TITLE: The effect of group exercise program on the self-efficacy and activities of
daily living in adults with cerebral palsy

  ABSTRACT:
[Purpose] This study was carried out to examine the effect of the application of group
exercise program composed to induce interests and assertive participation of adults with
cerebral palsy on the self-efficacy and activities of daily living, as well as to provide
basic clinical data that are effective and trustworthy in enhancing the physical and
emotional interaction in the future. [Subjects and Methods] Those among the 23 adult with
cerebral palsy who are the subjects of research and able to participate only in the
evaluation of measurement tools prior to and after the experiment were allocated to the
control group while only those who can participate in the group exercise program
implemented over 12 sessions were allocated to the experimental group. For the control
group, a range of motion of joint exercise and stretching exercise were executed on the
arms, legs and trunk, while for the experimental group, group exercise that is implemented
with participation of several subjects simultaneously was executed 2 times a week with 40
minutes for each session over a period of 6 weeks for the total of 12 sessions. [Results]
In both the experimental group and the control group, there were statistically significant
changes in the average scores of self-efficacy and activities of daily living after the
exercise in comparison to that prior to the exercise. Moreover, there were statistically
significant differences in self-efficacy and activities of daily living in terms of
quantity of change prior to and after the exercise between the two groups. [Conclusion]
Therefore, group exercise program composed to induce physical and emotional interaction,
and active participation of adults with cerebral palsy can be considered as an effective
intervention method in improving their self-efficacy and activities of daily living.

BODY.INTRODUCTION:
Adult with cerebral palsy is accompanied by chronic pain as the secondary problem arising
from reduction in mobility and motor ability and such chronic pain induces musculoskeletal
deformity1), and, ultimately, affects the
daily life or social activities of the patient2). Although adult with cerebral palsy requires therapeutic
intervention due to a diverse range of musculoskeletal symptoms and functional problems3), realistically, youth with cerebral palsy is
not able to maintain physical training through health service approach after graduation from
school. Accordingly, they complain of a lot of pain in muscles and joints, and increasingly
lose locomotion ability including walking as they get older due to the degradation and
reduction in the range of motion of joint and muscle strength. Therefore, cerebral palsy
requires care throughout the life and, for this purpose, physiotherapist must put in efforts
to optimize independence of the patient from all aspects throughout the patient's life by
enhancing the motor performances centered-around therapeutic exercise4). However, in the case of cerebral palsy, it is the reality
that majority of researches are on the health status of children since the therapeutic
approach is not predominantly focused on being implemented on adults5).  Self-efficacy means the confidence that one can perform specific tasks in relation to the
body6). That is, it can be defined as the
ability to specifically organize actions for performing of activities related to the given
tasks under specific situations that include the elements that are ambiguous, difficult to
be anticipated and imparts tension due to the discernment of one's capabilities7). In fact, disabled persons are prone to
having distorted cognition of one's body or activities due to loss of parts of the body,
functional impairment and emotional disability, and may display difficulties in social
adaptation including interpersonal relationship or group life because of low self-efficacy
and sociability. In addition, since loss of such abilities further reduces the movement and
interaction ability of the bodily parts in accordance with the environmental change for the
efficient performance of exercise, the activities of daily living of adult with cerebral
palsy including self-care, transfer and locomotion, communication and social cognition, etc.
become limited.  Hutzter and Bar-Eli8) stated that exercise
is necessary to improve the emotions and mental health of disabled persons, while Cameron
and Monroe4) asserted that therapeutic
exercise for cerebral palsy must be composed of goal-directed, functional and significant
movements by considering the extent, type, cognition level and areas of the interest of
disability, etc. If group exercise is applied to the adults with cerebral palsy who lacks
activities due to body locomotive disability, it can impart affirmative effect on provision
of motivation for life and promote social interaction among the participants9). That is, it is possible to improve
self-efficacy in organizing and executing behavioral process necessary in accomplishment of
goals related to body by having the patients to repetitively learn to solve exercise
problems by practicing the ability to achieve the goals for specific tasks and by improving
the adaptation ability under a diverse range of circumstances7). Accordingly, the enhancement of confidence and self-regard that one
can perform specific tasks can affect the development of activities of daily living and
sociability since they induce improvement of the qualitative level of exercise
performances.  Although multifaceted clinical researches on systematic health and medical services with
high quality provided to children with cerebral palsy have been carried out at home and
abroad until now, there has been almost no therapeutic intervention on adults with cerebral
palsy with musculoskeletal symptoms and functional problems. Moreover, there is insufficient
research on their general health status and need for rehabilitation. Therefore, this study
was carried out to examine the effect of the application of group exercise program composed
to induce interests and assertive participation of adults with cerebral palsy on the
self-efficacy and activities of daily living, as well as to provide basic clinical data that
are effective and trustworthy in enhancing the physical and emotional interaction in the
future.

BODY.SUBJECTS AND METHODS:
In this study, adult with cerebral palsy in the age bracket of 18–30 years diagnosed with
disability of levels 1 to 2 encephalopathy by medical specialists in the areas of
rehabilitation medicine and neurosurgery were selected as the experimental group. The
detailed criteria for selection of the subjects of the study included the following.
Firstly, those who can sustain seated posture on supplementary wheelchair. Secondly, those
capable of performing boccia exercise, which is the group exercise program. Thirdly, those
who achieved more than 18 points in the Mini-Mental Status Examination and has no
difficulties in communicating and interacting with the researcher and participants. After
having listened to the detailed explanations on the purpose, method, procedures,
direct/indirect inconveniences and/or potential risks of the researcher, the subjects of the
study consented to voluntarily participate in the experiment on their own will. In addition,
this study was approved by the Life Ethics Committee of DONG-EUI University that
responsibilities for the ensuring of human rights, dignity and safety of the research
subjects will be fulfilled (IRB No. DIRB-201602-HR-R-007).  This study was executed in quasi-experimental study design method in order to examine the
effects of group exercise program on the self-efficacy and activities of daily living of
adult with cerebral palsy. Those among the 23 adult with cerebral palsy who are the subjects
of research and able to participate only in the evaluation of measurement tools prior to and
after the experiment for personal reasons were allocated to the control group while only
those who can participate in the group exercise program implemented over 12 sessions were
allocated to the experimental group. For the control group, a range of motion of joint
exercise and stretching exercise were executed on the arms, legs and trunk, while for the
experimental group, group exercise that is implemented with participation of several
subjects simultaneously was executed 2 times a week with 40 minutes for each session over a
period of 6 weeks for the total of 12 sessions. The group exercise program included boccia
exercise, which is a sport for disabled persons due to cerebral palsy, that uses balls for
the purposes of enhancement of interest and assertive participation of adults with cerebral
palsy, and the detailed order of the exercise was composed in the following sequence:  First, warm-up exercise (10 minutes): Emotional stability and establishment of rapport A
range of motion of joint exercise and stretching exercise for arms, legs and trunk. Second,
main exercise (20 minutes): Enhancement of body coordination and mobility, fortification of
muscle strength and endurance, and enhancement of activities and participation Boccia game
(group game with 3–4 persons). Third, tidying-up exercise (10 minutes): Body massage and
deep breathing training.  For the boccia exercise, which is the main exercise, the 3–4 person group game of the
Boccia Game Regulation Manual (9th edition: 2005–2008) published by the Cerebral
Palsy-International Sports and Recreation Association (CP-ISR) was applied in order to
enable emotional support through interaction for and to enable adults with cerebral palsy to
enjoy the game by competing among the participants, while at the same time, enhancing the
body mobility and coordination10). Warm-up
and tidying-up exercise, at the time of execution of group exercise program, were conducted
by the research assistants who received sufficient training on the detailed exercise
procedures in advance under the guidance of the physiotherapists with more than 5 years of
experiences in neurodevelopmental treatment. In addition, this exercise conducted only on
the experimental group was executed under the supervision and assistance of 1 judge
registered with the Judging Committee of the Korea Disabled Persons Boccia Federation and
research assistant, respectively.  General self-efficacy and functional self-efficacy were measured for the self-efficacy in
considerations for 3 aspects including the level, intensity and generality of the
subjects7). The general self-efficacy is
the tool developed by Sherer & Maddux11) and modified by Bosscher & Smit12) to make measurement easier using eliminating ambiguous words and
questions with low relevance. This measurement tool is divided into three domains, which are
progressiveness domain (3 questions), efforts domain (5 questions) and continuity domain (4
questions), encompassing 12 questions with 5-point scale answers for each question. For the
functional self-efficacy, 9 easy questions answered that it can be done with the assistance
of others and 9 questions with the exclusion of 5 questions related to independent mobility
or walking in the self-efficacy scale related to functional activities developed by
Resnick13) were used. For both
self-efficacies, answers ranged from "Have no confidence at all=0 point" to "Completely
confident=10 points," with higher score indicating higher self-efficacy. The reliability of
this scale was Cronbach's α=0.8614).  The functional status of the adult with cerebral palsy including the evaluation of the
basic activities of daily living is measured by using the Modified Barthel Index (MBI)15). This measurement tool is composed of a
total of 10 specific daily life activities including 7 items of self-care indices and 3
items of mobility indices. Different score is given for each of the items in accordance with
the relative importance, and 5-scaled score can be given in accordance with the extent of
the functions of the patient within an item (0–100 points). With the inter-examiner
reliability of 0.84, the Modified Barthel Index has been reported as a measurement tool with
high reliability16).  Data collected in this study were analyzed by using SPSS 22.0 program for Windows (IBM
Corp., USA) and the significance level, α, was set at 0.05 for statistical verification.
Descriptive statistics were computed for the general characteristics of the research
subjects and parameter test was executed for the regularity in the measurement variables
after having confirmed through Kolmogorov-Smirnov analysis. Paired t-test was executed to
analyze the changes in self-efficacy of the experimental group and the control group prior
to and after the experiment, and independent t-test was executed to compare the difference
between the two groups.

BODY.RESULTS:
General characteristics of research subjects are given in the Table 1Table 1.Characteristics of the subjects (N=23)VariablesExperimental group(N=11)Control group(N=12)Gender (male/female)a6/57/5Age (years)b22.36 (3.47)21.83 (3.01)Height (cm) b160.50 (7.72)161.61 (6.32)Weight (kg) b57.93 (8.49)60.31 (8.52)Gestational age (weeks) b36.09 (3.11)33.67 (4.81)Birth weight (g) b2,693.64 (856.17) 2,284.17 (767.18)Incubator care (weeks) b3.91 (4.48)5.58 (3. 96) aNumber (%), bMean (SD).. We evaluate whether the means for two independent groups are associated with
the equal of variances using Levene's test. Moreover, the changes in the average score
within the group of the experimental and control groups for the general and functional
self-efficacy, and activities of daily living, as well as the results of the analysis of the
differences in the quantity of changes prior to and after the exercise between the two
groups are presented in the Table 1. In both the
experimental group and the control group, there were statistically significant changes in
the average scores of self-efficacy and activities of daily living after the exercise in
comparison to that prior to the exercise. Moreover, there was statistically significant
differences in self-efficacy and activities of daily living in terms of quantity of change
prior to and after the exercise between the two groups (p<0.05) (Table 2Table 2.Comparison of Self-efficacy Scale and MBI within and between groups
(N=23)VariablesGroupPre-exercisePost-exerciseChange valuesGeneral Self-efficacy ScaleExperimental51.82 (10.55)54.27 (11.03)*2.45 (1.13)Control49.42 (11.75)50.83 (12.03)*1.42 (1.00)*Functional Self-efficacy ScaleExperimental41.81 (10.17)44.00 (10.37)*2.18 (0.75)Control39.00 (12.39)40.50 (12.22)*1.50 (0.67)*Modified Barthel IndexExperimental39.00 (9.34)41.81 (10.24)*2.82 (1.25)Control35.67 (11.41)37.25 (11.77)*1.58 (1.38)*Values are mean (SD). *p<0.05.).

BODY.DISCUSSION:
The main problems that manifests in youth and adults with cerebral palsy include damages to
nerve system, pain and fatigue due to increase in age, and degeneration of locomotion skills
due to lack of physical activities17).
Although there is trend of gradual increase in the anticipated lifespan of children with
cerebral palsy and prevalence rate of adult with cerebral palsy since such children receive
special medical rehabilitation services due to the advancement of modern medicine5), focus on therapeutic approaches for
majority of cerebral palsy is failing to be transferred from children to adults. Therapeutic
exercise imparts affirmative effects on self-efficacy19) by increasing not only the physical awareness but also physical
self-awareness18), and physical
activities performance to greater extent if the self-efficacy is high20, 21). In addition,
since the performing of group exercise program as a part of physical education can not only
increase muscle strength and mobility but also improve the quality of life, it is said to be
highly beneficial therapeutic program from social aspect22). Therefore, this study examined the effect of application of group
exercise program that included boccia exercise, which is a sport for disabled persons with
cerebral palsy, on adult with cerebral palsy on the self-efficacy and activities of daily
living of the research subjects.  Self-efficacy is personal belief that one thinks one is physically capable and can succeed
in performing specific tasks23). Those
with cerebral palsy has the passive tendency of not doing things oneself, and weakening of
motivation for repetitively taking up challenges due to the lack of confidence arising from
having experienced having repetitive failures on the attempt for movements and behaviors as
one grows because of disability in posture and exercise. Accordingly, cerebral palsy lowers
the self-efficacy of a person as one becomes adult, thereby increasing actual fear towards
activity performance and failure to maximally demonstrate one's potentials. As such, it is
important to induce the patients to put in even greater efforts with attention necessary for
the task situation by improving the self-efficacy. In this study, the quantity of changes in
self-efficacy of the adult with cerebral palsy in the experimental group who performed 6
weeks of group exercise program significantly increased more than that of the subjects in
the control group. This is believed to be the result of the improvement in confidence of
research subjects in the experimental group on their own capabilities by studying a diverse
range of external stimulations in the process of participating in the group exercise
program, appropriately controlling the environment in order to achieve good results and
successfully composing and performing necessary actions.  The affirmative self-respect that can be obtained when therapeutic exercise is performed
continuously enhances the cognition on the physical efficacy and external appearance, and,
furthermore, has high possibility of promoting psychological growth such as
self-accommodation and happiness24).
Moreover, they asserted that motivation for taking up the challenges and achieving the goals
for the given tasks, and confidence on and anticipation for the results of the efforts put
impart influence on the changes in physical activities7), and that beliefs on the physical activities lead to cognition of
the body and improve the ability to control oneself25). It is believed that adults with cerebral palsy were able to
enhance the confidence and belief that they can successfully perform the actions necessary
in overcoming their physical disabilities and performing the given tasks by recognizing
their won and other's body schema, and improving mutual friendliness through the group
exercise in this study also. Accordingly, it is deemed that group exercise program will be
helpful in improving the inaccurate body awareness and low self-efficacy of adults with
cerebral palsy, and in drawing out the potentials to lead them to participate in challenging
tasks through inducing of strong internal motivation.  Since cerebral palsy needs life-long care, it is necessary to enhance motor performances
and maximally improve independence in daily life through therapeutic exercise4). In addition, in the case of cerebral palsy,
since characteristics for each of the types of the disabilities reduce body function and
impart direct effect on the activities of daily living, social functions and quality of life
are degraded even further with increased severity of disability. Isometric and functional
muscle strength increased, walking stride got longer and cadence increased when group
exercise program was executed on 8 children in the age bracket of 4–8 years with spastic
diplegia26). In addition, Verschuren et
al.27) also discovered that not only the
physical fitness but also the level of participation activities and quality of life improved
as the results of execution of group exercise program over a period of 8 months on children
with cerebral palsy. This study also produced significant greater increase in the quantity
of changes in the activities of daily living in the experimental group in comparison to the
control group when group exercise program was executed on adults with cerebral palsy for 6
weeks. This is determined to be the results of experiencing of automatic and natural
movements by performing the group exercise activities by adults with cerebral palsy and
advancement of the integrated ability of adults with cerebral palsy to execute cognitive,
social and behavioral functions to appropriately coping with the environmental demands such
as other persons and new tasks. Although many physiotherapists have the concern that group
exercise program, when compared to individual customized therapy as a method of one-on-one
therapy, could result in substantially reduced attention, group exercise can be seen as a
highly beneficial intervention method for adults with cerebral palsy since it can provide
increase in health and mobility as well as a diverse range of benefits that can lead to
improvement of participation in daily life and quality of life additionally on the basis of
the results of this study.  The group therapy program executed by interacting with peer constituent members is more
effective than individual practices28),
and that interaction activities composed of competition and cooperation with colleagues
assist with the improvement of daily life by inducing motivation for learning29). It is believed that it was possible to
establish social interactions such as sense of belonging and accomplishment, mutual support
and abiding by rules in the process of cooperating with each other in order to accomplish
the same goal of winning the game as members of the same team in this study also since
boccia exercise, a sports for disabled persons with cerebral palsy, is executed as a group
formatted competition activity. That is, adult with cerebral palsy could not only learn new
tasks and concepts by performing group exercise program but also acquire social skills
though responding interaction on the basis of the actions of colleagues by paying attention
to the actions of other participants, thereby improving the participation in daily life and
quality of life.  Accordingly, group exercise program executed on adult with cerebral palsy can improve
self-efficacy through reduction in anxiety and enhancement of psychological confidence of
the participants, and improve the activities of daily living through physical activities
that enable them to learn functional and cognitive things. Moreover, the program enables the
patents to perform interesting and challenging therapy along with the experience of comfort
of engaging in the program with other disabled persons with cerebral palsy. The finding of
this study showed to be the results of self-efficacy promotion by performing the group
exercise program of adults with cerebral palsy. That is, self-efficacy will be responsive to
environmental change, which facilitates success and increases long-term motivation and will
improve their efforts toward change when they were in unresponsive environment. High level
of self-efficacy improved confidence to produce designated performance in a specific
situation and succeed in an achievement or a task in activities of daily living. Therefore,
group exercise program composed to induce physical and emotional interaction, and active
participation of adults with cerebral palsy can be considered as an effective intervention
method in improving their self-efficacy and activities of daily living.

Question: Compared to Control what was the result of Group exercise program on Daily activity?
Evidence: Moreover, there was statistically significant
differences in self-efficacy and activities of daily living in terms of quantity of change
prior to and after the exercise between the two groups (p<0.05) 
Answer: significantly increased