Application of Movement &

Therapeutic Exercise in Cerebral

Palsy

Mei Wulan
Department of Physical Medicine & Rehabilitation
Medical Faculty of Univ. Airlangga/Dr. Soetomo General Academic Hospital
Surabaya
Introduction

´ Cerebral palsy (CP) affects activity and social participation in

children
´ encompasses permanent and non-progressive disorders that
develop during the prenatal, perinatal, or post natal period
following various effects on the brain that has not yet fully
developed

disturbances in the neuromuscular, musculoskeletal, and sensory

systems of the children

inadequate posture and motility

(Gates et al., 2012)
 Introduction
´ These problems then result in decreased independence and
physical activity, leading to a sedentary lifestyle and a negative
effect on the child’s physical development.
´ The muscle weakness in the trunk and lower extremity is especially
important for ambulation and requires strength training

to increased muscle power, flexibility, posture, and balance

also increases the activity level

(Canadian Society for Exercise Physiology, 2013)

 The normal condition

´Normal neural development is related to :

- progressive strength increase,
- increased contraction speed, and
- isometric maximum voluntary contraction power

´The repetition of normal movement leads to stronger

neural networks in the nervous system in healthy
children
(Maltais et al., 2014)
Pathophysiology of Strength Insufficiency

´Strength loss in the affected extremities of children

with CP compared to their peers, even when the
child with CP is at a high functional level

Due to :
´Disturbed neural mechanism
´Muscle tissue changes

(Maltais et al., 2014)

The neurologic basis of weakness in CP

´A child with CP will repeat abnormal movement

patterns strengthening of the abnormal
neural networks

Pyramidal tract damage

´motor units work in an inadequate, irregular, and

slower than normal manner following UMN
damage.
The muscular basis of weakness in CP

´In the past, it was believed that muscle tissue

histology would not change

´Recent studies have revealed that the disturbances

in the morphological structure of the skeletal muscle

´Sinkjaer et al, have demonstrated that the muscle

tissue can show histopathological changes after an
UMN lesion
(Sinkjaer et al., 2013)
 The muscle changes in CP

Characterized by :
´ predominant type I and low power
´ selective type II (a) and (b) atrophy
Marbini et al., CP have a decrease in the m. Triceps surae and
adductor muscle cross-sectional area
´ The sarcomere lengths to be abnormally long
´ The fascicle length is shorter
´ The amount of collagen is increased and myosin production

(Sinkjaer et al., 2013)

Health-related physical fitness for CP

´Robson reviewed, the majority of CP are inactive,

creating lower levels of physical fitness, may have
greater chance of developing cardiovascular
disease

´Evidence of three HR-physical fitness for CP :

- cardiorespiratory endurance
- muscle strength
- anaerobic fitness
Cardiorespiratory Endurance

´ The capacity of the body to perform physical activity, depends on

the aerobic.
´ “aerobic” activities such as walking, running, cycling, swimming or
propelling a wheelchair
´ recent studies have shown that aerobic exercise training using
functional activities such as walking and running performed
separately, or in combination with strength training or anaerobic
training (sprinting type activities), results in a significant increase in
cardiorespiratory endurance.

(Verschuren &Takken, 2010)

Cardiorespiratory Endurance

´ Exercise training on a cycle ergometer, had no clear effect

on the mobility-related impairments and limitations of CP
´ 8–9 months of functional aerobic and anaerobic exercise
may result in an immediate increase in their habitual
physical activity,
´ Much of the exercise training effects to cardiorespiratory
fitness and mobility capacity are lost during the first 4 months
after the training

muscle imbalance is so prominent

(Scholtes et al., 2012 ; Novak e al., 2013)

 Strengthening Exercise

´strength training, performed according to scientific

principles,

´to increase strength in cerebral palsy,

´enhancing activity and participation including those

components related to gait function, defined in the ICF

(Taylor et al., 2013)

Considerations for strengthening exercise program
in CP
´including intensity, duration, which muscles to
strengthen, and how to strengthen them

´Choose the muscles to be strengthened should

depend on the functional motor goals
´Care must be taken to not increase or cause muscle
imbalance or muscles that are already strong or
shortened

(Damiano et al., 2010)

Resistive exercises were:

- sit to stand, - stairs,

- heel raises, - cycling,
- squats, - half knee rises,
- step ups, - isotonic exercises with
- lateral step ups, cuff weights
- weight lifting machines,
- leg press

(Scholtes et al., 2010; Verschuren, 2011)

The National Strength and Conditioning Association guidelines
for :
´ Electrical stimulation may be an alternative or adjunct
method
´ Strengthening exercise and ES have both been shown to
increase muscle size in cerebral palsy

(Damiano et al., 2013)

Anaerobic fitness (anaerobic power and
muscle endurance)
´ Muscular endurance is the ability to repeat or to maintain high-
intensity muscular contractions over a short time (<2 min)
´ Anaerobic fitness is relevant to health through its relationship to
physical activity and mobility
´ Children with cerebral palsy have lower anaerobic fitness
´ The deficit in anaerobic fitness increases with increasing motor
impairment

(Balemans et al., 2013)

´ The anaerobic fitness of children with CP has been measured
in the laboratory setting using the Wingate Anaerobic Test

expensive, may require modification and may not be readily

accessible

The Muscle Power Sprint Test

consists of six (walking/running) or three (self-propelling a
wheelchair) 10-m sprints, done as fast as possible, separated by
10-second rest periods

(Verschuren et al., 2013)

´ Evaluation of cardiorespiratory endurance in youth with
cerebral palsy using cerebral palsy-specific shuttle run test

Shuttle run/wheel field test

(Verschuren et al., 2013)

Implications for Rehabilitation
Young people with cerebral palsy have
´Reduced levels of habitual physical activity
´Do not meet the recommended levels to maintain
good health.
´Clinicians should encourage and facilitate
opportunities to increase habitual physical activity
and reduce the amount of time spent sedentary
´Make transitional fitness programs
(Carlon et al., 2012; Lauruschkus et al., 2017)
The following are recommended:
1. should accumulate at least 60 minutes of moderate to
vigorous-intensity physical activity daily.
2. Most of daily physical activity should be aerobic.
Vigorous-intensity activities should be incorporated,
including those that strengthen muscle and bone, at
least 3 times per week.

(Janssen, 2007)
 Recommended levels of physical
activity 5–17 years old
´play, games, sports, recreation, physical education or
planned exercise

• In the context of family, school, and community activities

• In order to improve cardiorespiratory and muscular fitness,
bone health, cardiovascular and metabolic health biomarkers
and reduced symptoms of anxiety and depression
The self-selected
physical activities
Exercising programs in a
wheelchair or on an
exercise mat are other
exercise options

Mat “dancing”
 Take Home Message

´Weakness in cerebral palsy based on neurologic and

muscle tissue changes
´Movement and therapeutic exercise is needed
´Strengthening exercises must be correct in choosing
the muscles to be strengthened
´The combination of exercise will increase physical
activity and performance
THANK YOU