Division Division of of Physiotherapy STANDING WITH WITH AND AND WITHOUT VIBRATION IN IN CHILDREN WITH SEVERE CEREBRAL PALSY

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1 From From the the Department of of Neurobiology, Care Care Sciences Sciences and and Society, Society, Division Division of of Physiotherapy Karolinska Karolinska Institutet, Institutet, Stockholm, Sweden Sweden STANDING WITH WITH AND AND WITHOUT VIBRATION IN IN CHILDREN WITH SEVERE CEREBRAL PALSY Ylva Ylva Dalén Dalén Stockholm Stockholm

2 The published paper was reproduced with kind permission from the publisher. Ylva Dalén 2011 ISBN Printed by Reproprint AB Printed by 2011 Gårdsvägen 4, Solna

3 ABSTRACT Children with severe cerebral palsy (CP) risk fragile bones, fractures and hip dislocation due to disuse. A standing shell allows these children weight bearing in an upright position. Recommended standing time is one to two hours/day but evaluations are lacking. The aim of Study I was to assess the effects of time spent in the standing shell on bone mineral density (BMD) and hip dislocation. A cross-sectional design was used. Eighteen children with severe CP median age 10.5 years, modified Ashworth score (MAS) 0-1 (n=7) and 2-4 (n=11) participated. The standing shell was used a median of 40 (4-164) min/day. DEXA measurements of BMD in the lumbar spine were 73% of age-matched children. X-ray of the hips showed a migration index of 27 (0-52) % in the most dislocated hip. Standing time was not associated with BMD but in the eleven children with spasticity standing time was significantly and negatively associated with hip dislocation. The aim of Study II was to evaluate the effects of a unique platform using whole body vibration (WBV) on bone mineral content (BMC), to note the reactions of the children and to record any negative side-effects. A modified cross-over experimental design was used. Four boys with severe CP, median age 4 years, Insulin-like growth factor-i standard deviation score (IGF-I SDS) median -0.42µg/L, participated. Two boys used the platform for 8/9 months and two were controls (period I). After one year of no use, users and controls exchanged roles (period II). The boys in period I were exposed to vibration a median of 2.5 (range 1-6) occasions/month with a median of 12.5 (3-23) min/occasion. IGF-I SDS differed from baseline to end of period I in children exposed to vibration 1.8/1.0 in contrast to not exposed -0.1/0.9 µg/l. BMC in one leg differed 8.9/-4.3 and -3.2/-5.1g, respectively. The boys in period II were exposed a median of 6.5 (range 1-12) occasions/month 10 (6-10) min/occasion. IGF-I SDS differed from baseline to end of period II in children exposed to vibration -0.7/1.6 in contrast to not exposed -1.0/-0.2 µg/l. BMC in one leg differed 13.7/16.3 and 9.9/3.9g, respectively. No negative side-effects were recorded. Conclusion: Time spent in the standing shell alone may not influence bone mineral density in children with severe cerebral palsy and may even have a negative effect on hip dislocation in children with spasticity. Standing in the standing shell on a platform with whole body vibration may be an effective and enjoyable method to increase bone mineral content in children with severe cerebral palsy.

4 LIST OF ABBREVIATIONS AI BMC BMD BMI CP CPUP DEXA G GMFCS GMFM Hz IGF-I MAS MI RMS SD SDS SQRT WBV Acetabular index Bone mineral content Bone mineral density Body mass index Cerebral palsy The Swedish National Health Care Quality Program for prevention of hip dislocation and severe contractures in Cerebral Palsy Dual energy x-ray absorptiometry Gravitation force Gross motor classification system Gross motor function measurement Hertz Insulin like growth factor I Modified Ashworth scale Migration index Root mean square Standard deviation Standard deviation score Square root transformation Whole body vibration

5 LIST OF PUBLICATIONS STUDY I Dalén Y, Sääf M, Ringertz H, Klefbeck B, Mattsson E, Haglund-Åkerlind Y. Effects of standing on bone density and hip dislocation in children with severe cerebral palsy. Advances in Physiotherapy 2010; 12: STUDY II Dalén Y, Sääf M, Nyrén S, Mattsson E, Haglund-Åkerlind Y, Klefbeck B. Effects of standing on a unique vibrating platform on bone mineral content in four boys with severe cerebral palsy. In manuscript. Study I is reproduced by kind permission from Informa Healthcare.

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7 CONTENTS BACKGROUND 1 INTRODUCTION 2 CEREBRAL PALSY 3 SPASTICITY 3 HIP DISLOCATION 5 OSTEOPOROSIS 6 PREVENTION and TREATMENT OF OSTEOPOROSIS IN CP 8 Nutrition 8 Orthopaedic interventions 8 Pharmacologic interventions 8 Physiotherapy 8 VIBRATION 10 THE VIBRATING PLATFORM 12 AIMS 14 METHODS 14 DESIGN 14 PARTICIPANTS 14 STATISTICS 17 RESULTS 18 STUDY I 18 STUDY II 19 DISCUSSION 20 CONCLUSION 25 CLINICAL IMPLICATIONS 25 ACKNOWLEDGEMENTS 26 REFERENCES 28 APPENDIX

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9 BACKGROUND In clinical practice working as a physiotherapist among children with disabilities, I experienced a non-violent fracture in a child with severe cerebral palsy (CP). That experience made me aware of the fact that these children can develop a fragile skeleton over time, partly due to disuse, because children with severe CP cannot attain an upright position or run and jump like other children. A standing shell is commonly used in Sweden to allow children with severe CP to attain an upright position. One aim of this is to prevent osteoporosis, and the recommended time in the standing shell is one to two hours daily. This recommended time is often hard to achieve in clinical practice, because even though the children often like to be in an upright position, they seldom want to stand strapped in a standing shell for such a long time. Through additional studies in special pedagogy I learned the importance of giving the children an opportunity to influence their own activity and increase their cognitive development through action, especially through acts that demonstrate cause and effect. I found no studies to support the hypothesis that standing in a standing shell for one or two hours would increase bone density, and I wanted to find out whether it would. I also wanted to make standing in a standing shell more effective and enjoyable for the children. 1

10 INTRODUCTION Physical activity and movement, the importance of which have been recognized since before the time of Aristotle ( BCE), are greatly restricted in children with severe CP; this in turn limits these children s abilities to interact with their environment. Interaction with the environment was first elaborated by Plato ( BCE) as the primary cause of development in the child. Plato conceptualized the child as an inquiring explorer whose motivation for learning and development was primarily internal. The educationalists Lev Vygotskij ( ) and Jean Piaget ( ) agreed with this view. Piaget (Wadsworth, 2004) wrote, It is obvious that the teacher as organizer remains indispensable in order to create the situations and construct the initial devices which present useful problems to the child ; these problems, he theorized, fuel the processes of invention or construction which occur inside the mind of the individual. In addition to having restricted movement, many children with severe CP cannot express themselves through speech. According to Wadsworth (2004), although language contributes to intellectual advancement, it is not absolutely necessary, and action is another way to achieve a higher intellectual level. Children with severe CP need more and better opportunities to be active and to explore cause and effect in order to improve and expand their cognitive development. Independent transfer has been considered the most important factor in communication skills and cognitive development (Granlund and Olsson, 1988). Spasticity in different forms and weak muscles may prevent normal voluntary movements and may also lead to deficient postural control, making it difficult for the children to attain an upright position and dynamic weight-bearing on the skeleton. Lack of dynamic weight-bearing and insufficient nutrition are two important factors that make children with severe CP prone to fractures, some of which occur spontaneously as a result of fragile bones (Stevenson et al., 2006, Maruyama et al., 2010). The importance of weight-bearing for the skeleton is shown by the postnatal adaptation of the skeleton to the environment outside the womb, in which the femoral diaphysis decreases volumetrically by about 30% during the first six months, probably because the baby is no longer kicking the inside of the uterus and thus no longer engaging in frequent resistant training (Rauch and Schoenau, 2001). 2

11 CEREBRAL PALSY CP is the most common cause of severe physical disability in childhood, and the prevalence of CP in the western world is reported to be between 2 to 3 per 1000 live births (Surveillance of Cerebral Palsy in Europe (SCPE), 2000). CP is defined as a group of permanent, but not unchanging, disorders of movement and/or posture and of motor function, which are due to a nonprogressive interference, lesion, or abnormality of the developing/immature brain (SCPE 2000). CP is caused by a lesion in the brain right before, during, or right after the birth. Depending on the origin of the lesion, whether the origin is the basal ganglia, cerebellum, cerebral cortex, brainstem, or descending spinal tracts, the symptoms of the consequential motor disorder vary greatly. The Gross Motor Function Classification System (GMFCS) is commonly used in clinical practice to assess motor function and classify children accordingly (Palisano et al., 1997). It is a classification derived from the Gross Motor Function Measurement (GMFM), a clinical measure designed to evaluate change in gross motor function in children with CP, developed by Palisano et al. (1997). GMFCS was tested for reliability and stability over time by Wood and Rosenbaum (2000). They found that GMFCS can validly predict motor function for children with CP. GMFCS uses a 5-level scale, with levels I (least severe) to V (most severe), that classifies the gross motor function of children and youth with CP on the basis of their self-initiated movement, with particular emphasis on sitting, walking, and wheeled mobility. The purpose of GMFCS is to classify a child s present gross motor function, not to judge quality of movement or potential for improvement. It describes the need for use of assistive devices and how the child functions in his regular environment (Palisano et al., 1997). SPASTICITY Spasticity is a common feature of CP, more prevalent in more severe forms of CP, which can be increased by anxiety, emotional state, pain, surface contact, or other sensory input. Spasticity is hypertonia in which one or both of the following signs are present: Resistance to externally imposed movement increases with increasing speed of stretch and varies with the direction of joint movement, and/or Resistance to externally imposed movement rises rapidly above a threshold speed or joint angle (spastic catch). (Sanger et al., 2003). 3

12 Spasticity is complex; children with CP often have a combination of multiple symptoms and clinical signs that contribute to their disability, so there is a need for definitions that take a broader perspective. Sanger et al. (2003), contributed with additional definitions that were developed at the National Institutes of Health in April 2001: Dystonia: A movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures or both. Rigidity: Hypertonia in which all of the following are true: The resistance to externally imposed joint movement is present at very low speeds of movement, does not depend on imposed speed and does not exhibit a speed or angle threshold Simultaneous co-contraction of agonists and antagonists may occur and this is reflected in an immediate resistance to a reversal of the direction of movement about a joint The limb does not tend to return toward a particular fixed posture or extreme joint angle Voluntary activity in distant muscle groups does not lead to involuntary movements about the rigid joints, although rigidity may worsen. Because the variety of symptoms differs from child to child, clinical assessment of spasticity is difficult to standardize. The Modified Ashworth Scale (MAS) is commonly used in clinical practice to assess spasticity (Peacock and Staudt, 1991). It grades the resistance encountered in a specific muscle group by means of passively moving one limb of a child in supine position through its range of motion at a non-specified velocity. The MAS scores are as follows: 0 = hypotonic, less than normal muscle tone, floppy; 1 = normal, no increase in muscle tone; 2 = mild, slight increase in tone, catch in limb movement, or minimal resistance to movement through less than half the range; 3 = moderate, more marked increase in tone through most of the range of motion, but affected part is easily moved; 4 = severe, considerable increase in tone, passive movement difficult; 5 = extreme, affected part rigid in flexion or extension (Peacock and Staudt, 1991). The MAS was found to be reliable by Ghotbi et al. (2009). To decrease spasticity, injections with Botulinum toxin in spastic muscles and intrathecal Baclofen are frequently used. The Botulinum toxin distributions need to be repeated every 3 6 months. 4

13 HIP DISLOCATION The hip joint consists of the head of the femur and the acetabular roof of the pelvis. When the head of the femur migrates in a lateral direction out of the socket, it is called hip subluxation. A manifest luxation is considered present when the migration exceeds 80% (Eklöf et al., 1988). Hip X-ray and assessment of the hip migration index (MI) (Reimers, 1980) are common in clinical practice and reported to be sufficient in screening for dislocation in children with CP (Fig. 1). An MI up to 16% in children under four years of age and an MI up to 24% in children 12 years of age or over is considered normal; higher figures represent subluxation. An MI of 33% is the cut-off point for initiating treatment in Sweden (Hägglund et al., 2007a). This means that 33% of the caput femoris is not covered by the acetabular roof of the pelvis. Acetabular index (AI) is another common index used to assess hip dislocation (Fig. 1). Since lateral dislocation of the femoral head is common without acetabular dysplasia and since acetabular dysplasia occurs later than the lateral dislocation, MI seems to be the most useful measurement when evaluating hip dislocation in children with CP (Hägglund et al., 2007a). Fig.1. Measurement of acetabular index (AI) and migration index (MI=A/B 100). Published with permission from the Swedish National Health Care Quality Program for prevention of hip dislocation and severe contractures in cerebral palsy (CPUP). Children with CP are born with a normal hip joint, but the natural history of hip development showed that 46% of children not walking independently had one or both hips subluxated or had treatment for their hips by the age of five years (Scrutton et al., 2001). Hip dislocation can start when children are as young as two years of age and is reported more severe for children in GMFCS V. The risk for an MI over 40% has been reported in 64% of children classified as GMFCS V (Hägglund et al., 2007b). 5

14 OSTEOPOROSIS Bone is living tissue that adjusts to its environment. There are three major cell types that provide adaptation through bone turnover: osteoblasts (form bone), osteoclasts (resorb bone), and osteocytes (load sensitive mechanostats ). Bone cells react to the hormonal and nutritional situation and also to mechanical loading/weight bearing. Bone also consists of two different macroscopic tissues: trabecular bone (the vertebrae) and cortical bone (the long bones). The human body consists of up to 20% trabecular bone, where turnover is faster and thus more quickly influenced by hormones, for example in the vertebrae. Rubin et al. (2006) showed in sheep that cortical bone, for example the long bones of the legs, are influenced by mechanical stimuli such as vibration (Fig. 2). The natural history of gain in bone mineral density (BMD) in children with CP is important to understand when discussing changes in BMD over time. A prospective study over two to three years with 69 subjects with CP concluded that children with severe CP developed osteoporosis over the course of their lives. They did not lose bone mineral, but compared to agematched children without disabilities (z-score), BMD increased much less (Henderson et al., 2005). Fig.2. Three-dimensional reconstructions of trabecular bone from the distal femur in control sheep (left) as compared with the same region of experimental sheep (right), which had been subjected to vibrations for 20 minutes/day of a low-level (0.3G), high-frequency (30 Hz) mechanical signal. The experimental bones have improved connectivity and enhanced bone volume fraction, and they are stiffer and stronger than the control bone. Printed with permission from the author (Rubin et al., 2006). 6

15 Children with CP are born with a normal skeleton, but as they grow older and are unable to walk, run, and jump like other children, the skeleton turns fragile and the risk for fractures increases (Henderson et al., 2002, Stevenson et al., 2006). Spasticity also induces mechanical forces on the proximal femur, which can give rise to bone deformities such as acetabular malformations that facilitate hip dislocation (Shefelbine and Carter, 2004). Many of the children who sustain a fracture will sustain repeated fractures, most commonly in the femur (Henderson 1997, Presedo et al., 2007, Maruyama et al., 2010). The reason for the fracture is sometimes unknown; fractures can occur spontaneously, contributing to great pain and suffering, and the fracture diagnosis is often delayed (Presedo et al., 2007, Maruyama et al., 2010). The risk of fracture is reported highest in non-ambulatory children with anticonvulsant medication, lower triceps skinfold z-score, and a prior history of fracture (Henderson et al., 2002, Presedo et al., 2007). The diagnoses Osteoporosis in children and adolescents requires the presence of both a clinically significant fracture history and low bone mineral content (BMC) g or BMD g/cm 2 according to Rauch et al. (2008). Rauch et al. (2008) also recommended that the diagnosis should not be made on the basis of densitometry criteria alone, as in the adult population, and further define osteoporosis as: A clinically significant fracture history is one or more of the following: Long bone fracture of the lower extremities Vertebral compression fracture Two or more long-bone fractures of the upper extremities Low BMC or BMD is defined as a BMC or areal BMD z-score that is less than or equal to -2.0, adjusted for age, gender and body size, as appropriate (Rauch et al., 2008). Due to the increased risk of fractures in children who lack dynamic weightbearing on their skeleton, measurements of bone mass in children are becoming more frequent. Dual-energy X-ray absorptiometry (DEXA) is the most commonly employed technique for bone mass determinations. The radiation dose is low, and precision and accuracy are high. Body composition, BMD, and BMC can all be derived from DEXA. BMC is considered better to use for prospective measurements in children, since growth of the skeleton is taken under consideration. Because the beam in BMD measurements needs to pass further through large bone, it can falsely seem to indicate higher bone density in the large bone. The effect can be illustrated by two different-sized 7

16 bottles placed in the sunshine: the larger bottle will cast a darker shadow even if the two bottles contain the same amount of liquid (Rauch and Schoenau, 2001). Lately, there have been discussions about whether or not BMD measurements by DEXA are accurate and reliable in trabecular bone, considering the presence of both absorptiometrically disparate intra-osseous bone marrow and the extra-osseous mixture of fat and lean soft tissues. In cortical bone, the measurements would seem to be more reliable (Bolotin, 2007). PREVENTION and TREATMENT OF OSTEOPOROSIS IN CP Nutrition Children with severe CP have difficulty eating and swallowing, mostly due to abnormal muscle tone. It is therefore often difficult for them to consume sufficient nutrients, and malnourishment and growth failure are common in children with severe CP (Thommessen, 1991). This is more an effect of the low quantity of food they are able to ingest, rather than the quality of food they eat (Sullivan et al., 2002). Analysis of insulin-like growth factor-i (IGF- I) levels in the blood can indicate whether a child has a sufficient nutrition. Circulating IGF-I is mainly produced in the liver, and normal levels depend on both nutrition and growth hormone secretion (Thissen et al., 1999). Individual nutritional assessment and management is important in the overall care of children with CP. Orthopaedic interventions Orthopaedic interventions aim at improving the functional ability of the child, and include surgery and orthotic devices. Surgical preventive actions include muscle prolongation, selective dorsal rhizotomy, and osteotomies, however, the reoperation rate can be over 50% in children with severe CP (Shefelbine and Carter, 2004). Pharmacologic interventions In Sweden, to our knowledge, pharmaceuticals to increase bone density are not used for children with severe CP; there are, however, reports from other countries about the effect of osteoporosis-specific drugs in children with CP (Bachrach et al., 2010). Physiotherapy Physiotherapy aims to prevent impairment and activity limitation. Postural management equipment and orthotics are often used for positioning in standing, sitting, and lying, to encourage active movement, maintain muscle 8

17 length, control or prevent deformity, and increase function. The sorts of aerobic exercise that create cardiovascular and musculoskeletal fitness in other children cannot be offered to children with severe CP. Creating methods to make physical activity available to children with severe disabilities is a challenge for the future and is in line with Articles 6, 23, and 24 of the United Nations Convention on the Rights of the Child (1989). In the 1980s a multidisciplinary team consisting of a physiotherapist, an orthopaedic surgeon, and orthopaedic engineers in Uppsala, Sweden, developed a standing shell (Fig. 3) to allow children with severe disabilities to be placed in a maintainable upright position. It is mainly prescribed by orthopaedic surgeons, often on the request of a physiotherapist. The aim of the standing shell is to create the optimal alignment of body segments in the individual child: to allow weight-bearing in an upright position in order to increase bone density and prevent hip dislocation and contractures to vary the body position, and to facilitate postural control in children with severe disabilities (Ölund, 2003). A unique standing shell for the individual child is produced by orthopaedic engineers in an orthopaedic workshop. Symptoms in children with severe CP vary greatly by type and severity, so the orthopaedic engineer starts by noting the child s contractures and spasticity. After that, a plaster cast is formed around the legs and back of the child. A sheet of polyethylene plastic, 4 mm to 10 mm thick depending on the need for stability, is then heated, formed, and adjusted to the cast. The orthopaedic engineer then manually evaluates the child s weight-bearing in the standing shell in order to make adjustments and add the necessary fittings for optimal alignment and weight-bearing. The standing shell is fastened in front with straps. As the child grows, the legs of the standing shell are commonly lengthened and a complete new standing shell is needed about once a year as long as the child grows. In addition to any orthopaedic results, the standing shell provides the child with access to dining and work tables, eye contact with peers, and a variety of social and personal benefits. 9

18 a. b. c. Fig. 3. Three individually moulded standing shells shown from different angles: from posterior position (a and c) and from lateral position (b). One standing shell (c) includes a neck support. Handles to be used by caregivers when moving the child in the standing shell are shown in pictures a and c. The black bars between the legs secure stability. Decorative patterns on the standing shell are chosen by the child and/ /or the parents. The recommended standing time varies from one to two hours (Ölund, 2003). There is no published study to our knowledge exploring whether time spent in the standing shelll has an effect on bone mass or hip dislocation. Children seem to enjoy the upright position, but for many children being strapped in a standing shell for up to two hours per day may be a difficult goal to achieve. VIBRATION Weight-bearing is static in a person standing still, but becomes dynamic with the addition of a force (as in jumping), measurable by Newtons (N; 1 N = the power required to accelerate a mass of 1 kg by 1 m/s 2 ). Whole body vibration (WBV) can cause dynamic weight-bearing in the skeleton of a standing subject. Vibration is the rapid linear motion of a particle or of an elastic solid about an equilibrium position. Frequency refers to the number of cycles (or waves) that a vibrating object completes in one second. The unit of frequency is hertz (Hz). A complete cycle of vibration occurs when the object moves from one extreme position to the other extreme (peak-to-peak). Amplitude is the maximumm excursion of the wave from the zero or equilibrium point. The intensity of vibration depends on its amplitude. 10

19 Peak-to-peak displacement is the distance from a negative peak to a positive peak. If the waveform is symmetrical, the value is exactly twice the value of the peak amplitude (Fig.4). Amplitude Peak-to-peak displacement Time Fig.4. One cycle of vibration. Amplitude and peak-to-peak displacement are shown. The speed or velocity of a vibrating object varies from zero to maximum during each cycle of vibration. It moves fastest as it passes through its natural stationary (zero) position to an extreme position. The vibrating object slows down as it approaches the extreme, where it stops, and then moves in the opposite direction, through the stationary position toward the other extreme. Speed of vibration is expressed in units of metres per second (m/s). Acceleration is a measure of how quickly speed changes with time. The unit of acceleration is metres per second squared (m/s 2 ). A heavy object standing on a vibrating platform will have smaller accelerations compared to a lighter object since its amplitude will be smaller due to its heavier weight. If the motors have constant amplitude, the acceleration will increase with weight. Gravity and Gravitational force (G) are similar concepts that could lead to confusion. Gravity describes the attractive force that exists between earth or any celestial body and any object. The unit G describes the acceleration imposed on a person during occasions of dynamic weight-bearing such as vibrations or acceleration. One G equals 9.81m/s 2. Root Mean Square amplitude (RMS) is the square root of the average of the squared values of the waveform. In the case of the sine wave, the RMS value 11

20 is times the peak value. RMS values are important when discussing power or energy imposed on a human standing on a vibrating platform since it reflects the mean power of platform acceleration. There are many ways to describe vibrations in research and the descriptions are inconsistent among different studies of WBV exercise. Lorenzen et al. (2009) propose that a standardized terminology including peak-to-peak displacement (mm), frequency (Hz), maximum acceleration (m/s 2 ), and how the maximum acceleration was determined should be used in future WBV research to allow between-study comparisons. THE VIBRATING PLATFORM To motivate the children in the standing shell, give them a tool to explore cause and effect, and make dynamic loading enjoyable, a vibration platform with additional functions was constructed (Fig. 5). The child in a standing shell was placed on the platform and securely fastened. At the touch of colourful buttons, the child could induce vibrations, raising and lowering, and 90-degree turns to the left and right. The platform remained stationary unless the child pressed the buttons. Fig.5. The vibrating platform with a standing shell. Frequency-weighted acceleration measures vibration accelerations at different frequencies to correspond to human vibration sensitivity and is used to calculate the vibration dose imposed on the individual human body. Because vibration dose is dependent on the weight of the user, to ensure that the vibration dose for children using the platform was within the limits of the 12

21 European directives, two girls without disabilities, both aged eight years, the first weighing 26.5 kg and the second 37.5 kg, used the platform with a frequency of 50 Hz for ten minutes. The frequency-weighted acceleration dose measured with HealthVib (CVK AB, Aurorum Science Park 1C, Luleå, Sweden) after 10 minutes was 1.71 m/s 2 for the first girl and 1.60 m/s 2 for the second. Converted to an eight-hour period (a working day), the doses were 0.25 and 0.23 m/s 2, well within the limit of 0.50 m/s 2 set by EU directive 2002/44/EG and SS-ISO (see Table 1 and Appendix). Permission was given by the parents of the girls. Table 1. Maximal acceleration measured as gravitation force (G), metre/second squared (m/s 2 ), and root mean square (RMS) of the amplitude value over time in the platform when unloaded. Frequency G m/s 2 RMS To assess the figures in Table 1, the Vibro Scanner (NetterVibration, Fritz-Ullmann-Straße 9, Mainz-Kastel, Germany) was used. The new vibrating platform was intended to give the children an opportunity to promote their bone density while playing and having fun. However, it was not known whether use of the vibrating platform would influence BMC or hip dislocation in children with severe CP or whether the children would tolerate the generated movements and sounds. 13

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