BeFAST or BeSTRONG: a randomized control trial comparing sports skill training to lower extremity strength training for children who have cerebral palsy

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A Hilderley¹, D Fehlings¹, M Taylor², JL Chen³, F Virginia Wright¹

¹Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, Canada; ²Hospital for Sick Children, University of Toronto, Toronto, Canada; ³University of Toronto, Sunnybrook Research Institute, Toronto, Canada

Background and Objective(s): Interventions for independently ambulatory children with cerebral palsy (CP) often target improvement and acquisition of advanced gross motor skills. A randomized trial was designed to evaluate whether sports skill training (BeFAST) is superior to conventional lower extremity strength training (BeSTRONG) in improving motor skills of children with CP.

Study Design: Two group parallel arm randomized control trial.

Study Participants & Setting: Twenty children ages 8–17 years (mean age 12.0, SD 2.6, 13 males) with hemiplegic (n=9) or diplegic CP (n=11) in GMFCS Level I (n=15) or II (n=5) were recruited from three local rehabilitation centres. Each was able to actively dorsiflex ≥5 degrees (ankle) and follow multi-step directions.

Materials/Methods: Participants were randomized (diagnosis/age stratified) to either the 6-week, 16-session BeFAST (n=11) or BeSTRONG (n=9) intervention. These menu-based training programs were individualized to address 3 to 5 Canadian Occupational Performance Measure (COPM) motor goals set by the child at baseline. Content of each 45-minute session was adapted based on the child's feedback. Baseline, post-intervention, and 4-month post-intervention assessments were completed by a blinded physiotherapist assessor. Co-primary outcomes were the COPM, Challenge (Rasch score), and 6-minute walk test (6MWT). Program enjoyment was evaluated via the child-report Physical Activity Enjoyment Scale (PACES). Factorial ANOVAs assessed group and time effects (Bonferroni adjustment for pairwise comparisons).

Results: All 20 participants completed the post-intervention assessment and 18 completed the follow-up 2 assessment (one missing/group). Baseline scores were similar (minimum p=0.379). Overall, there was significant within-subject change over time for the COPM Performance (COPM-P) and Satisfaction (COPM-S) and Challenge (p≤0.001), but not 6MWT (p=0.240). Between group COPM-P differences were significant across time (p=0.041). At post-intervention, scores were significantly higher in BeFAST for the COPM-P (p=0.001) and COPM-S (p=0.026). Post-intervention COPM mean changes were significant and clinically important (i.e.,≥2 points [pts]) in BeFAST (COPM-P: 3.85 pts, SE 0.46, p<0.001; COPM-S: 4.19 pts, SE 0.46, p<0.001), but not in BeSTRONG (COPM-P: 1.75 pts, SE 0.57, p=0.054; COPM-S: 2.02 pts, SE 0.65, p=0.052). However, BeSTRONG COMP-P mean change from baseline to follow-up 2 was significant (2.54 pts, SE 0.64, p=0.016). Within group Challenge changes suggest slight advantages of BeFAST. Specifically, the BeFAST group improved significantly on the Challenge post-intervention (mean change 2.52 pts, SE 0.78, p=0.031), while mean change in BeSTRONG was not significant (2.28 pts, SE 0.74, p=0.055). COPM-P, COPM-S, and Challenge post-intervention scores were maintained in both groups at follow-up 2 (p=1.00). High program enjoyment was reported, with mean PACES scores of 4.40/5 (SD 0.33) in BeFAST and 4.05/5 (SD 0.59) in BeSTRONG.

Conclusions/Significance: Sports skill training was at least as effective as conventional strength training for supporting advanced motor skill gains in children with CP (GMFCS I/II), and may be an effective training option to directly target children's goals.