a critical updatefor the clinician. Eur J Paediatr Neurol.2009;13(5):387–396. https://doi.org/10.1016/j.ejpn.2008.07.0093.Bryant E, Pountney T, Williams H, Edelman N.Can a six-week exercise intervention improvegross motor function for non-ambulant childrenwith cerebral palsy? a pilot randomized controlledtrial. Clin Rehabil. 2013;27(2):150–159. 9.Nagae LM, Hoon AH Jr, Stashinko E, Lin D,Zhang W, Levey E, et al. Diffusion tensor imagingin children with periventricular leukomalacia:variability of injuries to white matter tracts. Am JNeuroradiol. 2007;28(7):1213–1222. https://doi.org/10.3174/ajnr.A0534Chang MC, Jang SH, Yoe SS, Lee E, Kim S, LeeDG, et al. Diffusion tensor imaging demonstratedradiological differences between diplegic andquadriplegic cerebral palsy. Neurosci .neulet.2012.01.065Englander ZA, Pizoli CE, Batrachenko A, Sun J,Worley G, Mikati MA, et al. Diffuse reduction ofwhite matter connectivity in cerebral palsy withspecific vulnerability of long range fiber tracts.Neuroimage Clin. 2013;2:440–447. https://doi.org/10.1016/j.nicl.2013.03.006Pannek KB, Boyd RN, Fiori S, Guzzetta A, RoseSE. Assessment of the structural brain networkreveals altered connectivity in children withunilateral cerebral palsy due to periventricularwhite matter lesions. Neuroimage Clin
exercise therapy by a well-trained exercise instructor who came to each child's home or school to conduct the exercise therapy sessions. The structured programme was implemented and conducted as after-school exercise sessions. The children underwent 6 months of exercise therapy at a frequency of twice a week, and duration of 1 h each session.
INDEX PRESENTATION 5 THE THUMB 7 MECHANICAL EXERCISES 8 SECTION 1 THUMB Exercise 1 12 Exercise 2 13 Exercise 3 - 4 14 Exercise 5 15 Estudio 1 16 SECTION 2 THUMB WITH JUMPS Exercise 6 17 Exercise 7 - 8 18 Exercise 9 19 Exercise 10 20 Exercise 11 - 12 21 Estudio 6 22 SECTION 3 GOLPE Exercise 13 23 Exercise 14 24 Exercise 15 25 Exercise 16 - 17 26 Exercise 18 27 .
Chapter 1 Exercise Solutions Exercise 1.1 Exercise 1.2 Exercise 1.3 Exercise 1.4 Exercise 1.5 Exercise 1.6 Exercise 1.7 Exercise 1.8 Exercise 1.9 Exercise 1.10 Exercise 1.11 Exercise 1.12 Fawwaz T. Ulaby and Umberto Ravaioli, Fundamentals of Applied Electromagnetics c 2019 Prentice Hall
Occupational Therapy Occupational Therapy Information 29 Occupational Therapy Programs 30 Occupational Therapy Articulation Agreements 31 Occupational Therapy Prerequisites 33 Physical Therapy Physical Therapy Information 35 Physical Therapy Programs and Prerequisites 36 Physical Therapy Articulation Agreements 37 Physical Therapy vs .
100 At least 30 months, but less than 36 months 90 At least 24 months, but less than 30 months 80 At least 18 months, but less than 24 months 70 At least 12 months, but less than 18 months 60 At least 6 months, but less than 12 months 50 At least 90 days, but less than 6 mo
in the history of family therapy. They include Bowen Natural Systems Theory, contex-tual therapy, Virginia Satir’s Growth Model, brief therapy of the Mental Research Insti-tute, strategic family therapy, Milan Systemic Family Therapy, structural family therapy, solution-focused brief therapy, and narrative therapy.
exercise therapy (B), exercise therapy plus massage therapy (C) and advice to stay active (D). The study has an E-health approach, and study participants are being recruited through advertising with a mix of traditional and online marketing channels. Web-based self-report questionnaires
Vibe Excel pro, GymnaUnighy NV, Bilzen, Belgium) were set at 50Hz and 4mm, respectively. Whole body vibration was applied during the same sessions as exercise therapy, with a 15-min rest between the two treatments [44, 45]. Exercise therapy Patients of both groups received 4weeks of exercise therapy (3 sessions of 45 to 60min/week) in two phases,
course. The course was advertised as a training for social and philanthropic work. Birmingham was the first UK University to give aspiring social workers full status as students. From its founding in 1900 University staff had been actively involved in social welfare and philanthropic work in the City of Birmingham. Through research into the employment and housing conditions of poor people in .
