# Exercise as it relates to Disease/Positive Impact of Exercise on Cerebral Palsy Children

The following fact sheet is an analysis of the article titled Effect of Physical Exercise Programme on Gross Motor Function of Children with Cerebral Palsy published by Bhutia, Nair and Surujlal in November 2015.

## What is the background to this research?
#### Cerebral Palsy

Cerebral Palsy (CP) is a neurological disease the occurs in utero, during infancy or early childhood. It is characterised by limited movement, impaired balance and postural control due to abnormal development or damage to the brain. The severity of this disorder is dependent on the extent of damage to the brain. It is common for CP patients to experience spasticity due to impaired development of their skeletal muscle structure. Spasticity is defined as an increased tone in muscle and an increase in the deep tendon reflexes.

#### Cerebral Palsy and Exercise

Exercise has many benefits for CP suffers, particularly children during developmental phases. One benefit that majority of CP patients indicate as the most important is reduced severity of spasticity events. Exercise programmes prescribed typically contain the 4 types of exercise stated in the table below, as as benefits associated leads to greater quality of life.
| Type of Exercise | Benefits |
| Cardiorespiratory Endurance | improved aerobic capacity improved aerobic endurance |
| Skeletal Muscle Strength | improved functional strength improved functional capacity to perform activities of daily living (ADL) |
| Skeletal Muscle Endurance | decreased fatigue improved work capacity improved capacity to perform ADL's |
| Flexibility | increased range of motion improved coordination and skill of movements |

#### Research

The effect of exercise on CP has been broadly studied in past decades in order to evaluate improvement on quality of life for CP patients. In the study under analysis, the main aim of the study was to evaluate the effectiveness of exercise in improving quality of life for CP children. A combination of flexibility,skeletal muscle strength and skeletal muscle endurance training formed the basis for the exercise programme intervention within this study. As stated above, there are many benefits associated with this type of exercise.

## Where is the research from?

The following research was conducted by Bhutia and Nair from India, along with Surujlal from North-West University in South Africa. It was undertaken in a Kerala State Government funded institute for the mentally challenged located in Southern India.
Bhutia has previously studied throughout India observing the effects of physical activity on health, as well as Nair focussing on sport and coaching. Both studying from Lakshmibai National College for Physical Education (LNCPE). Surujlal's previous study has focussed on Economic Sciences and Information Technology. There are potential issues regarding the quality of this research as only Bhutia has previously studied in the area of physical activity and health. Another factor contributing to questioning the quality of research is that Surujlal's area of study is completely unrelated to the study, therefore showing a lack of experience.
There are various studies conducted in India focussing on CP. This is largely due to the prevalence of this disease in India. Approximately 15-20% of all physically disabled children suffer from CP, and it is estimated that approximately 3 in 1000 births result in CP. The government has issued numerous schemes in relation to education and employment, for more information visit Central Government Schemes.
Within India, there are multiple institutes which attend to the needs of individuals suffering from CP. However, many parts of India are poor and therefore the level of care in developing areas may not be as good as richer areas. Although, this study was conducted in Kerala, which is to considered to be a well-off state. This suggests that this research may be relevant to Australia as the level of care in the richer states of India is similar to that in Australia in regard to helping children improve their quality of life.

## What kind of research was this?

This study was a randomised control trial, once the participants were considered eligible, they were randomly assigned to either the control or experimental group. Following the 12-week training period, researchers were aware of which children participated in the training program for both pre- and post-testing. This indicates that there is some bias present within the study as the researchers had prior knowledge to which children were expected to improve in GMFM 88 post intervention test.
The use of a control group was necessary to compare the results of sedentary and active children with CP. It is mentioned in the study that the children were normally in a confined space within the institution. Whereas during the training program they were taken out of the institute for exercise. The researchers noted a positive change in their emotions. A part from the 12-week training program, it was suggested that the new surrounding for these children nurtured both their physical and motor development hence leading to greater results.

## What did the research involve?
#### Testing Requirements

Each individual was required to take part in the Gross Motor Function Measure (GMFM) 88. This comprised of 5 different tests which each measure change in gross motor function specifically for children with CP over a certain period. They were given 3 attempts to complete each test. Both groups (control and intervention) were initially tested as well as following a 12-week training program.

#### Requirements of the Participants Partaking in the Exercise Programme

The participants assigned to the experimental group were required to partake in an exercise program 3 times per week over a 12-week period. Each session lasted between 50-60 minutes, with increasing intensity as the weeks progressed. The aim of this was to improve quality of life through enhancing general movement. Each training session consisted of a warm up, strengthening, coordination and assisted exercises, static and assisted passive stretching and a cooldown.
| Section of Program | Components |
| Warm Up (10 Minutes) | Slow walking, stretching, rotation around joints, head rotation, arm flexion and extension, shoulder rolls/rotation, forward and backward bending and deep breathing |
| Strengthening Exercises | Utilising body weight as resistance, included: callisthenic exercise, knee flexion and extension, plantar flexion and dorsiflexion and chest raises in prone position |
| Coordination Exercises | Tossing, holding, passing and kicking of a ball (all different coloured balls were used to enhance coordination improvements) |
| Assisted Exercises | Utilising a Swiss Ball, trunk extension, chest lifts, forward and back bridge, lying on the ball, rolling |
| Static Stretching | Neck, shoulders and sides |
| Assisted Passive Stretching | Shoulders and upper arms, upper back, chest, buttocks, hamstrings, quadriceps, hips and ankles |
| Cool down (10 Minutes) | Breathing exercises, relaxation of the body, shaking and light massages |

#### Methodology

The methodology used in this study was a good approach as it involved both pre and post testing for both groups. However, it may have been beneficial to test the intervention group midway through the program. This would allow the researchers to track their improvement and make adjustments to the program accordingly, which may have resulted in greater improvements.

#### Limitations

A major limitation of this study is the sample size as it only consisted of 10 CP children. The study may have benefitted from sampling a larger group, gaining greater reliability of results. Another limitation is that only 1 female was included in the study. Through testing an equal population of female and males it would have allowed the researchers to account for natural physical differences between sexes, particularly in relation to muscular strength/growth.

## What were the basic results?

The results showed that the exercise programme was beneficial for children with CP. Significant increases from pre to post testing were shown in lying, rolling over, sitting and standing; all of which are key areas of improving CP children's daily living.
The control group had minimal increases, varying from 0%-2.8% across the board for their GMFM scores. It is clearly evident that the experimental group had greater improvements and hence suggests this is due to the exercise program. Increases in lying and rolling, standing and walking, running and jumping were 15.32%, 26,37% and 4.27% respectively. This may be due to the passive stretching element of the program as it incorporated all major body parts and therefore led to an improvement in stable and free body movements. There were also improvements in sitting by 18.23%. This improvement, along with standing and walking is suggested to be because of the strengthening exercises improving overall strength of CP patients. The results found in this study were strongly supported by a study conducted by Damiano and Abel in 1998 which explored the functional outcomes of strength training in spastic CP.

## What conclusions can we take from this research?

From the findings presented in this study, it is evident that appropriate exercise prescription can be beneficial in improving everyday movements for children suffering from CP. Therefore, exercise programme should be strongly encouraged by practicitioners to their clients as it can have significant positive effects on individual's lives.

#### Other Studies

The influence of exercise on CP children is a highly studied topic with majority of researchers favouring the use of exercise for treatment.
An article written by Leinweber and colleagues conducted in 2016 indicate that acute physical activity actually has a negative effect on postural stability. This article assisted in validating that the intensity of exercise prescribed should be closely monitoring to ensure that is is not causing negative effects.
Another study conducted by Kelly and Darrah focuses on the use of aquatic exercise to reduce loading on joints hence not negatively affecting their postural stability. This article indicates that this may be a better approach for an exercise programme due to the benefits above.

## Practical advice

CP is a topic studied frequently particularly in relation to exercise and the benefits associated with this. Individuals with CP should participate in regular physical activity as it is proven to improve activities of daily living such as sitting, lying, rolling and standing.
However, it is key that program prescribed for this population are closely monitored as well as completing pre-screening. This is to ensure that the program doesn't have a negative effect on their postural stability through overloading the joints and muscles and that correct intensity is prescribed. Pre-screening is important as CP individuals have an increased risk of developing cardiovascular disease and stroke. Overall, CP children should be encourages and prescribed correctly to gain optimal results.

## Further information/resources

* Interventions & therapy for CP sufferers https://www.cerebralpalsy.org.au/about-cerebral-palsy/interventions-and-therapies/
* Cerebral palsy - the facts http://cpaustralia.com.au/learning-center/the-facts/
* Choice, passion, life http://www.cpl.org.au

## Reference list

* 1 2 3 4 Bhutia C, Nair U, Surujlal J. Effect of Physical Exercise Programme on Gross Motor Function of Children with Cerebral Palsy. African Journal for Physical, Health Education, Recreation and Dance. 2015;:1-13.
* 1 2 Durstine J, Moore G, Painter P, Roberts S. ACSM Exercise Management for Persons with Chronic Diseases and Disabilities. 3rd ed. United States of America: Human Kinetics; 2009.
* ↑ Medical Definition of Spasticity [Internet]. MedicineNet. 2017 [cited 15 September 2017]. Available from: http://www.medicinenet.com/script/main/art.asp?articlekey=10974
* ↑ Ehrman J. Clinical exercise physiology. 3rd ed. Champaign, IL: Human Kinetics; 2013.
* ↑ Vyas A, Kori V, Rajagopala S, Patel K. Etiopathological study on cerebral palsy and its management by Shashtika Shali Pinda Sweda and Samvardhana Ghrita. AYU (An International Quarterly Journal of Research in Ayurveda). 2013;34(1):56.
* ↑ List of Richest States (by GDP) in India [Internet]. World List Mania - Listing the Top. 2017 [cited 17 September 2017]. Available from: https://www.worldlistmania.com/list-richest-states-by-gdp-india/
* ↑ Leineweber M, Wyss D, Dufour S, Gane C, Zabjek K, Bouyer L et al. The Effects of Acute Intense Physical Exercise on Postural Stability in Children With Cerebral Palsy. Adapted Physical Activity Quarterly. 2016;33(3):271-282.
* ↑ Kelly M, Darrah J. Aquatic exercise for children with cerebral palsy. Developmental Medicine & Child Neurology. 2005;47(12):838.