# Exercise as it relates to Disease/Progressive resistance training in children with cerebral palsy

This is a critique of the effects of progressive resistance training on children with Hypertonic Cerebral Palsy. This critique has been written by u3145718, for assessment purposes at the University of Canberra for the unit; Health, Disease and Exercise.
The paper can be found as the first reference.

## Background of the Research

Cerebral Palsy is an umbrella term used to describe a group of disorders. This critique focuses on resistance training as a treatment method for Cerebral Palsy.

### What is Hypertonic Cerebral Palsy?

Cerebral Palsy is a neurological disorder of movement and posture due to a defect or lesion of the immature brain. Cerebral Palsy is a disorder developed in early childhood and is then set to persist through the entire lifespan. Hypertonic Cerebral Palsy is a type of cerebral palsy that is marked by extreme spasticity and muscle tone of muscles, this is due to damage of the neurones and or the cerebellum responsible for controlling muscle tone and controlled muscle movement.
According to several studies, the benefits of resistance training on children with Cerebral Palsy are:
· Increase isokinetic strength of muscle groups trained
· Improve self selected walking speed
· Improve ability to walk up and down stairs
· Slightly increase Gross Motor Function Measure testing results

## The Research
### Where was the Research Conducted?

The research was conducted at the Physiotherapy Department of two special schools in Glasgow.

### What Type of Study was this?

The study was an experimental, repeated measures pilot study. Measurements were taken at baseline, immediately after six week training program and four weeks post training program.

### Who was Involved in the Study?

The study consisted of a group of eight children, between the age of five-twelve years of age. Inclusion criteria was: diagnosis of bilateral Hypertonic Cerebral Palsy, aged between 5-12, ability to walk with or without aid, ability to follow basic instructions and provisional informed consent. Subjects age, weight, height, and Gross Motor Classification Level were recorded at baseline. The program consisted of flexion and extension based movements at the knee performed in a seated position, with weights attached to a cuff on the ankle, weight increased by 0.25 kg at the discretion of the observing physicians. Exercise sessions were conducted three times a week, with at least one day between sessions.

## Results
### What Were the Basic Results?

* The mean age of participants was eight years and five months, the mean height was one hundred-sixteen point seven five centimeters and the mean weight was twenty-six point six kilograms.
* Increase in the strength of the quadriceps and hamstring groups
* Decrease in the resistance to passive stretch
* Improvement in gait parameters
* Improvement in GMFM scores
The following is a further investigation into the improvements in strength and resistance to passive stretch.

##### Strength of the Quadriceps and Hamstrings Groups

Measures of strength of these muscles were taken prior to the intervention, just after the six week intervention and then four weeks after the intervention. In the below table shows the means for left and right hamstring strength for pre intervention, post intervention and at the four week follow up.
| Muscle Strength (kg of force) | Pre Intervention Mean (SD) | Post Intervention Mean (SD) | 4 Week Follow Up Mean (SD) |
| Quadriceps (Right) | 6.7 (3.2) | 9.3 (2.9) | 8.9 (2.9) |
| Quadriceps (Left) | 7.0 (3.0) | 9.3 (2.7) | 9.7 (2.7) |
| Hamstrings (Right) | 2.4 (1.8) | 4.5 (2.8) | 4.5 (2.7) |
| Hamstrings (Left) | 2.3 (1.9) | 4.3(2.2) | 4.6 (2.2) |
The means for both quadriceps and hamstrings groups increased significantly in both the post intervention and four week follow up measures. This increase in muscular strength is believed to help the participants in walking/mobility and reduces their risk of falls.

##### Resistance to Passive Stretch

As Hypertonic Cerebral Palsy is defined as extreme spasticity of the muscles, stretching the muscle can present as a challenge. Muscle tone was measured by measuring the resistance to passive stretch via a myometer, this was conducted at the hamstrings and the quadriceps muscle groups. The means for the resistance to passive stretch measured pre intervention, post intervention and at the four week follow up are as follows:
| Passive Stretch (kg of force) | Pre Intervention (SD) | Post Intervention (SD) | 4 Week Follow Up (SD) |
| Quadriceps (Right) | 2.0 (1.0) | 1.9 (0.6) | 1.6 (0.8) |
| Quadriceps (Left) | 2.5 (1.5) | 2.0 (0.9) | 1.7 (0.9) |
| Hamstrings (Right) | 2.4 (0.8) | 2.1 (0.5) | 1.9 (0.2) |
| Hamstrings (Left) | 1.9 (0.8) | 1.6 (0.4) | 1.5 (0.5) |
There is a decrease in the amount of resistance to passive stretching among the patients, at both the post intervention and the four week follow up. This reduces the amount of spasticity within the muscles and will allow for more fluid movements.

### How Did the Researchers Interpret the Results?

From the results the researches determined that progressive resistance training had a positive impact on functionality in children with Cerebral Palsy. There was a strong correlation between progressive resistance training and an increase in muscular strength, a decrease in resistance to passive stretching, an improvement in gait kinetics and an improvement in Gross Motor Function Measure, all of which leading to an increase in funcitonality. All data was analysed using an analysis of variance test and a Tukey significant test to test the significance of the values.

### What Conclusions Should be Taken Away From This Research?

We can conclude that resistance training has numerous benefits and no adverse effects for children with Cerebral Palsy. There are some limitations from the study although, there was only a small number of participants, and there was a lack of diversity between participants (ie. race and cultural), this didn't allow for any cultural or race related comparisons.

### What Are the Implications of The Research?

This study shows that the application of regular, progressive resistance training can have numerous acute benefits on children with Cerebral Palsy. However, more research in this field should be conducted to find the long term effects, future research should also look to include a variety of cultures and races and look at any cultural differences resistance training has on this population.

## Further reading

Cerebral Palsy Alliance: https://www.cerebralpalsy.org.au/
Systematic Review of RT and CP: Physical Medicine and Rehabilitation Journals
Health Related Fitness for Children and Adults with Cerebral Palsy: http://www.acsm.org/public-information/sportsmedicinebasics/cerebral-palsy

## References

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