Muscle Strengthening in Cerebral Palsy

Gill Holmes Gait Laboratory Manager Alder Hey Childrens NHS Foundation Trust

Plan.
Historical background. Treatment strategies. Alder Hey work. Research ideas.

What Is Muscle Strength?

the ability of a muscle or group of muscles to
produce tension and a resulting force in one maximal effort, either dynamically or statically, in relation to the demands put upon it (Burton, 2002)

Why the Focus on Strengthening?

Historically..

Despite weakness being clinically recognized terms cerebral palsy,-plegia. Phelps (1950s) advocated resisted exercise to develop strength or skill in weakened muscle. Strengthening contra-indicated due to advent of Neurodevelopmental therapy. Spasticity assumed to be primary culprit. Weakness not real - result of co-contraction of opposing muscle. Effort : increase co-contraction, reduce coordination. Impaired selective control prohibited performance of strengthening activities.

However..

Evidence supports the fact that strength is deficient in CP. Weakness directly related to functional performance.

Why Muscle is Weak in Cerebral Palsy.

Damage to CNS affects motor development and maturation (Leonard,Hirschfeld& Forssberg 199,1 Dietz & Berger 1995) Co-activation of muscles (Leonard et al 1991, Lin et al 1996, Lin 2001,Elder et al 2003) Which in turn inhibits activity - preventing muscles developing adult characteristics Fibre type disproportion altered fibre size Abnormal recruitment order

Effect of Spasticity

Biomechanical changes. Clinically pts with spasticity have increased joint stiffness resistant to stretch. 3 factors : a) passive muscle stiffness. b) neurally mediated reflex stiffness. c) active muscle stiffness. Evidence suggests that there is alteration in both neural input and intrinsic muscle mechanical properties.

Further Factors

Growth Increase in relationship between strength & anatomical cross-sectional area ( Elder et al 2003) Stiffness & reduction of physiological cross-sectional area (PCSA) Incomplete muscle activation (Elder et al 2003) inability to drive motor units to achieve higher levels of muscle contraction. Muscle function in CP has found to be reduced by approx 50% Contractures Connective tissue within muscle Physiological burn out syndrome - (Pimm 1992)

Effect of Ageing
Harridge & White (1993) Eur J Apply Physiol

120 torque (Nm) 100 80 60 40 20 0 Angular Velocity (rads 1) elderly young

Effect of Interventions

Negative effect of surgery similar changes to immobilisation Orthopaedic surgery Neurosurgery - dorsal rhizotomy Intrathecal baclofen Botulinum toxin

Summary

The effect of brain lesion (CP) alone has profound effect on muscle development and function in developing children. Activity or lack of activity further affects muscle function. Growth and physical maturation. Imposed treatment strategies whilst aiming to improve the situation may in fact be making situation worse. Lack of understanding as to the effects on muscle in different spastic aetiologies e.g. dystonia, ataxia etc. Effect of age at which spasticity is acquired.

Summary

Primary inability of agonist to produce force. Restriction of agonist i.e. Muscle imbalance, cocontraction, spasticity. Inappropriate muscle length i.e. too long / too short. Reduced activity level. Changes in muscle properties (stiffness / atrophy). Poor selective motor control. Hypotonia.

Effect of Exercise on Spasticity

Miller & Light 1997 - strength training in 9 adult right-sided hemiplegics. Findings - spasticity unchanged. Level of co-contraction greater before exercise. Appeared to improve agonist recruitment. Sahramann & Norton 1977. Colebatch 1986.

Is It Possible to Strengthen?

Damiano 1995 - progressive strengthening programme 14 children with spastic diplegia. All demonstrated increased quadriceps strength, reduced knee crouch and increased stride length. Macphail & Kramer 1995 - isokinetic strengthening of quadriceps & hamstrings in 17 adolescents with mild CP. Findings. Sharpe & Brouwer 1997 - similar findings.

Patterns of Weakness

Wiley & Damiano 1998 - patterns of muscle weakness in 30 community ambulant CP children. Distal weakness more prevalent. Difficulty moving out of synergy.

Spasticity V Strength

Damiano et al 2001 Findings Peak isometeric torque Peak voluntary torque Antagonists Peak resistance torque Stiffness Weakness Conclusion - relationship with spasticity, strength & function Evaluate before treating

General Exercise / Physical Fitness

Promotion of personal fitness in the general population. Offset decline in function due to ageing. Assist in maintaining physical independence. Evidence to show that people with disabilities also benefit (Rimmer 2001,Andersson 2001).

Benefits of Muscular Strength & Endurance

Increased fat-free mass & resting metabolic rate. Increased bone mass. Improved glucose tolerance. Reduction in injury from falls & lower back pain. A greater ability in activities of daily living.

Summary

Children with CP have true muscle weakness Strength directly related to function Children have the ability to get stronger - muscle has normal ability to respond to training Rate of strength increases are similar to that for muscle weakness not due to UMN lesion Strengthening has functional benefits Strengthening does not increase spasticity

Which Treatments Do We Use?

Treatment Strategies

Variety of methods. Progressive resistance weight training. Isometric training. Isokinetic training. Weight-bearing exercises.

Treatment Strategy

Dependent on pre-treatment evaluation Physical exam particularly strength ratios across a joint Identification of functional goal GMFCS level i.e level of impairment Patient specific

4 Main Principles
Overload Specificity Individuality Reversibility

(McArdle,2001;Bruton,2002)

Muscle Strengthening Strategies

Which muscles to be strengthened? Strengthen antagonists e.g hip extensors, quadriceps, ankle dorsiflexors Lengthen spastic agonists Concentrate on power producers for the task

Identify the goal Strength training should be prescriptive Minimise joint stress hydrotherapy

Muscle Strengthening Strategies

Types of resistance. Isotonic fixed load stressing parts of range differently machines / weights. Elastic increases with length. Isokinetic constant velocity with accommodating resistance throughout range - cybex.

Weakness end of ranges isotonic Weakness throughout range isokinetic Difficulty with quick movements isokinetic Eccentric weakness isokinetic

What Type of Training Programme?

Weight bearing exercise with added load (Mayston 2005). Circuit training. Swimming, cycling etc. Enjoyment offered in the community / fitness centres/ gym. Potential for inclusion and societal participation (Mayston 2005).

Muscle Strengthening Strategies

General Principles Load Repetitions Frequency Duration

Treatment Strategies

Strengthening high load, 3-8reps 3-5sets carried out slowly with control & rest Endurance medium load, 8-20 reps 5+sets moderate & sustained activity Power high load, 1-3 reps 10 +sets, fast activity with rest Damiano

Treatment Strategies

Load i.e work (65% of max voluntary contraction). Continue the progression. Allow muscle to recover. Training frequency allow time at least 3 times per week for 6 - 10 weeks. 8 week programme yielded strength gains of 12-30%. Maintenance programme. Additional benefits of strengthening & fitness across a lifetime.

Muscle Treatment Strategies - Summary

Loading muscles exercise stretching casting under tension electrical stimulation general fitness Muscles made to work

But Unfortunately !

We usually have to use the following techniques unloading muscles immobility & disuse muscle & tendon releases casting without tension but not without cost ! Muscles made not to work

Considerations

Risks and benefits of strength training - controversial topic. American Academy of Paediatrics - policy statement. Caution is urged when using maximum resistance or overloading muscle.

North West Region Paediatric Muscle Strengthening Group

2 Collaborative projects

Physiotherapists: Alder Hey and NW Region clinical expertise Researchers:Evidence-based Child Health Unit methodological expertise

USE OF MUSCLE STRENGTHENING IN CHILDREN WITH CEREBRAL PALSY

SURVEY OF PHYSIOTHERAPISTS

Aims of project

A survey of paediatric physiotherapists in the NW of England was carried out to ascertain current clinical practice with regards to use of muscle strengthening programmes in children and young people with cerebral palsy.

Method - questionnaire

Postal questionnaire (open and closed questions) with key themes: use of muscle strengthening programme types of muscle strengthening techniques used frequency of sessions progression of exercises methods used to assess muscle strengthening requirements training and education in muscle strengthening In particular - use of muscle strengthening in specific patient groups age groups GMFCS levels clinical interventions (pre-op, post-op, post serial casting, post-Bt) signs of deterioration / weakness identified at gait analysis

Method target population

Paediatric physiotherapists in NW England Region comprises 24 paediatric physiotherapy bases (data obtained from the north west regional Primary Care Trusts) Questionnaires, covering letters and stamped addressed envelopes sent to the managers of each centre for distribution amongst all their staff

Method - analysis

Data entered into SPSS (v13) double checked Frequencies calculated Responses from open-ended questions tabulated to facilitate qualitative assessment

Results

90 paediatric physiotherapists within the region submitted completed questionnaires. 37 respondents chose to identify their place of work, revealing that submissions were obtained from at least 18/24 surveyed centres.

Proportion using strengthening programme.

21/90 (23.3%) responders stated they did not use strengthening programme when treating patients with CP. Reasons given: Lack of knowledge 9/21 (10%). Lack of equipment 4/21 (4.4%). muscle strengthening considered inappropriate 7/21 (7.8%). I feel that effort often increases tightness in some muscle groups (one responder). Other reasons 5/21 (5.6%) included. muscle strengthening addressed but not within a programme (n=3). exercise advice given, but not within a programme due to workload. caseload does not include children with CP. 69/90 (76.6%) responders reported using strengthening programme.

Muscle strengthening methods used:

Functional exercises (eg sit-to-stand) 67/69 (97.1%) Individuals own body weight or gravity 61/69 (88.4%) Resistance devices (eg theraband, free weights or manual) 39/69 (56.5%) Gym equipment (eg treadmill, bike) 26/69 (37.7%) Hydrotherapy 50/69 (72.5%)

Frequency: Pre and Postop.

Frequency Pre & Post Operative
80 70 60 50 % 40 30 20 10 0 Presurgery 2-6 wks post surgery 7-12 wks post surgery 3-6 mths 6-12 mths 12+ mths post post surgery surgery surgery Daily 2/3 times p/wk Weekly Other

Frequency - Post Botox

Frequency - Post Botox
80 70 60 50 % 40 30 20 10 0 Daily Three times p/wk Weekly Other Post-Botox - 2-6wks Post-Botox 7-12wks Post-Botox - 3-6mtns

Frequency -Weakness Identified

Frequency - Weakness Identified
80 70 60 50 % 40 30 20 10 0 Daily Three times p/wk Weekly Other Weakness Identified - 26wks Weakness Identified - 7-12 wks Weakness Identified - 36mths

Frequency - Serial Casting

Frequency - Post Serial Casting
70 60 50 40 % 30 20 10 0 Daily 2/3 times p/w k Weekly Other Serial Casting - 2-6w ks Serial Casting - 7.12w ks Serial Casting - 3-6mths

Frequency: qualitative answers

Programme frequency directly related to family and patient compliance Frequency limited due to: Lack of support from local services Large clinical caseload Key people to supervise programmes: Physiotherapy assistants Educational supports Parents/carers

Progression- methods
4% 20% 25% Inc reas e holds Inc reas e w eight Change s tarting pos ition 21% 19% Change w ay muscle w orks Other Inc reas e reps

11%

Treatment discontinued when:

Goals reached 68.1% Poor compliance 78.3% No improvement 55.1% Plateau of function 49.3%

Advice given on cessation

Gym attendance 28% Activity clubs 58%

Cochrane review:
Muscle strengthening for children and adults with cerebral palsy

A well formulated question should include a description of:

P Initially children & adolescents 4-19 years with a diagnosis of cerebral palsy expanded to include adults. I Muscle strengthening including: graded resisted exercise, progressive resisted strengthening, weight bearing exercise with added load, isokinetic training, isotonic programmes, eccentric & concentric training programmes, electrical stimulation, functional strength training. C any of above e.g. eccentric versus concentric, load versus resistance. O measures of function e.g. gross motor function. - measures of muscle physiology & structural. change. Study design Randomised controlled trials.

Research pyramid of study designs used to assess the efficacy of therapy or intervention.
Systematic Review of Randomised Controlled Trials Confirmed Randomised Controlled Clinical Trials Single Randomised Controlled Clinical Trial Non Randomised Controlled clinical Trial Case Controlled Observational Studies Analysis of large computer databases Case Series with Historical Controls Case Series, Literature Control Uncontrolled Case Series Anecdotal Case

Objectives:

To determine the effectiveness of any form of muscle strengthening programme in children and adults with cerebral palsy. The effectiveness will be considered in terms of both measures of muscle function and muscle physiology/structure.

Sources Searched to Identify Studies

MEDLINE, EMBASE, CINAHL, PSYCINFO. The Cochrane Library. PEDro. Reference lists from included studies and review articles were scrutinised to identify any additional relevant trials missed by the search. Researchers known to be working in the field will be contacted to see if they are aware of any additional studies. We will also write to the authors of all included studies to see if they are aware of any additional studies not already identified by our review.

Preliminary findings:

Issues raised: training periods were short possibly too short as the weakness is a life long condition. Methods used to assess muscle strength were often incorrect. Meta analysis carried out - some areas favoured strengthening: Self- perception: behavioural conduct; body image. Muscle strength. GMFM dimension D. Some areas of participation e.g.formal activities/ skill based activities but not social or recreational activities.

Research Ideas

Intensive training over longer period 1 year. Intensive training v conventional physiotherapy following multi level surgery. Working together with sports scientists.

Muscle Strengthening Conclusions.

Muscle recruitment & co-activation problems are lifelong soft tissue management issues (Cusick 2002) Effect of immobility on general health and independence World-wide there is a move to guided treatments rather than the holistic Make adjustments as we go along Need to harness research into clinical treatment Further work required Which patients with CP will benefit Effect on mobility,function and participation

Thank you!

Determinants of Muscle Force.

Muscle fibre alignment Physiological cross-sectional area Motor unit recruitment Muscle fibre type and length Number of sarcomeres