Whole-body vibration training is a method for muscle strengthening that is increasingly used in a variety of clinical situations. Key descriptors of vibration devices include the frequency, the amplitude, and the direction of the vibration movement. In a typical vibration session, the user stands on the device in a static position or performs dynamic movements. Most authors hypothesize that vibrations stimulate muscle spindles and alpha-motoneurons, which initiate a muscle contraction. An immediate effect of a non-exhausting vibration session is an increase in muscle power. Most studies of the longer term use of vibration treatment in various disorders have pursued three therapeutic aims: increasing muscle strength, improving balance, and increasing bone mass. In a small pilot trial in children we noted improvements in standing function, lumbar spine bone mineral density, tibial bone mass, and calf muscle cross-sectional area.
The purpose of this study was to determine the effect of a new physiotherapy concept on bone density, muscle force and motor function in bilateral spastic cerebral palsy children.
In a retrospective data analysis 78 children were analysed. The concept included whole body vibration, physiotherapy, resistance training and treadmill training. The concept is structured in two in-patient stays and two periods of three months home-based vibration training. Outcome measures were dual-energy x-ray absorption (DXA), Leonardo Tilt Table and a modified Gross Motor Function Measure before and after six months of training.
Percent changes were highly significant for bone mineral density, -content, muscle mass and significant for angle of verticalisation, muscle force and modified Gross Motor Function Measure after six months training.
The new physiotherapy concept had a significant effect on bone mineral density, muscle force and gross motor function in bilateral spastic cerebral palsy children. This implicates an amelioration in all International Classification of Functioning, Disability and Health levels. The study serves as a basis for future research on evidence based paediatric physiotherapy taking into account developmental implications.
The routine clinical use of supported standing in hospitals, schools and homes currently exists. Questions arise as to the nature of the evidence used to justify this practice. This systematic review investigated the available evidence underlying supported standing use based on the Center for Evidence-Based Medicine (CEBM) Levels of Evidence framework.
The database search included MEDLINE, CINAHL, GoogleScholar, HighWire Press, PEDro, Cochrane Library databases, and APTAs Hooked on Evidence from January 1980 to October 2009 for studies that included supported standing devices for individuals of all ages, with a neuromuscular diagnosis. We identified 112 unique studies from which 39 met the inclusion criteria, 29 with adult and 10 with pediatric participants. In each group of studies were user and therapist survey responses in addition to results of clinical interventions.
The results are organized and reported by The International Classification of Function (ICF) framework in the following categories: b4: Functions of the cardiovascular, haematological, immunological, and respiratory systems; b5: Functions of the digestive, metabolic, and endocrine systems; b7: Neuromusculoskeletal and movement related functions; Combination of d4: Mobility, d8: Major life areas and Other activity and participation. The peer review journal studies mainly explored using supported standers for improving bone mineral density (BMD), cardiopulmonary function, muscle strength/function, and range of motion (ROM). The data were moderately strong for the use of supported standing for BMD increase, showed some support for decreasing hypertonicity (including spasticity) and improving ROM, and were inconclusive for other benefits of using supported standers for children and adults with neuromuscular disorders. The addition of whole body vibration (WBV) to supported standing activities appeared a promising trend but empirical data were inconclusive. The survey data from physical therapists (PTs) and participant users attributed numerous improved outcomes to supported standing: ROM, bowel/bladder, psychological, hypertonicity and pressure relief/bedsores. BMD was not a reported benefit according to the user group.
There exists a need for empirical mechanistic evidence to guide clinical supported standing programs across practice settings and with various-aged participants, particularly when considering a life-span approach to practice.
date: 1981 Sep;(159):111-22
author: Bleck E E
publication: Clinical Orthopedic Relat Re
pubmed ID: 7285447
The problem of osteoporosis superimposed on the basic collagen defect of osteogenesis imperfecta has been approached by the use of plastic containment orthoses for the lower limbs, in addition to developmentally staged mobility devices that assist early standing and walking. The purpose of forcing early weight-bearing is to provide stress to the lower limb bones in order to minimize osteoporosis, prevent refracture and deformity, and curb subsequent immobilization osteoporosis, thus breaking a vicious cycle. Management goals are based upon adult needs for independence: efficiency in daily living activities and in mobility. These goals were reached in most of our patients via use of plastic orthoses, early weight-bearing, and electrically powered wheelchairs. Manual osteoclasis of the tibia followed by plastic orthoses utilizing principles of fluid compression to support fractured or structurally weak bones appeared successful at the time of follow-up. Intramedullary rodding of the femur was necessary in most of the 12 children with osteogenesis imperfecta congenita. Supplementary plastic orthoses have reduced the refracture rate in both the tibia and the femur. Social integration of the children was reflected by the fact that among the 12 OI congenita cases, ten were attending regular educational institutions. Twelve OI tarda children fared well, all attaining complete independence in daily living, mobility and ambulation. Seven of this group were treated with intramedullary rodding of the femur or tibia and with plastic orthoses. Five patients required no treatment.
PURPOSE: Physiotherapists commonly use static weight-bearing exercises in children with cerebral palsy, which are believed to stimulate antigravity muscle strength, prevent hip dislocation, improve bone mineral density, improve self-esteem, improve feeding, assist bowel and urinary functions, reduce spasticity, and improve hand function. The effectiveness of these exercises has not been thoroughly investigated. This systematic review aimed to examine the research evidence of the effectiveness of static weight-bearing exercises in children with cerebral palsy. METHODS: Ten studies met the inclusion criteria for this review. RESULTS: The evidence supporting the effectiveness of static weight-bearing exercises in children with cerebral palsy, except the findings of increased bone density and temporary reduction in spasticity, remains limited because of an inadequate number of studies undertaken, inadequate rigor of the research designs and the small number of subjects involved. CONCLUSION: Clinicians should carefully consider all available evidence before making a decision regarding the potential effectiveness of static weight-bearing for the targeted outcomes.
author: Presedo A, Dabney KW, Miller F.
publication: J Pediatr Orthop. 2007 Mar;27(2):147-53.
Fractures in children with cerebral palsy (CP) constitute a common clinical problem. The purpose of this retrospective study is to analyze the demographics, identify risk factors, and delineate guidelines for treatment in 156 children with CP who were treated for fractures. To identify changes in demographics, children treated before 1992 (56 patients) were compared with those treated from 1992 to 2000. The latter group of children was compared with an age- and gender-matched group of CP children without fractures. Ambulatory status, the presence of contractures, nutritional status, seizure medication, the type of treatment received, final outcomes, and complications were recorded and statistically analyzed. The mean age at the time of the first fracture was 10 years. Sixty-six percent of patients had spastic quadriplegia, of whom 83% were nonambulatory. Eighty-two percent of fractures occurred in the lower limbs. Forty-eight percent were delayed in diagnosis with no cause determined. Children treated after 1992 had higher incidence of multiple fractures, lower incidence contractures, and a younger age at first fracture. This group showed a statistically significant difference for anticonvulsant therapy (P=0.001), CP pattern (P=0.005), ambulatory status (P=0.001), and osteopenia (P=0.001) when compared with the group of CP patients without fractures. Eighty percent of fractures were treated with a soft bulky dressing. Complications occurred in 17% of patients. The greatest risk factor for fracture is the nonambulatory CP child on anticonvulsant therapy. These risk factors seem to have increased, resulting in a higher prevalence of low energy fractures. Future research must focus on the underlying mechanisms and prevention of this condition.
A survey of 289 severely retarded inpatients at a school for retarded children in American Fork; Utah revealed 67 patients with osteomalacia as defined by hypocalcemia, hypophosphatemia, elevated serum alkaline phosphatase levels, and appropriate bone changes. Investigation of the variables which might influence bone mineralization revealed no differences in age, sex, physical activity, sunshine exposure, or dietary intake of vitamin D between the osteomalacia and nonosteomalacia groups. However, all of the patients with osteomalacia were receiving anticonvulsant medications, either phenobarbital, diphenylhydantoin, or both. Duration of anticonvulsant therapy was the most important contributing factor to the development of osteomalacia. Seventy-five percent of patients who had received anticonvulsants for more than ten years had osteomalacia. The single most costly medical problem at the school is the treatment of pathologic bone fractures due to demineralized bone.
STUDY DESIGN: Prospective study on patients with spinal cord injuries. OBJECTIVES: To evaluate the loss of bone mineral density (BMD) in various body regions of patients with spinal cord injury (SCI) and its dependence on weight bearing activities during 2 years post injury. METHODS: BMD of the whole body was measured in patients with SCI. Baseline measurement was performed in 6-16 weeks after SCI, the second and the third-respectively 12 and 24 months after injury. Fifty-four subjects were selected and divided into two groups: standing and non-standing. From these groups 27 pairs were made according to gender, age and height. RESULTS: There was found to be a well-marked decrease in BMD values for lower extremities, but there was no significant difference between paraplegic and tetraplegic patients 1 and 2 year after injury. Leg BMD reduced by 19.62% (95% CI, 17-22%) in the standing group and by 24% (95% CI, 21-27%) in non-standing group during the first year. Two years after SCI patients in standing group had significantly higher leg BMD-1.018 g/cm(2) (95% CI, 0.971-1.055 g/cm(2)) than in the non-standing group-0.91 g/cm(2) (95% CI, 0.872-0.958 g/cm(2)) (P<or=0.0001). CONCLUSION: SCI patients who performed daily standing >or=1 h and not less than 5 days per week, had significantly higher BMD in the lower extremities after 2 years in comparison to those patients who did not perform standing.
The incidence (42%) of vitamin D abnormalities is high in severely handicapped children and young adults who sustain fractures, especially those who sustain multiple fractures. Fractures occur primarily in the lower extremity and heal with simple immobilization. In patients with normal vitamin D levels, a history of a significant traumatic event should be identified and child abuse ruled out. Vitamin D-deficient patients respond to nutritional and vitamin D supplementation, with decreased fracture incidence.
author: Miller PR, Glazer DA.
publication: Clin Orthop Relat Res. 1976 Oct;(120):134-7.
This report deals with the treatment of 31 spontaneous fractures which occurred in 50 institutionalized patients who were bedridden primarily because of severe cerebral palsy associated with brain injury. More than one-half of the group sustained a spontaneous fracture. Satisfactory healing of all fractures with a minimum of complications occurred without any immobilization or realignment. In 4 patients with delayed compound wounds, the treatment consisted of resection of the protruding portion of the bone after allowing the bony protrusion to wall itself off.