Running training for children with generalised joint hypermobility - a feasibility study

Running Intervention protocol according to Consensus on Exercise Reporting Template (CERT guidelines) Adapted from: Gibson N, Chappell A, Blackmore AM, Morris S, Williams G, Bear N, Allison G. The effect of a running intervention on running ability and participation in children with cerebral palsy: a randomized controlled trial. Disabil Rehabil. 2018 Dec;40(25):3041-3049. doi: 10.1080/09638288.2017.1367426. Epub 2017 Aug 21. PMID: 28826274. 1. Exercise Equipment: Trampette, stairs, resistance bands, single step, cones, agility ladder, dumbbells, leg curl machine, leg press machine 2. Qualifications and training: Two or three senior physiotherapists (PTs) with experience in working with school-aged children with hypermobility spectrum disorder (HSD) will deliver the program. The lead physiotherapist has delivered this intervention for the past 8 years, undertook 15 hours training in rehabilitation of running for people with neurological conditions and undertook eight hours training in motivational interviewing which was delivered by a clinical psychologist. 3. Individual/group: Individualized programs will be established and progressed at individual rates. The individualized program will be delivered and performed in a group setting once per week and a home program provided to be performed three times per week. 4. Supervision: Participants will be supervised in a ratio of 1PT:3participants. The participants will be taught the exercises individually and once performing the exercise correctly, allowed to practice independently. 5. Adherence to exercise: Progress notes will be completed at the end of each session, including the level of difficulty of each exercise and number of repetitions, or time spent doing the exercise. Attendance will be recorded for each participant and reported as a number of sessions out of 10 possible sessions. Home program exercises will be prescribed weekly and home exercise diary sheets will be collected at the end of each week. 6. Motivation strategies: Participants will be encouraged with verbal feedback about their technique, both what was done well and what changes need to be made. Participants will be given a time or number of repetitions to aim for. Exercises will sometimes be incorporated into games. Participants will also be encouraged to “buddy up” with another group participant to encourage each other. Each participant will have a home program, with diary sheets issued and collected weekly to encourage adherence. Participants who do not attend a session without informing PTs of the reason will be called by one of the PTs the next day to encourage attendance. The PTs will use motivational interviewing techniques during the weekly one hour sessions to encourage participants to explore options for adhering to home prescribed exercises and for exploring and promoting physical activity in the community. 7a. Decision rule(s) for determining progression: Once the participant is consistently able to perform the exercise with good technique they will be progressed to the next level. Speed and quality of movement will be prioritized over load as the focus on ballistic movement is necessary for running. 7b. How program was progressed: The program incorporates a series of hierarchically challenging activities. [See Williams & Schache 2010 and Schache et al. 2014 for more detail on the activities]. Participants will be prescribed relevant activities to address the running gait impairments demonstrated for that individual. The individually tailored exercises will be derived by the therapist viewing slow motion observational sagittal and frontal video footage of the participant’s running gait and determining the abnormalities affecting the acquisition of typical running skill. The exercises/activities will target the three main muscle groups responsible for forward progression when walking and running, i.e. the ankle plantar flexors, hip flexors and hip extensors. Exercises will be progressed once good form/technique is demonstrated on the starting activity. The exercises may be performed on the trampette until the participant is able to perform the exercises overground. For simulation of leg turnover and appropriate foot contact alignment an activity termed the “claw” exercise will be utilized [See Williams & Schache 2010 and Schache et al., 2014 for more detail]. For participants whose motor control does not enable good technique, activities such as the “claw” will either be broken down into components, or facilitated with therapist handling until the participant is able to perform a cycle with good technique. This will be progressed by decreasing therapist facilitation and eventually adding resistance (for e.g., with resistance bands). Once the participant can run with good technique overground, slopes may be added, and the distance or speed increased depending on the individual goal. From slopes, participants progress to agility exercises. These began with simple cutting/side stepping exercises and progress in complexity. Once a reasonable level of agility is attained, sport specific skills relevant to the individual participant’s interest may be introduced. 8. Exercises: Please refer to Williams & Schache 2010 and Schache et al. 2014 for the types of exercises utilized to address different running impairments. Examples of exercises which may be used include: alternating feet on trampette, alternating feet with a knee lift on trampette, jumping, hopping, fast feet overground, fast feet with a knee lift, triple extension, skipping, running. Each session will utilise the following structure: 1 Warm-up: 5 min 2 Individualized exercises/activities: 45 min 3 Cool down: 5 min 4. Provision of home program: 5 min 9. Home program: All participants will receive a home program to be performed three times per week for approximately 15 minutes, which contains individually tailored exercises that have been learnt with the PTs and which they can perform independently with good technique. 10. Non-exercise components N/A 11. Type and number of adverse events: Adverse events will be recorded and followed up as per the protocol. 12. Setting: A community paediatric allied health clinic with outdoor grassed area and access to exercise equipment. 13. Exercise intervention: Participants are asked to attend one one-hour session per week with the home program performed another three times per week, for a total of 10 weeks. 14a. Generic/tailored: Each participant will receive an individually tailored program based on a core group of hierarchical exercises 14b. How the exercises are tailored: The exercises will be tailored for each participant according to the identified impairments impacting their running skill and by level of difficulty. The PTs will progress the exercises according to the participant’s response. Adjunct exercises will be added by the PTs if necessary, for example hip abductor strengthening exercises may be added if the participant cannot stabilize the pelvis while performing the exercises. 15. Decision rule for starting level: Participants will be started at the most challenging level they can perform with good technique. 16a. Adherence/fidelity: PTs will meet for 10 min following each session to discuss issues experienced by individuals in the group and find solutions.