Teaching Manually Assisted Cough to Caregivers of Children With Neuromuscular Disease.

BACKGROUND: Cough augmentation techniques are taught by health-care providers to improve secretion clearance and to help prevent respiratory infections in children with neuromuscular disease. There is some evidence of the effectiveness of a manually assisted cough when applied by health-care providers. However, it is unknown whether parents and caregivers may also be effective in applying manually assisted cough. The aim of this study was to evaluate whether parents and caregivers are effective at applying a manually assisted cough to a child with neuromuscular disease after being taught by a health-care provider. METHODS: For this prospective cohort study, children and their parents or caregivers were recruited from neuromuscular clinics in the Sydney Children's Hospitals Network. Cough peak flow was the outcome measure for the strength of the child's cough. Children were eligible to participate if their unassisted cough peak flow at baseline was <270 L/min. Parents and caregivers were taught a manually assisted cough by a physiotherapist before being measured. The cough peak flow was measured in the following order: (1) during an unassisted cough as baseline, (2) during a manually assisted cough performed by a physiotherapist, (3) during a manually assisted cough performed by a parent or caregiver, and (4) during an unassisted cough after intervention. RESULTS: Twenty-eight children (24 boys, 4 girls; mean ± SD age, 12 ± 3 y) completed the study. No clinically or statistically significant changes were found in the cough peak flow after the application of a manually assisted cough by parents or caregivers (95% CI -11 to 11 L/min) or by physiotherapists (95% CI -6 to 14 L/min). CONCLUSIONS: Parents and caregivers and health-care providers were ineffective at increasing cough peak flow in children with neuromuscular weakness when applying a manually assisted cough. A single training session was insufficient for a parent or caregiver to be able to apply a manually assisted cough effectively on his or her child with neuromuscular weakness. Further research is warranted to guide recommendations on how best to equip parents and caregivers with the skills to help manage children with neuromuscular disease.

Effect of cardiorespiratory training on aerobic fitness and carryover to activity in children with cerebral palsy: a systematic review.

The question under consideration was does cardiorespiratory training improve aerobic fitness in children with cerebral palsy and is there any carryover into activity? The study design consisted of a systematic review of randomized trials using the Cochrane Collaboration guidelines. Participants were children of school age with cerebral palsy. Intervention included cardiorespiratory training consisting of activities conducted for an extended period, which were progressed in terms of duration and/or intensity over time. Combination programs were included if cardiorespiratory training comprised at least half of the program. Outcomes had to include a measure of aerobic fitness, for example, peak oxygen uptake. In addition, measures of activity that reflect aerobic fitness, for example, 6-min Walk Test were also desirable. Three studies were identified which randomized participants to cardiorespiratory training or no intervention in addition to usual physiotherapy. A meta-analysis was not performed because of lack of data. Therefore, the between-group differences are reported in terms of percentage benefit. Short-term cardiorespiratory training (i.e. 2-4 months) increased aerobic fitness by 18-22% and long-term training (i.e. 8-9 months) by 26-41% compared with no additional intervention. Short-term training (i.e. 2-4 months) increased activity by 0-13%, and long-term training (i.e. 8-9 months) by 2-9%. The conclusion is that there is limited evidence about the effect of cardiorespiratory training in children with cerebral palsy. The available evidence suggests that training may improve aerobic fitness, but that there is little carryover into activity.

Muscle strengthening is not effective in children and adolescents with cerebral palsy: a systematic review.

QUESTION: Do strengthening interventions increase strength without increasing spasticity and improve activity, and is there any carryover after cessation in children and adolescents with cerebral palsy? DESIGN: Systematic review with meta-analysis of randomised trials. PARTICIPANTS: Children with spastic cerebral palsy between school age and 20 years. INTERVENTION: Strengthening interventions that involved repetitive, strong, or effortful muscle contractions and progressed as ability changed, such as biofeedback, electrical stimulation, and progressive resistance exercise. OUTCOME MEASURES: Strength was measured as continuous measures of maximum voluntary force or torque production. Spasticity was measured as velocity-dependent resistance to passive stretch. Activity was measured as continuous measures, eg, 10-m Walk Test, or using scales eg, the Gross Motor Function Measure. RESULTS: Six studies were identified and five had data that could be included in a metaanalysis. Strengthening interventions had no effect on strength (SMD 0.20, 95% CI -0.17 to 0.56), no effect on walking speed (MD 0.02 m/s, 95% CI -0.13 to 0.16), and had a small statistically-significant but not clinically-worthwhile effect on Gross Motor Function Measure (MD 2%, 95% CI 0 to 4). Only one study measured spasticity but did not report the between-group analysis. CONCLUSION: In children and adolescents with cerebral palsy who are walking, the current evidence suggests that strengthening interventions are neither effective nor worthwhile.