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Mobility in Adults with Cerebral Palsy: Determinants and Relevance in Daily Life

Mobility in Adults with Cerebral Palsy: Determinants and Relevance in Daily Life. Désirée B. Maltais, Nancy-Michelle Robitaille, Francine Dumas, Normand Boucher, Carol L. Richards Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Laval University,

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Mobility in Adults with Cerebral Palsy: Determinants and Relevance in Daily Life

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  1. Mobility in Adults with Cerebral Palsy: Determinants and Relevancein Daily Life Désirée B. Maltais, Nancy-Michelle Robitaille, Francine Dumas, Normand Boucher, Carol L. Richards Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Laval University, Quebec City, Canada

  2. Cerebral palsy (CP) is associatedwith mobility limitations • Fetal/infant brain development disturbed • Posture + movement development affected • Mobility limitation

  3. 85% (72%) 85% 15% 15% (13%) Why study adults with CP? Survival ≥ 20 years old ≈ 85% Survival ≥ 50 years old ≈ 72% Blair et al., 2001, Strauss et al., 2007, Liptak, 2008

  4. Why study mobility and walking? • Loss of mobility and walking skills over time • E.g. crawling, standing and walking • n = 30 adolescents and young adults with CP Krakovsky, 2007

  5. Walking ability ↓ with age • 40% (160/406) of adults with CP (18-72yrs) reported deterioration in walking skills • Associated with older age, delayed walking debut and severe neurological impairment Jahnsen et al., 2004

  6. Why study social participation? • Decreased social participation • n = 103, 16-20 yrs • no intellectual impairment • Life-H questionnaire • Most common limitations • Mobility (27%), self-care (23%), nutrition (27%) Donkervoort et al., 2007

  7. Walking ability (mobility) related tohealth, social participation • Walking ability (GMFCS) positively correlated with health (EuroQol 5D) (r = 0.84) Sandström et al., 2004 • Compared to those who walk without support • If use a walking aid • OR = 1.99 for NOT living independently • OR = 2.49 for NOT cohabitating Michelsen et al., 2006

  8. Project Participants • n = 145, 71 women • Clients of local rehabilitation centre (1984-2004) • 28.0 yrs (18-41 yrs, 71 women)

  9. Project: General Protocol • Health and lifestyle questionnaire • Based on questionnaire used in province-wide (Quebec) survey of lifestyle and health (1998) • Questionnaire administered as: • Telephone or face-to-face interview • Form sent to the participant by mail • Walking and mobility skills and potential determinants assessed in a subsample (n = 33, 21 ambulatory)

  10. Disability Creation Process Risk Factors Cause Personal Factors Environmental Factors Organic Systems Capabilities Integrity Impairment Ability Disability Facilitator Obstacle Interaction Life Habits Social Participation Handicap Situation (RIPPH, 1996; 1998)

  11. Subgroup Participants

  12. Subgroup Participants (2)

  13. Anthropometry Isometric muscle strength Hand-held dynomometer Elbow flex., ext.; knee extension Mobility (gross motor) skills Gross motor function measure (GMFM) Walking skills (n = 21) Six minute walk test Cardiorespiratory measures 5 meter walk Mobility and Walking

  14. Results (Correlations): Mobility-GMFM

  15. Results (Factor Analysis):Outcomes Having Separate Contributions to Mobility

  16. Results (Regression Analysis) : Relative Importance to Mobility ofKnee Extensor Strength and Weight • 50% of the variance (GMFM scores) explained by non-dominant knee extensor strength and weight • Non-dominant knee extensor strength (36%) • Weight (14%)

  17. Clinical Relevance: Can this informationbe used to develop interventions (mobility)? • Are weight and non-dominant knee extensor strength modifiable? • Weight was positively correlated with mobility • More mobile individuals: • are bigger (related to impairment? not modifiable?) • have better nutrition? modifiable? • Use clinical judgement to determine if non-dominant knee extensor strength modifiable • If not, according to data, targeting elbow flexors and dominant knee extensors may be more helpful • Elbow extensor strength not related to mobility

  18. 23-44 yrs Exercise (n=10) Control (n=7) All ambulatory Most used a wheelchair at least sometimes 2 x wk, 10 weeks Improve mobility: Targetseveral muscle groups Andersson et al., 2003

  19. R Knee ext. concentric, J R Knee ext. peak torque, Nm L Knee ext. concentric, J R Hip ext. isometric, kg R Hip abd., isometric, kg L Hip ext. isometric, kg L Hip abd., isometric, kg % Difference 1 2 3 5 6 4 7 Improve mobility: Target several muscle groups (2) Andersson et al., 2003

  20. Dimension D + E, % Pre-training Post-training Changes to Mobility:Gross Motor Function Measure Andersson et al., 2003

  21. Clinical Relevance Revisited:Can this information be used todevelop interventions (mobility)? • Use clinical judgement to determine if non-dominant knee extensor strength modifiable • If not according to data, targeting elbow flexors and dominant knee extensors may be more helpful • Elbow extensor strength not related to mobility • Targeting other muscle groups may be helpful • What group(s) may depend on mobility task in question

  22. Results (Correlations): Walking-6MWT Distance ·

  23. Results (Factor Analysis):Outcomes Having Separate Contributions to Walking

  24. Results: Relative Importance to Walking ofWalking-Related Skills and Exercise Intensity • 92% of the variance (6MWT distance) explained by walking related skills and exercise intensity • Walking-related skills (GMFM-E): 85% • Walking-related exercise intensity (O2 uptake): 7%

  25. Clinical Relevance: Can this informationbe used to develop interventions (walking)? • Are walking related skills and exercise intensity modifiable? • Yes and probably! • Lower limb strength training improves both walking related skills and six minute walk test results (Andersson et al., 2003) • Fitness and strength training improve walking related exercise intensity in children with CP (Verschuren et al., 2007)

  26. Improve mobility: Targetseveral muscle groups Andersson et al., 2003

  27. R Knee ext. concentric, J R Knee ext. peak torque, Nm L Knee ext. concentric, J R Hip ext. isometric, kg R Hip abd., isometric, kg L Hip ext. isometric, kg L Hip abd., isometric, kg % Difference 1 2 3 5 6 4 7 Improve mobility: Target several muscle groups (2) Andersson et al., 2003

  28. Dimension D + E, % Pre-training Post-training Changes to Mobility:Gross Motor Function Measure Andersson et al., 2003

  29. Changes to Walking Speed(Six Minute Walk Test) 31% increase No change in controls Andersson et al., 2003

  30. n = 86 , 7-18 yrs. GMFCS I, II 45 min, 2 x wk, 8 mo. Aerobic exercises (running) and strength training 38% increase Changes to Walking-Related Exercise Intensity (Modified Shuttle Run) (Verschuren et al., 2007)

  31. Social Participation Questionnaire:Life Habits (Life-H) • Objective: Evaluates the accomplishment of life habits • Contenu : Daily ActivitiesSocial Roles • Nutrition Responsibility Fitness Relations Personal Care Community Life Communication Education Housing Work Mobility Recreation • Based on two concepts: • 1) Level of difficulty • 2) Type of aid required • 10 point scale, 197 items

  32. Life Habits Accomplishment Scale

  33. Results (n = 30): Correlations BetweenSocial Participation (Life-H) and Mobility (GMFM-66)

  34. Results (n = 19): Correlations BetweenSocial Participation (Life-H) and Walking(6MWT)

  35. Clinical Relevance: Can this informationbe used to develop interventions to improve social participation? • ??? • Theoretically yes, since both mobility and waking skills are modifiable in adults with CP • Combination approach maybe most beneficial

  36. Changes to Walking-Related Exercise Intensity (Modified Shuttle Run) (Verschuren et al., 2007)

  37. Exercise Improves Social Participation inChildren and Adolescents with CP (Verschuren et al., 2007)

  38. Other Strategiesto Promote Social Participation • Based on literature from adults with physical disabilities in general (e.g., Fuhrer, 2000) • Improving social supports and enhancing adaptability (e.g., motivation) may also enhance social participation

  39. Take Home Message: Disability is muti-facetted and requires a multi-facetted intervention strategy, targetting factors that are modifiable Risk Factors Cause Personal Factors Environmental Factors Organic Systems Capabilities Integrity Impairment Ability Disability Facilitator Obstacle Interaction Life Habits Social Participation Handicap Situation (RIPPH, 1996; 1998)

  40. Clinical Relevance: Can this informationbe used to develop interventions (mobility)? • Use clinical judgement to determine if non-dominant knee extensor strength modifiable • If not, according to data, targeting elbow flexors and dominant knee extensors may be more helpful • Elbow extensor strength not related to mobility

  41. Clinical Relevance: Can this informationbe used to develop interventions (walking)? • Lower limb strength training improves both walking related skills and six minute walk test results • Fitness and strength training improve walking related exercise intensity in children with CP

  42. Other Strategiesto Promote Social Participation • Improving social supports and enhancing adaptability (e.g., motivation) may also enhance social participation

  43. Thank you! Participants! Research personnel: • Véronique Genesse • Jean Leblond • Kathia Roy • Daniel Tardif

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