Therapist-Designed Adaptive Riding in Children With Cerebral Palsy: Results of a Feasibility Study

Mattana Angsupaisal; Baudina Visser; Anne Alkema; Marja Meinsma-van der Tuin; Carel G.B. Maathuis; Heleen Reinders-Messelink; Mijna Hadders-Algra

doi:10.2522/ptj.20140146

Figures

Figure 1.

Schematic presentation of the study design, including the outcome measures. Moments of evaluation: T0=6 weeks before the start of the therapist-designed adaptive riding (AR) intervention, T1=start of the intervention, T2=end of the intervention. V1 and V2 represent the moments of video recording of the intervention during the second and eleventh sessions, respectively. In addition to the measurements shown, the child's appreciation of each intervention session was assessed with a 5-point “smiley scale.” The therapist-designed AR program was delivered with minimal hands-on guidance and maximal self-practice (1-hour group class, twice weekly). GMFM-88=88-item Gross Motor Function Measure, EMG=surface electromyography, PEDI=Dutch version of the Pediatric Evaluation of Disability Inventory.

Figure 2.

Development of 88-item Gross Motor Function Measure (GMFM-88) scores. (A) Box plots of total GMFM-88 scores for the group data 6 weeks before the start of the therapist-designed adaptive riding (AR) intervention (T0), at the start of the intervention (T1), and at the end of the intervention (T2). Horizontal lines indicate median values, boxes indicate interquartile ranges, and vertical lines indicate the full range. Wilcoxon signed rank test: P=.075 for T1 versus T0 and P=.028* for T2 versus T1 (asterisk represents significant difference). (B–D) Individual developmental trajectories of the percentage scores for the total GMFM-88 (B) and the goal areas (GMFM-88 dimension D [standing] [C] and GMFM-88 dimension E [walking, running, and jumping] [D]) during the baseline (T0 to T1) and during the therapist-designed AR intervention (T1 to T2). Participants 4 and 5 had previous AR intervention experience; the other children did not. For clarity, the GMFM-88 scales (y-axes) in panels C and D differ from those in panels A and B.

Figure 3.

Examples of electromyographic (EMG) recordings of postural muscle activity during reaching while sitting. (A) Trial for participant 1 before the therapist-designed adaptive riding (TDAR) intervention. (B) Trial for participant 1 at the end of the TDAR intervention. The vertical dashed lines represent the presence of the reaching movement; the left line represents the moment at which the video indicated the start of the reaching movement, and the right line represents the end of the reaching movement, as observed in a video. The short, bold vertical lines denote the onset of significant EMG bursts, as defined by the computer algorithm. The biceps brachii muscle was the prime mover in both trials; that is, it was the arm muscle initiating the reaching movement. The vertical dotted line indicates the onset of the reaching movement by the prime mover. Both trials showed direction specificity at the neck and trunk levels. In both trials, the neck extensor muscle was activated before the neck flexor muscle. At the trunk level, direction specificity was expressed in 2 different ways: In panel A, thoracic extensor and lumbar extensor muscles were activated but the rectus abdominis muscle was not recruited; in panel B, the thoracic and lumbar extensor muscles were recruited before the rectus abdominis muscle. Panel A illustrates top-down recruitment, during which the neck extensor muscle was recruited before the thoracic and lumbar extensor muscles. Panel B illustrates a mixed order of recruitment of the dorsal muscles.

Figure 4.

Changes in top-down recruitment order from T1 (before the intervention) to T2 (after the intervention). (A) Box plots of the group data for the various types of recruitment order at T1 (white boxes) and T2 (gray boxes). The horizontal bars indicate the median values, the boxes indicate the interquartile ranges, the vertical lines indicate the full range, and the circle is an outlier. In group analyses of the effect of the therapist-designed adaptive riding intervention on top-down recruitment order, the P value was .173 (Wilcoxon signed rank test). (B) Individual data on frequency of top-down recruitment order at T1 (white bars) and T2 (black bars). The frequency in participant 5 at T2 was 0%.

Tables

Table 1.

Frequencies of Posture and Balance Challenges During TDAR Sessions^{^a}

↵^a The quantitative data were from video analysis of therapist-designed adaptive riding (TDAR) sessions at the beginning (V1) and at the end (V2) of the program. Data represent the number of challenges performed; P values represent the differences between V1 and V2 (Wilcoxon signed rank test). In arm challenges, posture and balance were challenged by exercises such as “raise your arms high up in the air” and “fly like an airplane”; in body sway challenges, posture and balance were challenged by exercises such as lying prone or leaning backward on the horse; in horse challenges, posture and balance were challenged by, for instance, a change from walking to trotting.

Table 2.

Group Comparisons of Outcome Measures at Each Assessment^{^a}

↵^a T0=6 weeks before the start of the therapist-designed adaptive riding (TDAR) intervention; T1=start of the TDAR intervention; T2=end of the TDAR intervention; MCID=minimal clinically important difference of a large effect size for Gross Motor Function Classification System level III¹⁸; ICF-CY=International Classification of Functioning, Disability and Health: Children and Youth Version; GMFM-88=88-item Gross Motor Function Measure; A=activity; NA=not available; PEDI=Dutch version of the Pediatric Evaluation of Disability Inventory; A/P=activities and participation; P=participation; QoL=quality of life; Self-Esteem=Behavioral Rating Scale of Presented Self-Esteem; Pe=personal factors; DISABKIDS=cerebral palsy module of disease-specific DISABKIDS (higher scores denote a poorer outcome); KIDSCREEN-52=generic KIDSCREEN-52; BS/F=body structure and function.
^b Values are reported as median (range) (minimum–maximum) for the 6 participants unless otherwise indicated.
^c Bold values exceeded the MCIDs.
^d The goal areas of the GMFM-88 were dimension D (standing) and dimension E (walking, running, and jumping).
^e In the modified Tardieu Scale, a 5-point rating scale (grades) was used to describe the quality of the muscle reaction. A grade of 0 indicated no resistance throughout the course of the passive movement; a grade of 1 indicated slight resistance throughout the course of the passive movement (no clear “catch” at a precise angle); a grade of 2 indicated a clear catch at a precise angle, interrupting the passive movement, followed by release; a grade of 3 indicated fatigable clonus (<10 seconds when maintaining the pressure and appearing at a precise angle); and a grade of 4 indicated infatigable clonus (>10 seconds when maintaining the pressure at a precise angle). Spasticity grades were obtained for 6 participants unless otherwise indicated. In addition, 2 angles (R1 and R2) were determined: R1 was the angle of catch after a high-velocity stretch, and R2 was the passive range of motion after a low-velocity stretch. The difference between the 2 angles (R2−R1) represented the level of dynamic contracture in the joint. Negative values indicated plantar flexion at the ankle joint.

Supplementary Data

eAppendix

Files in this Data Supplement:

eAppendix (PDF) (40 KB) - This data supplement contains the following eAppendix:
- eAppendix. Classification of Activities and Assistance During Equine Movement