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Table 1 Example of group and individual physiotherapy session content

From: GRIN: “GRoup versus INdividual physiotherapy following lower limb intra-muscular Botulinum Toxin-A injections for ambulant children with cerebral palsy: an assessor-masked randomised comparison trial”: study protocol

Physiotherapy component

Time (minutes)

Theoretical rationale

Activity examples

Warm up activities

5

Activities have been chosen to prepare the child’s mind and body for the therapy session. In the group model, dynamics will be encouraged by performing games/activities as a group.

• Animal and yoga postures

• Dancing to music/musical statues

• Balloon tennis

Lower limb flexibility

10

Exercises have been selected to mobilize lower limb joints and muscles through the available range using sustained stretching of agonists injected with BoNT-A for a minimum of five repetitions of 30 seconds duration [71, 72].

• In paired long sitting facing each other with feet together, pass the ball between each other (hamstring stretch)

• Heel dips off the edge of a step (calf stretch)

Circuit Stations:

 

Four stations with one minute rest between each one:

 

Station 1 Functional strengthening

5

Repetitive, weight-bearing activities have been chosen to improve muscle strength required for functional activities that reflect goals identified via the COPM [36, 44]. The focus is on concentric and eccentric muscle activity using body weight resistance. Intensity will be specific to each individual, aiming for 70% of maximum effort, with progression occurring through increasing the number of repetitions or the difficulty of the task (e.g. lower the height of the chair for sit to stand; increase the height of the step for step-ups; increase the speed to complete the activity). Three sets of 10 repetitions is the aim for all participants [7375].

• Sit to stand

• Squat to stand

• Forward and lateral step ups and downs

• Stair climbing.

Station 2 Standing and dynamic balance

5

Activities have been selected to improve the limits of stability in standing tasks relevant to balance goals identified on the COPM.

• Activities in standing where the participant has to reach or squat for an object outside the base of their support

• Games standing on one leg (SLS) with/without support as required (e.g. dribble a ball around the weight-bearing leg)

Station 3 Targeted motor control

5

Individualised activities will be set for each participant to facilitate task practise of functional goals identified on the COPM. Repetition/practise and incremental progression of tasks will occur each week, and through the home programme, to reinforce motor learning [76].

• SLS activities +/− support e.g. dribble ball around standing foot.

• Kicking to goal (start with large goal area and gradually decrease size).

Goal example:

• Kick ball between 2 people (start with larger ball, decreasing to age appropriate size; progress to kicking ball further to side and increase speed).

Improve XX ability to kick the ball when playing soccer with friends at school

• Be able to make contact with the ball 8 out of 10 attempts

• Improve accuracy of kicking to a target (5/10 successful attempts)

• Dribble ball around obstacles (e.g. figure of 8 around cones).

Station 4 Fitness/agility

5

Activities or games will be carried out to challenge and improve participants’ agility and fitness, aiming for carry-over into physical activity goals (such as being able to run in the playground during school breaks without needing to sit down to rest).

• Timed obstacle races

• Shuttle runs

• Relay races.

Warm down activities

5

Children will participate in activities that continue to mobilise muscles through range to maximise flexibility, prevent muscle soreness and injury, as well as facilitate reduction in heart rate and temperature to ensure they are in a less aroused state prior to leaving therapy.

• Yoga

• ‘Simon Says’

• Songs with actions

Review of home programme

10

Review of home programme with each caregiver and participant.

Includes incrementally progressing activities related to the functional performance goals (COPM).

  1. Key: BoNT-A: Botulinum Toxin-Type A; COPM: Canadian Occupational Performance Measure; SLS: single leg stance.