Influence of Aerobic Exercise on Inhibitory Control of Excutive Function in Spastic Hemiplegic Cerebral Palsy: A Randomized Controlled Trail
Phase: NA
Conditions: Spastic Hemiplegic Cerebral Palsy
Sponsor: South Valley University

Official Title of Study: - 
 
INFLUENCE OF AEROBIC EXERCISE ON 
INHIBITORY CONTROL OF EXCUTIVE 
FUNCTION IN SPASTIC HEMIPLEGIC 
CEREBRAL PALSY: A Randomized 
Controlled Trail 
 
 
 
 
 
 
 
 
 
 
Document Date: - 27/11/2019. 
 
 
 
 
 
Human Subjects protection review board 
approval date: - 31/03/2019 

INFLUENCE OF AEROBIC EXERCISE ON INHIBITORY CONTROL 
OF EXCUTIVE FUNCTION IN SPASTIC HEMIPLEGIC CEREBRAL 
PALSY: A Randomized Controlled Trail 
Abstract 
Background: Inhibitory control of executive functions is one of the main specific 
cognitive impairments that affect children with cerebral palsy, cognitive skills begin 
to develop in infancy and continue till adolescence it changes across the lifespan of an 
individual and has great effect on their participation and quality of life. Aim: To 
investigate the influence of aerobic exercise on inhibitory control of executive 
functions in spastic hemiplegic cerebral palsy. Methods: Sixty children with spastic 
hemiplegic cerebral palsy were enrolled in this study and were assessed for eligibility. 
Their aged ranged from seven and eleven. Children were assigned randomly into two 
equal groups. Group (A) received AE in addition to selected physical therapy program 
and (B) treated with same selected physical therapy program only. The treatment was 
conducted for one hour, three times / weak for three successful months. Eriksen 
flanker test and Stroop Color-Word test were used to assess inhibitory control of EF 
pre and post treatment. Results: Post treatment there was significant increase in 
accuracy in Eriksen flanker test and Stroop Color-Word test and decrease in reaction 
time (congruent and incongruent) only in study group, P< 0.05. Conclusion: Aerobic 
Exercises has significant effect on inhibitory control of executive functions in spastic 
hemiplegic cerebral palsy.  
Key words:  Hemiplegic cerebral palsy, inhibitory control of executive functions and 
aerobic exercise. 
Implication and contribution: - 
           This article discuss how aerobic exercise improve inhibitory control of 
executive function which showed as significant increasing in Flanker/Stroop test 
accuracy and a significant decreasing in FRTc, FRTic, SRTc and SRTic only in study 
group this improvement will has great effect on children participation, social 
interactions  and there quality of life. 
 

Introduction: 
           Cerebral palsy (CP) is permanent disorders of developing movement and 
posture which led to reduced activity. It is the most common cause of physical 
disability that refers to non-progressive neurological condition occurs in infant brain 
[1]. Motor impairment frequently is secondary disturbances as communication, 
presence of epilepsy [2], and secondary musculoskeletal problems [3].Hemiplegic CP 
is a subtype in which one side of the body is involved. It affects about 1 in 1,300 live 
births [4]. It is characterized by a clinical pattern of unilateral motor impairment [5]. 
Severity motor impairment depends on the site and severity of brain [6].Early injury 
in brain had concomitantly on motor, function and cognitive [7].Cognitive ability is a 
mental process of acquiring knowledge and understanding through acquired 
knowledge and experience [8]. 
          Executive function (EF) is comprise distinct yet highly interrelated components 
as cognitive flexibility [9].Because EF involved in arrangement of action and 
behavioral aspect of EF [10], such difficulty initiating new non routine actions, and a 
lack of impulse control [11].EF received considerable interest and are strong 
predictors of children`s early school success and it includes intentional 
shifting/flexibility, working memory, and inhibitory control [12]. 
Inhibitory control is separable cognitive process by comprise construct of 
executive function and emerge only in middle to late childhood, with improvements 
ability to execute complex [13].  
Aerobic exercise (AE) improves oxygen consumption by the body. Which 
consider activity uses large muscles. AE interpretation is continuous and rhythmic 
process led to heart and lungs work better [14].AE create changes and increase in 
oxygen saturation and cerebral blood flow [15]. AE training increase cerebral 
perfusion[16],metabolism [17], reduce in Aβ load [18], up-regulation of 
neurotrophins [17], and hippocampal neurogenesis [19].Exercises provide rise of 
serum calcium and might transport to activate rate limiting enzyme for catecholamine 
synthesis. Nor epinephrine and dopamine are neurotransmitters [20].AE is an efficient 
strategy to positively influence executive control during [21], and after exercise [22]. 
 

Subjects and methods: 
          A pretest-posttest randomized controlled study conducted in outpatient clinic in 
Faculty of Physical Therapy, Cairo University. Informed consent was provided for 
each child from their parents. The procedures followed were in accordance with the 
Institutional Ethical Committee Clearance of the Faculty of Physical Therapy Cairo 
University No: P.T. REC/012/002278. The study was registered on Clinicaltrial.gov 
and registration number was NCT04154566. 
Subjects: Sixty children with spastic hemiplegic cerebral palsy were enrolled in this 
study and were assessed for eligibility. Their aged ranged from seven and eleven 
years, they were from both sexes, they have left side hemiplegic cerebral palsy and 
they were able to walk independently. All children were selected with score 28 or 
more according to pediatric symptom chick list that suggest presence of significance 
behavior and emotional problems. We excluded children with visual or auditory 
problems, children with history of drug intake that may affect the cognitive function, 
medically unstable children especially with cardiovascular disorders and 
uncooperative children. 
           Children assigned randomly into 2 equal groups. Group (A) study who 
received aerobic exercise in addition to selected physical therapy program. Group (B) 
control who received selected physical therapy program only. The treatment was 
conducted one hour, three times / weak for three successful months. 
Materials for evaluation: 
          Eriksen Flanker test and Stroop Color-Word test were used to assess inhibitory 
control of EF pre and after treatment.  
1) Eriksen Flanker Test has been widely examined inhibitory aspect of 
executive function [23]. The Flanker task consisted of 20 trials consisted of 2 
trials with congruent reaction time (FRTc) or incongruent reaction time 
(FRTic) to certain visual stimuli. Congruent is a horizontally arranged array of 
arrows presented in the same direction. Incongruent trial have similar array of 
arrows, but the middle arrow displayed in the opposite direction. Children 
respond to direction of arrows by press RT or LT finger button quickly and 
accurately. 

2) Stroop Color-Word Test using word color to measure selective attention and 
cognitive flexibility and  most described measured to individual’s capability to 
shift cognitive set [24]; to  measure of cognitive inhibition or inhibit an over 
learned in favor one. Colors names illustrated and printed in conflicting ink 
and participants asked to respond the name and color of ink more word by 
pressing corresponding first letter for color if red press(r) button if yellow 
press (y) button if orange press (o) button if purple press (p) button if green 
press (g) button if blue press (b) button as quickly and accurately as possible. 
The Stroop test divided to 20 trials (two trial types) with normal congruent 
(SRTc) or incongruent reaction (SRTic) to certain visual. Normal trial was 
when color of the ink is the same color of the word and interfere trial the color 
of the ink not the same as the color of word. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Flow chart 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig 1, flow chart 
 
Methods of Treatment  
           Group (A) which is the study group received 20 min. selected physical therapy 
program which contain strengthening exercises for upper limb and lower limb 
muscles,  stretching exercises for elbow extensors, hand supinator, wrist extensors, 
knee extensors and ankle dorsiflexors, balancing exercises, coordination exercises and 
Assessed for 
eligibility (n= 66)
 
Randomized 
(n=60)
 
Allocation 
Allocated to intervention (n=30)  
 Received allocated intervention (n=30)  
 Did not receive allocated intervention (give 
reasons) (n= 0 ) 
Allocated to intervention (n=30)  
 Received allocated intervention (n= 30 ) 
 Did not receive allocated intervention (give 
reasons) (n=0 ) 
Excluded (n=6)  
 Not meeting inclusion criteria 
(n=3)  
 Declined to participate (n=3)  
 Other reasons (n= 0)
 
Analysis
 
 
Analysis
 
 
Analyzed (n=30)
 
 Excluded from analysis 
(n=0)
 
Analyzed (n=30)
 
 Excluded from analysis 
(n=0)
 

gait training exercises in open environment. In addition to aerobic exercise on a 
bicycle ergometer for 40 min. Bicycle ergometer (Monark Rehab trainer model 
88E) was used to train children in study group. It is a stationary bicycle with an 
ergometer (electronically braked) to measure the work done by the exerciser. Which 
equipped with electronic meter illustrated pedal revolutions/min, pedal revolutions 
and time function. It provides low-gain, safe, and effective cardiovascular exercise. 
This low-impact movement does not put much stress on joints.  
           Before starting the training procedure each child was instructed to wear 
comfortable training suit and shoes and to sit vertically on the bicycle ergometer seat 
with erect back. Extra strap was placed on child's feet to provide complete fixation on 
ergometer pedal. The exercise on bicycle was done under supervision of researcher to 
ensure correct and accurate application. 
           In the first week, children bicycled to tolerance at 40% to 50% max HR, and to 
70% max HR in second week. AE Intensity was systematically increased for child to 
keep conditioning at 70%.max HR, (max HR =220-age) [25].First five min of each 
session dedicated to warming up exercise on bicycle in the form of slow increasing 
followed by active phase of exercise for 30 min., and cooling down for five min. with 
intensity and speed reduced gradually till resting heart rate [26]. 
           Group (B) which was exposed only to same physical therapy program for one 
hour. Treatment was conducted one hour, three times / weak for three successful 
months. 
Statistical analysis  
For analysis of data in the present study, SPSS software version 21 used for 
analysis data. Descriptive statistics was used to identify the mean and standard 
deviation for each variable. Chi-square test was used to compare number and 
percentage of sex distribution between both groups. Paired t-test was used to compare 
variables pre and post –treatment within group. Unpaired t-test used determined 
variables pre and post -treatment between both groups. P- Value ≤ 0.05 was 
considered significant (P ≤ 0.05).   
 

Results: 
Child`s general characteristics: 
The characteristic of children represented in (Table 1). There was no 
significant observation among different groups belong to age, grade and sex 
distribution. 
Table (1): Characteristics of children: 
 
Study group (GA) 
Control group (GB) 
P-value 
Age (years) 
9.77±1.135 
9.2±1.243 
0.0703 
Gender (N. (%)) 
Male 
21 (70%) 
17 (56.7%) 
0.2839 
Female 
9 (30%) 
13 (43.3%) 
Grade (years) 
4.77±1.135 
4.2±1.243 
0.0703 
Flanker test: 
Comparison of the mean values of (Flanker test accuracy, FRTc and FRTic) 
between both groups pre-treatment revealed no significant difference. Post- treatment; 
significant increasing was noted in Flanker test accuracy and a significant decreasing 
in FRTc and FRTic only in study group. The percent of improvement were (21.9%. 
25.91% and 22.44%) respectively (Table 2). 
Table (2): Intra- and inter-group comparison between mean values of Flanker 
test variables pre and post treatment in both groups: 
 
Flanker test 
Pre-treatment 
(Mean± SD) 
Post-treatment 
(Mean± SD) 
P- value 
Flanker test 
accuracy  
Study  
73.83± 10.4 
90± 10.91 
0.0001** 
Control 
78.5± 11.9 
82± 10.88 
0.0589 
P 
0.1112 
0.0061* 
 
Flanker test 
congruent reaction 
time (FRTc)  
Study  
1567± 369.2 
1161± 291.7 
0.0001** 
Control  
1588± 438.6 
1489± 509 
0.0923 
P 
0.8408 
0.0033* 
 
Flanker test 
incongruent 
reaction time 
(FRTic) 
Study  
1827± 779.6 
1417± 588.1 
0.0104* 
Control 
1847± 787.6 
1792± 755.7 
0.6164 
P 
0.9213 
0.036* 
 
SD: standard deviation, P-value: probability value, * Significant = P< 0.05. 
 

Stroop test: 
Comparison of the mean values of (Stroop test accuracy, SRTc and SRTic) 
between both groups pre-treatment revealed no significant difference. Post- treatment; 
there was a significant increase in Stroop test accuracy and a significant decrease in 
SRTc and SRTic only in study group. The percent of improvement were (18.9%. 
24.88% and 11.97%) respectively (Table3). 
Table (3): Intra- and inter-group comparison by Stroop test variables pre and 
post treatment in both groups: 
 
Stroop test 
Pre-treatment 
(Mean± SD) 
Post-
treatment 
(Mean± SD) 
P- value 
Stroop test 
accuracy  
Study  
70.17± 8.758 
83.5± 11.15 
0.0001** 
Control  
73.17± 9.048
 
75.67± 12.37
0.1380 
P 
0.1971 
0.0126* 
 
Stroop test 
congruent 
reaction time 
(SRTc)  
Study  
2982± 992 
2240± 947.7 
0.0001** 
Control  
2923± 895.5 
2752± 911.1 
0.1842 
P 
0.8116 
0.0373* 
 
Stroop test 
incongruent 
reaction time 
(SRTic) 
Study  
3007± 885.1 
2647± 729.9 
0.0102* 
Control  
3118± 746.3 
2990± 558.4 
0.2187 
P 
0.6011 
0.0459* 
 
SD: standard deviation, P-value: probability value, * Significant = P< 0.05. 
 
Discussion: 
           Children that was selected in this study have left side hemiplegic cerebral palsy 
that agreed with Godefroy & Bogousslausky 2007 [27]who concluded that damage 
in  right hemisphere, hemi-spatial neglect is the most frequent deficit where there is 
impaired or lost ability to react to or to process sensory stimuli in the hemispace 
opposite to the lesion side. This visuospatial perceptual deficits can affect different 
cognitive activities which show up as difficulty copying designs, making 
constructions, discriminating pattern of faces, selecting the correct sleeve and self-
monitoring left side or covering the paretic shoulder. 
The current study, selection of hemiplegic cerebral palsied children comes in 
agreement with Bodimeade et al. [28]who concluded that EF impairment is a central 

feature of CP when compared EF in children with CP (mean age 11 y/o) to typically 
developing controls. 
Using a bicycle ergometer related to safety was our foremost concern for the 
participants. The bicycles were powered by participants and easy which led to reduce 
fall risk that considered a prevalent problem. 
The present study was revealed significant improvement of all measured 
variables of inhibitory control of EF after three successful months that agreed with 
Renaud et al. 2010[29] that found 12 weeks supervised exercise is associated with 
improving the attention.  
Results of present study revealed significant improvement of all measured 
variables in study group (A) as there was significant increase in accuracy and 
significant decrease reaction time congruent and incongruent that means improvement 
of inhibitory control of EF this was attributed to AE. 
The results of the present study proved that there was no significant 
improvement in all measured variables of Flanker test accuracy, FRTc and FRTic in 
the control group (B), while there was significant improvement in all measured 
variables of Flanker test accuracy, FRTc and FRTic in the study group (A) which 
might be to physiological effect of AE on brain and increases cerebral tissue 
oxygenation, blood flow. This result agreed with Kluding et al., 2011 [30]. 
The improvement of EF after AEs may be due to activity in cortical areas 
(right medial frontal gyrus), superior frontal gyrus, and superior parietal lobe. It 
increases number of interconnections in frontal and parietal gray matter, and increases 
prefrontal and anterior cingulate plasticity in the aging brain with neurologically 
intact young adults that agreed with (Colcombe and Kramer, 2004). [31]. 
The results of this study showed that there was significant changes in all 
measured variables Stroop test accuracy, SRTc and SRTic when comparing pre and 
post treatment variables between two groups in favor of the study group (A) this 
improvement comes in agreement with Ainslie et al., (2008) [32] who reported that 
AE increases oxygen consumption, reduces blood pressure and resting heart rate, also 
proved to promote angiogenesis and increase in capillary density. 

Most studies supported greater improvements of EF after moderate to 
vigorous AE in typically developing (TD) child (Verburgh et al., 2014) [33]. 
Improvements EF after sustained AEs (over months) is required for cognitive 
improvement this comes in agreement with Masley 2009. [34]. 
Previous studies have reported improved performance on a variety of 
cognitive task categories, information processing, memory, and executive function, 
after a single bout of AE Hillman et al.,2009[35]. 
The significant improvement in post treatment Stroop test accuracy, SRTc and 
SRTic is supported by Etnier and Chang 2009[36]that reported improvement in 
Stroop Test after acute moderate-intensity strength exercise (10 sets of 10 repetitions 
for six exercises) session in healthy middle-aged (49 ± 9 years) adults.  
Benefits of physical exercise in promoting increased EF and consistent with 
similar to studies of Chang et al., 2014[37] and Pan et al., 2015 [38]. 
Our results take the opposite trend of Ploughman et al., (2008) [39] that noted 
the treadmill exercise have not led to improve in cognitive function. Discrepancy 
between present and Ploughman et al. [39] might be due to small size and duration 
of physical therapy of Ploughman et al. [39] study. It was assumed that sustained AE 
(over months) is required for cognitive improvement (Masley, 2009). [37]. 
Data also contradicted with Correia et al., (2010) [40] who found acute 
strengthening exercises not have significant alterations in levels of brain-derived 
neurotrophic factor plasma concentrations. The discrepancy of results between two 
studies may be attributed to the type of exercise program. 
Conclusion: AE has significant effect on inhibitory control of executive functions in 
spastic hemiplegic cerebral palsy children. 
 
 
 

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