# Exercise as it relates to Disease/Functional Strength Training in Children with Cerebral Palsy

This is an analysis of a journal article “Functional strength training in cerebral palsy: a pilot study of a group circuit training class for children aged 4–8 years” by Blundell SW, Shepherd RB, Dean CM, Adams RD. This has been created by u3097172 as a university assignment for the University of Canberra, unit: Health, Disease and Exercise.

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

Cerebral Palsy (CP) is a term used to identify a group of neurological disorders that effects a person’s movement and posture. It occurs due to damage to the brain either before, during or after birth, when the child’s brain is under developed. It is the leading cause of physical disability in children, accounting for 1 in 500 births worldwide. Individuals suffering from CP may experience:
* Impaired muscle functions such as spasticity
* Low muscular strength
* And decreased motor control
There are many different types of Cerebral Palsy, all effecting individuals in different ways. They can be classified by how its effects people’s movement, the severity of the effects and the body part effected. There is currently no cure for Cerebral Palsy as majority of cause associated with the malformation of the baby’s brain are unknown.

##### Cerebral Palsy and strength training research

Previously, strength training in children with Cerebral Palsy was perceived to be detrimental as it increased spasticity or led to greater abnormalities in movement patterns. However, recent studies demonstrate that strength training, in a variety of forms, provides many benefits without adverse effects to movement. Improvements in strength, mobility, flexibility, posture, functional movement (eg. Gait) and many important psychological benefits were associated with strength training in children affected.

## Where is the research from?

The current study was conducted at The University of Sydney NSW. The researcher was from the Faculty of Health Sciences and worked in conjunction with the Spastic Centre of NSW. The article was published in The Journal of Clinical Rehabilitation, which is a peer reviewed journal covering the field of disability and rehabilitation

## What kind of research was this?

The study was a nonrandomised ABA trial designed to determine the effects of task- specific functional strength training in children ages 4–8 years, delivered as a group circuit class. Non- randomised ABA trials aim to estimate the effectiveness of an intervention on an assigned group, measured multiple times over a particular study period. Non randomised trials are seen to have poor validity and used as observational studies, however, can be useful to identify new interventions that can be consider by trial groups in high quality studies such as RCT’s.

## What did the research involve?
### The Subjects

The research involved a small sample size that was invited to participate in the study.
* 8 children (7 Males/ 1 Female)
* Aged between- 4-8years with the Mean age of 6.3 ± 1.3
* 7 Children diagnosed with spastic diplegia and 1 child diagnosed with spastic/ataxic quadriplegia

### The Intervention/ The strength training

* 4 weeks of circuit classes performed after school
* Sessions were conducted twice weekly (total of 8 sessions all together) and lasted 1 hour each
* Children performed functional based movements such as; walking on a treadmill, step ups, sit-to-stands, and leg presses
* Main focuses of the strength training were; lower limb strengthening and endurance, improve segment control of lower limbs, improve motor learning and improve balance.

### The measurements

* Isometric strength test: Hips, knees ankle flexion/ extension were measured using a hand help dynamometer. The dynamometer tests were carried out on each muscle group until the child could complete 3 consistent tests, however, wouldn’t exceed 6 tests.
* Lower extremity functional strength test: The Lateral step test was used to measure Lower extremity functional strength and overall functional strength. The test was performed over a 15 second period and the number of steps were measured.
* Functional motor performance: The Sit-to-stand, 10m walk, 2minute walk and Nine-Hole peg test were used to measure motor performance. Using walking speed, stride length and cadence observed during the tests, total motor performance was calculated.
All measurements were assessed in 4 phases; the baseline (2weeks prior to of study), the Pre-test (start of study period), the End phase (post study period), Follow up (8 weeks post study period).

### Other therapy influences

All children had received previous therapy throughout childhood and prior to the beginning of study. None of the participants were involved in any other form of physiotherapy during the study term. However, during the strength session, participants were monitored by 2 supervising physiotherapists and were given individuals sessions if needed.

## What were the basic results?

The results demonstrate that isometric strength, functional strength and motor performance increased significantly following training and were maintained over the 8 week follow up post strength training. Increases in isometric strength were found in approximately 60% of the muscle groups tested, with a mean increase of 47% in isometric strength pre to post training. The number of lateral steps performed in 15seconds increased from 2.6-7.9 ±3.8 repetitions with limbs becoming more proportional. This demonstrates that there was an increase in Lower extremity function and strength. Finally, 10meter walking times decreased by an average of 22% due to the increase in stride length, and sit-to-stand performance increased due to the reduction of set high from 27 cm-17 cm on average. Both of these measurements indicate that motor performance increased.

## What conclusions should be taken away from this research?

The study identifies the strong relationship between strength training and function in children with cerebral palsy. The use of a short term strength program may provide functional benefits and lead to significant improvements in functional capacity. However, The use of a non-randomised ABA trial means that this study only provides an observation between the relationship of the intervention and group. In addition, the use of only one participation group, no use of a control group, the small sample size, the use of only one follow up measurement, short training term all decrease the validity of the research.

## What are the implications of this research?

Although the study has its limitations, it does provide the same positive result identified in other research being conducted on strength training and cerebral palsy. Strength training provides significant improvement in cerebral palsy suffers functional capacity and may be used as a component of physiotherapy.

## Further Information

* Cerebral Palsy Alliance website: https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/
* Fitness training for Cerebral Palsy: https://www.cerebralpalsy.org.au/about-cerebral-palsy/interventions-and-therapies/fitness-training-for-children-adolescents-and-adults-with-cerebral-palsy/#1464753561973-da6d47be-ccbf
* The brain that changed: http://www.sbs.com.au/news/thefeed/article/2016/09/24/brain-changed-walking-kokoda-trail-cerebral-palsy

## References

* 1 2 3 4 5 6 7 8 Blundell SW, Shepherd RB, Dean CM, Adams RD. Functional strength training in cerebral palsy: a pilot study of a group circuit training class for children aged 4–8 years [Internet]. Feb 2003 [Cited 10.9.16]. Volume 17(1):48-57. Available from: http://cre.sagepub.com.ezproxy.canberra.edu.au/content/17/1/48.full.pdf+html
* 1 2 Scholtes VA, Becher JG, Comuth A, Dekkers H, Van Dijk L, Dallmeijer AJ. Effectiveness of functional progressive resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: a randomized controlled trial. [Internet]. 28 Jan 2010 [Cited 10.9.16]. Vol 52(6):107-113. Available from: http://zh9bf5sp6t.search.serialssolutions.com/?ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc%3AUTF-8&rfr_id=info%3Asid%2Fsummon.serialssolutions.com&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Effectiveness+of+functional+progressive+resistance+exercise+strength+training+on+muscle+strength+and+mobility+in+children+with+cerebral+palsy%3A+a+randomized+controlled+trial&rft.jtitle=Developmental+Medicine+%26+Child+Neurology&rft.au=SCHOLTES%2C+VANESSA+A&rft.au=BECHER%2C+JULES+G&rft.au=COMUTH%2C+ANTON&rft.au=DEKKERS%2C+HURNET&rft.date=2010-06-01&rft.issn=0012-1622&rft.eissn=1469-8749&rft.volume=52&rft.issue=6&rft.spage=e107&rft.epage=e113&rft_id=info:doi/10.1111%2Fj.1469-8749.2009.03604.x&rft.externalDBID=n%2Fa&rft.externalDocID=10_1111_j_1469_8749_2009_03604_x&paramdict=en-US
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* ↑ MacPhail HE, Kramer JF. Effect of isokinetic strength-training on functional ability and walking efficiency in adolescents with cerebral palsy [Internet]. Sept 1995 [Cited 16.9.16]. Vol 37(9);763-775. Available from: http://canberra.summon.serialssolutions.com.ezproxy.canberra.edu.au/search?q=Effect%20of%20isokinetic%20strength-training%20on%20functional%20ability%20and%20walking%20efficiency%20in%20adolescents%20with%20cerebral%20palsy.#!/search/document?ho=t&l=en&q=Effect%20of%20isokinetic%20strength-training%20on%20functional%20ability%20and%20walking%20efficiency%20in%20adolescents%20with%20cerebral%20palsy.&id=FETCHMERGED-LOGICAL-c1093-20cbf0921ccd447fb4c00c1aae33eeaa9f43dd57c6db5a4a0125cbe7824208022
* ↑ Damiano DL, Vaughan CL, Abel MF. Muscle response to heavy resistance exercise in children with spastic cerebral palsy [Internet]. Aug 1995 [Cited 16.9.16]. Vol 37(8):731. Available from: http://canberra.summon.serialssolutions.com/search?q=Muscle%20response%20to%20heavy%20resistance%20exercise%20in%20children%20with%20spastic%20cerebral%20palsy.#!/search/document?ho=t&l=en&q=Muscle%20response%20to%20heavy%20resistance%20exercise%20in%20children%20with%20spastic%20cerebral%20palsy.&id=FETCHMERGED-LOGICAL-c1091-c743726bc398cbcb55572bb802dee243ca009ece584ef5d6a51bb6e6bceae8752
* ↑ Kelly LE, Damiano DL, Vaughn CL. Effects of quadriceps femoris muscle strengthening on crouch gait in children with spastic diplegia [Internet]. Aug 1995 [Cited 16.9.16]. Vol 75(8):658-667. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7644570
* ↑ Darrah J, Fan JSW, Chen LC, Watkins B. Review of the Effects of Progressive Resisted Muscle Strengthening in Children with Cerebral Palsy: A Clinical Consensus Exercise [Internet]. Jan 1997 [Cited 16.9.16]. Vol 9(1). Available from: https://www.researchgate.net/publication/232175198_Review_of_the_Effects_of_Progressive_Resisted_Muscle_Strengthening_in_Children_with_Cerebral_Palsy_A_Clinical_Consensus_Exercise
* ↑ Fowler EG, Ho TW, Nwigwe AI, Dorey FJ.The effect of quadriceps femoris muscle strengthening exercises on spasticity in children with cerebral palsy. [Internet]. June 2001 [Cited 16.9.16]. Vol 81(6):1215-1223 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11380277
* ↑ Abel MF, Damiano DL. Functional outcomes of strength training in spastic cerebral palsy [Internet]. Feb 1998 [Cited 16.9.16]. Vol 79(2):119-25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9473991