The characteristics of the sample are detailed in table 1. The participants in the EG had a mean age of 7.31 (sd: 3.09), while in the CG the average age was 10.20 (sd: 4.71). The percentage of men in the EG was 69.23% and 90% in the CG. Regarding the type of CP according to the anatomical distribution, 6 children with diplegia and 7 with tetraplegia participated in the EG. In the CG, 4 with diplegia, 1 with triplegia and 5 with tetraplegia participated. The distribution by GMFCS levels in the EG was 2 children at level II, 6 at level III and 5 at level IV, while in the CG it was 5 level II, 2 level III and 3 level IV. There are no differences between groups that influence the results.
Table 1. Characteristics of the sample.
|
|
|
EG
|
CG
|
N
|
13
|
10
|
Mean age (sd)
|
7.31 (3.09)
|
10.20 (4.71)
|
Men
|
69.23%
|
90%
|
CP Type 1
|
|
|
Diplegia
|
46.15%
|
40%
|
Triplegia
|
0%
|
10%
|
Tetraplegia
|
53.85%
|
50%
|
CP Type 2
|
|
|
Mixed
|
23.08%
|
10%
|
Spastic
|
76.92%
|
90%
|
GMFCS Level
|
|
|
II
|
15.38%
|
50%
|
III
|
46.15%
|
20%
|
IV
|
38.46%
|
30%
|
Cognitive impairment
|
|
|
Yes
|
61.54%
|
50%
|
No
|
38.46%
|
50%
|
Average number of weekly physiotherapy sessions (sd)
|
2.92 (0.95)
|
3.50 (1.43)
|
EG: experimental group, CG: control group, sd: standard deviation, CP: cerebral palsy, GMFCS: Gross Motor Function Classification System
Gait
In the GMFM-88, dimension D, the EG participants obtained an average of 0.21 in the pretest, and 0.30 in the post-test. The CG participants obtained an average of 0.47 and 0.46 in the pretest and post-test, respectively. At follow-up, the EG and CG obtained a mean of 0.41 and 0.46, respectively. The pretest-post-test and follow-up analysis of variance showed differences with respect to the time x group interaction [F (2.32) =12.7585, p= 8.425406e-05, η2=0.016], with small effect sizes. In the GMFM -88, dimension E, the EG participants obtained an average of 0.16 and 0.24, in the pretest and in the post-test, respectively. In the CG they obtained an average of 0.44 in the pretest and 0.47 in the post-test. At follow-up, the EG and CG participants obtained an average of 0.27 and 0.44, respectively. In the robust mixed ANOVA pretest-posttest and follow-up, no differences were found regarding interaction (p=0.1579). Table 2 shows the comparisons between groups of GMFM D, GMFM E. Figure 2 shows the interaction between time and group.
Table 2. Comparisons between groups of GMFM D and GMFM E.
|
Pretest Mean (SD)
|
Postest Mean (SD)
|
Follow-up Mean (SD)
|
Pretest-post-test and follow-up analysis of variance
|
|
EG (n=10)
|
CG (n=10)
|
EG (n=10)
|
CG (n=10)
|
EG (n=8)
|
CG (n=10)
|
p
|
η2
|
GMFMD
|
0.21 (0.24)
|
0.47 (0.37)
|
0.36 (0.25)
|
0.46 (0.37)
|
0.41 (0.30)
|
0.46 (0.36)
|
8.425406e-05
|
0.016
|
GMFME
|
0.16 (0.16)
|
0.44 (0.37)
|
0.24 (0.20)
|
0.47 (0.36)
|
0.27 (0.23)
|
0.44 (0.37)
|
0.1579
|
--
|
SD: standard deviation, EG: experimental group, CG: control group, GMFMD: Gross Motor Function Measure Dimension D, GMFME: Gross Motor Function Measure Dimension E, p: statistical significant, η2: effect size
Figure 2. Interaction graph between time and group of GMFMD
GMFMD: Gross Motor Function Measure Dimension D
Muscular strength
Hip flexion
In the flexion strength in the left hip, the EG obtained an average of 1.46 and 2.35, in the pretest and in the posttest, respectively. In the CG they obtained an average of 3.62 in the pretest and 3.10 in the posttest. At follow-up, the EG and CG obtained a mean of 3.56 and 3.25, respectively. In the right hip, in the EG they obtained an average of 1.25 and 2.45, in the pretest and in the posttest, respectively. In the CG they obtained an average of 3.45 and 2.85, in the pretest and in the posttest, respectively. At follow-up, the EG and CG obtained a mean of 3.19 and 3.15, respectively. The pretest-posttest and follow-up analysis of variance showed differences with respect to the group x time interaction [F (2.32) = 7.358, p= 2.350e-03, η2 = 0.128], in left hip flexion strength. In the right hip, differences were also found with respect to the interaction [F (2.32) = 8.045, p= 1.478e- 03, η2 = 0.142]. (Figures 3 and 4). (Table 3).
Figure 3. Interaction graph between time and group of left hip flexion strength
Figure 4. Interaction graph between time and group of right hip flexion strength
Hip extension
In the extension strength in the left hip, the EG participants obtained an average of 0.10 and 0.60, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 0.95 in the pretest and 0.70 in the posttest. At follow-up, the EG and CG obtained a mean of 1.12 and 0.75, respectively. In the right hip, the EG obtained an average of 0.10 and 0.53, in the pretest and in the posttest, respectively. The CG obtained an average of 1.20 in the pretest and 0.80 in the posttest. At follow-up, the EG and CG obtained a mean of 0.88 and 0.95, respectively. In the pretest-posttest and follow-up analysis of variance, differences were found with respect to the interaction [F (2.32) = 4.672, p= 0.017, η2 = 0.035], in right hip extension strength. (Figure 5). In the left hip, no differences were found with respect to the interaction [F (2.32) = 3.0606, p=0.0608, η2=0.04119]. (Table 3).
Figure 5. Interaction graph between time and group of right hip extension strength
Hip abduction
In the abduction strength in the left hip, the EG participants obtained an average of 0.32 and 1.35, in the pretest and in the posttest, respectively. Those from the CG obtained an average of 2.05 and 1.30, in the pretest and in the posttest, respectively. At follow-up, the EG and CG obtained a mean of 2.22 and 1.15, respectively. In the right hip, the EG participants obtained an average of 0.42 and 1.25, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 2.25 in the pretest and 1.30 in the posttest. At follow-up, the EG and CG participants obtained a mean of 1.88 and 1.00, respectively. In the analysis of variance pretest-posttest and follow-up, differences were found with respect to the interaction [p=0.0147, η2 = 0.179] in the left hip. In the abduction strength of the right hip, differences were also found with respect to the interaction [F (2.32) = 8.721, p= 9.481e-04, η2 = 0.196]. (Figures 6 and 7). (Table 3).
Figure 6. Interaction graph between time and group of left hip abduction strength
Figure 7. Interaction graph between time and group of right hip abduction strength
Knee flexion
In the flexion strength in the left knee, the EG participants obtained an average of 1.18 and 2.23, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 2.65 in the pretest and 1.95 in the posttest. At follow-up, the EG and CG obtained, respectively, a mean of 2.60 and 2.30. In the right knee, the mean EG in the pretest was 1.25, and in the posttest it was 2.20. In the CG, the pretest mean was 2.75 and the posttest mean was 2.15. At follow-up, the EG and CG participants obtained a mean of 2.66 and 2.35, respectively. In the ANOVA, differences were found in the strength of the left knee with respect to the group x time interaction [F (2.32) = 9.762, p = 4.899e-04, η2 = 0.222]. In right knee strength, differences were also found in the group x time interaction [F (2.32) = 4.867, p= 1.427e-02, η2 = 0.147]. (Figures 8 and 9). (Table 3).
Figure 8. Interaction graph between time and group of left knee flexion strength
Figure 9. Interaction graph between time and group of right knee flexion strength
Knee extension
In the extension strength in the left knee, the EG participants obtained an average of 1.00 and 1.99, in the pretest and in the posttest, respectively. Those in the CG obtained an average of 1.84 in the pretest and 2.20 in the posttest. At follow-up, the EG and CG obtained a mean of 2.09 and 2.35, respectively. In the right knee, the EG participants obtained an average of 1.10 and 2.40, in the pretest and in the posttest, respectively. The CG participants obtained an average of 1.95 in the pretest and 2.45 in the posttest. At follow-up, the EG and CG participants obtained an average of 2.05 and 2.55, respectively. In right knee extension, no differences were found with respect to the interaction [F (2.32) = 0 .3893, p=0.6807, η2=0.00496], as in left knee extension (p=0.4747). (Table 3)
Table 3. Comparisons between groups of hip and knee strength.
|
Pretest Mean (SD)
|
Posttest Mean (SD)
|
Follow-up Mean (SD)
|
Pretest-post-test and follow-up analysis of variance
|
Strength
|
EG (n=10)
|
CG (n=10)
|
EG (n=10)
|
CG (n=10)
|
EG (n=8)
|
CG (n=10)
|
p
|
η2
|
Left hip flexion
|
1.46 (0.78)
|
3.62 (1.97)
|
2.35 (0.26)
|
3.10 (1.15)
|
3.56 (2.29)
|
3.25 (1.27)
|
2.350e-03
|
0.128
|
Right hip flexion
|
1.25 (0.75)
|
3.45 (1.86)
|
2.45 (0.28)
|
2.85 (1.18)
|
3.19 (1.46)
|
3.15 (1.16)
|
1.478e- 03
|
0.142
|
Left hip extension
|
0.10 (0.32)
|
0.95 (1.71)
|
0.60 (0.94)
|
0.70 (1.03)
|
1.12 (1.79)
|
0.75 (1.23)
|
0.0608
|
0.04119
|
Right hip extension
|
0.10 (0.32)
|
1.20 (1.86)
|
0.53 (0.82)
|
0.80 (1.21)
|
0.88 (1.22)
|
0.95 (1.32)
|
0.017
|
0.035
|
Left hip abduction
|
0.32 (0.53)
|
2.05 (1.88)
|
1.35 (0.82)
|
1.30 (0.98)
|
2.22 (1.77)
|
1.15 (1.11)
|
0.0147
|
0.179
|
Right hip abduction
|
0.42 (0.50)
|
2.25 (1.72)
|
1.25 (0.75)
|
1.30 (1.01)
|
1.88 (1.58)
|
1 (0.97)
|
9.481e-04
|
0.196
|
Left knee flexion
|
1.18 (0.72)
|
2.65 (1.25)
|
2.23 (0.48)
|
1.95 (0.86)
|
2.60 (0.92)
|
2.30 (0.71)
|
4.899e-04
|
0.222
|
Right knee flexion
|
1.25 (0.68)
|
2.75 (1.89)
|
2.20 (0.48)
|
2.15 (0.63)
|
2.66 (1.03)
|
2.35 (0.78)
|
1.427e-02
|
0.147
|
Left knee extension
|
1 (0.85)
|
1.84 (1.73)
|
1.99 (0.62)
|
2.20 (1.7)
|
2.09 (1.26)
|
2.35 (1.73)
|
0.4747
|
------
|
Right knee extension
|
1.10 (0.84)
|
1.95 (1.59)
|
2.40 (1.26)
|
2.45 (2.05)
|
2.05 (1.7)
|
2.55 (2.34)
|
0.6807
|
0.00496
|
SD: standard deviation, EG: Experimental Group, CG: Control Group, n: sample
ROM
Knee flexion
In the flexion movement of the left knee, the EG participants obtained an average of 126.5 and 119, in the pretest and in the posttest, respectively. The CG participants obtained an average of 127 and 128 in the pretest and posttest, respectively. At follow-up, EG and CG participants scored an average of 130 and 128, respectively. In the right knee, the EG participants obtained an average of 128 and 121, in the pretest and in the posttest, respectively. The CG participants obtained an average of 127 and 127 in the pretest and posttest, respectively. At follow-up, EG and CG participants scored an average of 130 and 128, respectively. In the left knee flexion ROM, the pretest-posttest and follow-up analysis of variance showed differences with respect to interaction (p=0.0054, η2 = 0.071). with medium effect size. In the ROM of right knee flexion, the analysis showed differences with respect to interaction (p=0.0054, η2 = 0.053), with medium and small effect sizes respectively. (Table 4).
Knee extension
In the extension movement in the left knee, the EG participants obtained an average of -2.30 in the pretest, and -1.30 in the posttest. The CG participants obtained an average of -2 and -1.5, in the pretest and in the posttest, respectively. At follow-up, EG and CG participants obtained a mean of -0.62 and -1, respectively. In the right knee, the EG participants obtained an average of -2.50 and -1.30, in the pretest and in the posttest, respectively. The CG participants obtained an average of -3 and -3.50, in the pretest and in the posttest, respectively. At follow-up, EG and CG participants obtained a mean of -0.62 and -1, respectively. In the left knee extension ROM, the ANOVA pretest-posttest and follow-up showed no differences with respect to interaction [F (2.32) = 0.0097, p=0.9903]. In the right knee extension ROM, no differences were found with respect to interaction [F (2,32) = 0.4777, p=0.6245]. (Table 4)
Table 4. Comparisons between groups of knee ROM.
|
Pretest Mean (SD)
|
Posttest Mean (SD)
|
Follow-up Mean (SD)
|
Pretest-post-test and follow-up analysis of variance
|
ROM
|
EG (n=10)
|
CG (n=10)
|
EG (n=10)
|
CG (n=10)
|
EG (n=8)
|
CG (n=10)
|
p
|
η2
|
Left knee flexion
|
126.50 (11.07)
|
127 (15.67)
|
119 (7.38)
|
128 (11.35)
|
130 (0)
|
128 (10.33)
|
0.0054
|
0.071
|
Right knee flexion
|
128 (6.32)
|
127 (15.67)
|
121 (3.16)
|
127 (13.37)
|
130 (0)
|
128 (10.33)
|
0.0054
|
0.053
|
Left knee extension
|
-2.30 (3.89)
|
-2 (6.32)
|
-1.30 (2.16)
|
-1.50 (4.74)
|
-0.62 (1.77)
|
-1 (3.16)
|
0.9903
|
6.026e-05
|
Right knee extension
|
-2.50 (4.25)
|
-3 (9.49)
|
-1.30 (2.16)
|
-3.50 (9.44)
|
-0.62 (1.77)
|
-2.50 (6.35)
|
0.6245
|
0.002
|
SD: standard deviation, EG: Experimental Group, CG: Control Group, n: sample, ROM: range of motion