DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Increases in muscle volume after plantarflexor strength training in

children with spastic cerebral palsy
ANNE E MCNEE MPTHY1,2 | MARTIN GOUGH FRCS
1
| MATT C MORRISSEY SCD 2 | ADAM P SHORTLAND PHD 1
1 One Small Step Gait Laboratory, Guy's Hospital, London, UK. 2 Division of Applied Biomedical Research, School of Biomedical and Health Sciences, Kings College,
London, UK.

Correspondence to Anne McNee at One Small Step Gait Laboratory, St Thomas Street, London SE1 9RT, UK. E-mail: anne.mcnee@gstt.nhs.uk

PUBLICATION DATA
Accepted for publication 31st October 2008.
Published Online 21st January 2009
ACKNOWLEDGEMENTS
This study was funded by the Nancie Finnie
Charitable Trust. The authors would like to
thank Jill Larkins and Eskinder Solomon for
assistance with the training, and Nicola
Fry and the staff at the gait laboratory for
assistance with data collection.
Children with spastic cerebral palsy (CP) have small, weak muscles. However,
change in muscle size due to resistance training in this group is unknown. We
investigated the effect of plantarflexor strengthening on muscle volume, gait,
and function in 13 ambulant children with spastic CP (seven males, six females;
mean age 10y 11mo, SD 3y 0mo, range 6y 11mo–16y 11mo; eight with diplegia,
five with hemiplegia; Gross Motor Function Classification System level I, six;
level II, five; level III, two). Assessments were performed before training, 5 and
10 weeks into training, and at a 3-month follow-up. Medial and lateral
gastrocnemius volumes were computed from three-dimensional ultrasound
images. The number of unilateral heel raises able to be achieved on each side
was assessed. Function was measured using three-dimensional gait analysis,
the ‘timed up and go’ test, the Gillette Functional Assessment Questionnaire,
and the Functional Mobility Scale. Training involved heel raises or Thera-Band
resistance, 4 times a week for 10 weeks. Medial and lateral gastrocnemius
volumes increased by 17 and 14% at week 5 (p=0.03, p=0.028). This increase was
maintained at week 10 and follow-up (medial gastrocnemius p=0.001, p<0.001;
lateral gastrocnemius p=0.006, p=0.007). Heel raises (mean number) increased
by week 5 (p=0.002). This was maintained at week 10 and follow-up (p<0.001;
p<0.001). No significant change in measured function was observed. Muscle
volume increased in response to training in children with spastic CP. The role
of progressive strength training in maintaining long-term function is discussed.

Children with spastic cerebral palsy (CP) have profound
weakness of the muscles of their lower limbs. Using dyna-
mometry, Wiley and Damiano1 demonstrated that muscle
groups in independently ambulant children with spastic
CP produce as little as 52% of the force of those in
matched typically developing children during maximum
voluntary contraction. The origin of this profound weak-
ness is multifactorial, with deficits in motor unit activation
accounting for as much as 73% of loss of force2 and reduc-
tions in muscle volume being as much as 50%.3,4 Muscular
performance may be further compromised by deleterious
changes in muscle tissue properties5 and coactivation of
antagonist muscle groups.6
Resistance training has become an increasingly common
intervention aiming to improve function by increasing
muscular strength.7-12 Damiano et al.7 trained the knee
extensors in a group of children with spastic CP over 6
weeks using free weights. They found an increase in knee
extensor force by up to 160% and a small reduction (5) in
knee flexion at initial contact. Using circuit training, Unger
et al.11 increased the strength of the upper limb, trunk, and
proximal lower limb musculature in 23 children with spas-
tic CP over 8 weeks. This training also significantly
reduced the degree of crouch by 5. Engsberg et al.12
found a small increase in walking speed and increased
stride length in four participants who strengthened their
ankle plantarflexors. In the same study, minimum knee
flexion in stance and dimension E of the Gross Motor
Function Measure (GMFM) improved in participants who
trained their dorsiflexors as well as their plantarflexors.
Dodd et al.10 describe a lower-limb extensor training pro-
gramme using closed kinetic chain exercises for 10 children

ª The Authors. Journal compilation ª Mac Keith Press 2009

DOI: 10.1111/j.1469-8749.2008.03230.x 429

with spastic CP. Combined lower-limb extensor strength
increased after 6 weeks of training and remained improved
at 12-week follow-up. These authors also found a trend
towards improvement in GMFM dimension E. However,
this did not reach significance. Overall, short-term
strengthening programmes appear to result in increased
strength associated with only mild improvements in gait
and function.
The effect of resistance training on muscle size in chil-
dren with spastic CP is unknown. To increase the size of
healthy muscle progressive strength training for a pro-
longed period is required. It is thought that improved mus-
cle activation is responsible for the major portion of
strength gained within the first 3 to 5 weeks of training.13
After this time, increases in strength are mainly due to
hypertrophy. The mild gains in function reported in the
literature after training in individuals with spastic CP may
be in part due to the short training period adopted by the
investigators.
The potential impact of a strengthening programme
may also vary according to the muscle group(s) targeted. In
spastic CP, the distal lower-limb musculature is weaker1
and may be proportionally smaller than proximal muscles.3
In normal human walking, the plantarflexors provide much
of the force required to support the body and advance the
lower limbs, particularly in mid- and late stance.14 Typical
changes to the gait pattern of children with spastic CP are
ankle plantarflexion through stance and swing, and
increased knee and hip flexion in stance.15 Concentrating
on strengthening the plantarflexors rather than more prox-
imal musculature may improve the functional outcome of
training for this group. We hypothesized that a 10-week
programme of plantarflexor strengthening would result in
muscle hypertrophy, normalization of the gait pattern (par-
ticularly improvements in ankle dorsiflexion because of the
pennate nature of the muscle trained16 and knee extension
in stance), and an improvement in walking function in a
group of children with mild spastic CP.
METHOD
Participants
Ethical approval for the study was granted by the local hos-
pital research ethics committee. Participants were recruited
through the orthopaedic clinic of the Evelina Children’s
Hospital, London, and from three community physio-
therapy departments (The Phoenix Centre, Bromley, The
Kaleidoscope Centre, London, and the Wilfred Sheldon
Centre, London). The inclusion criteria were a diagnosis
of spastic CP and the ability to walk for 10m with or with-
out the use of a mobility aid. Participants were excluded if
they had undergone surgery in the past year, or had had
botulinum toxin A injections in the past 6 months or serial
430 Developmental Medicine & Child Neurology 2009, 51: 429–435
14698749, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2008.03230.x by Cochrane Chile, Wiley Online Library on [30/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
casting in the past 3 months, or were not able to comply
with the requirements of gait analysis or our training sche-
dule. They were also excluded if they had an ankle plantar-
flexion contracture greater than 15 or had a knee or hip
fixed-flexion deformity greater than 10. Written informed
consent from the parents or guardians of participants was
obtained before the first assessment. The participants gave
verbal consent after reading or listening to a short descrip-
tion of the project. Twenty-two children agreed to partici-
pate; 20 started the programme, with 14 completing it and
13 attending for assessment. Ten participants completed
the follow-up assessment 12 weeks after cessation of
training.
Training programme
The participants trained four times each week for 10
weeks. Three of these sessions took place at home and one
session was conducted at the tertiary centre, where the
exercises were evaluated and progressed by a physiothera-
pist (AM). Each training session consisted of a 3 to 5 min-
utes aerobic warm-up, followed by plantarflexor stretches
conducted by the participant while standing. Maximum
available dorsiflexion was attained and body weight was
used to maintain the stretch. The plantarflexor strengthen-
ing exercises were then performed. The session was com-
pleted by a 3 to 5 minute cool-down and plantarflexor
stretches. The strengthening exercises were progressive in
that loading levels were monitored and adjusted to main-
tain muscle loading as muscle strength increased. The left
and right plantarflexors were strengthened independently.
The load applied to each side was dependent on the evalu-
ated strength of that side. The exercises were performed
in three to four sets, with participants performing the
maximum number of repetitions that they could produce
(minimum of six repetitions up to a limit of 12, corres-
ponding to 6 to 12 repetitions maximum). Participants
were required to rest for a minimum of 2 minute between
sets. For those participants who were able to perform more
than 12 heel raises, exercises were progressed by adding
weight to a rucksack worn on the participant’s back. Not
all participants could achieve single-leg heel raises and 10
children began their exercise programme using an elasti-
cated band (Thera-Band, The Hygenic Corporation,
Akron, OH, USA) to provide resistance to the plantarflex-
ors on one or both lower limbs. The Thera-Band exercise
was performed with the participant in the long-sitting posi-
tion, i.e. with the knee in full extension. For those using
the Thera-Band for resistance training, when a limit of 12
repetitions was reached, their exercises were progressed by
using a heavier Thera-Band or by changing to heel raises.
The training routine (sets, repetitions, types, and load)
was recorded in a diary. During the 3-month period after

training, the amount of exercise completed by each partici-
pant was not monitored.
Assessment
Each participant was examined by two authors (AS, AM)
and other gait laboratory staff before the training period
(baseline), 5 weeks into training (week 5), on completion of
the 10-week training (week 10), and at 12-week follow-up
after completion of training. Assessment and training were
always conducted on different days. Maximum passive
ankle dorsiflexion range of movement with the knee held
in both flexion and extension was measured using a hand-
held goniometer. Body height, mass, and lower limb length
were measured. The number of heel raises that each partic-
ipant could perform on each lower limb was counted.17
The ‘timed up and go’ test,18 Functional Mobility Scale,19
and Gillette Functional Assessment Questionnaire20 were
used to assess functional mobility.
A three-dimensional analysis system (7-camera Vicon
612, Vicon, Oxford, UK) was used to evaluate each partici-
pant’s barefoot gait pattern at a self-selected speed. The
mean of five trials from the right and left lower limbs at
each assessment was analysed. Minimum knee flexion in
stance and peak dorsiflexion were extracted from the aver-
aged data. Self-selected walking velocity, cadence, and
stride length were also measured.
A freehand three-dimensional tracking system (Com-
pactScan, TomTec GMBH, Munich, Germany) was used
to acquire the images from the video output of an ultra-
sound scanner (SSD-1000, ALOKA, Tokyo, Japan) while
simultaneously recording the position and orientation of
the ultrasonic probe.21 Longitudinal scans were taken from
the calcaneus to the femoral condyles following the courses
of the Achilles tendon and head of the gastrocnemii
(Fig. 1). Scans were taken on both legs with the participant
prone, and the ankle at its resting angle (relaxed position of
the foot) and at the angle of maximum passive dorsiflexion
MG muscle belly
Knee Foot
Figure 1: Longitudinal ultrasonic image of the medial gastrocnemius
from one female participant (age 8y 5mo) before exercising. MG,
medial gastrocnemius.
14698749, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2008.03230.x by Cochrane Chile, Wiley Online Library on [30/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
(achieved through manual manipulation) with the knee in
full extension. A three-dimensional volume containing the
muscle was reconstructed. Muscle cross-sectional area was
measured at each of 10 equally spaced sections along the
length of the muscle. Volume was calculated using disk
summation. Raw volume data and volume data normalized
to body mass were analysed.
Statistical analysis
One-way repeated-measure analysis of variance was
used to test for the effects of the strengthening regime
on muscle volume, passive ankle range of motion, and
specific gait parameters. A Fisher least-significant-
difference post-hoc test was used to ascertain significant
changes between assessments. A p value <0.05 was con-
sidered significant. Functional scores and number of
heel raises were compared using the Friedman test. For
the variables that showed significant changes, Conover
post-hoc tests were applied, again at a significance level
of 95%.
RESULTS
Thirteen participants (seven males, six females) aged
between 6 years 11 months and 16 years 11 months (mean
10y 11mo, SD 3y) participated in training. Eight partici-
pants had a diagnosis of diplegia and five had hemiplegia.
Two participants required a Kaye walker for assistance with
walking (Gross Motor Functional Classification System
[GMFCS] level III ). All others were independently ambu-
lant (six at GMFCS level I; five at GMFCS level II).
Ten participants (15 limbs) began training using a
Thera-Band as resistance. During the 10-week pro-
gramme, six participants (seven limbs) progressed to heel
raise exercises, two participants (two limbs) used a combi-
nation of heel raises and Thera-Band exercises, and four
participants (six limbs) were unable to progress to heel
raise exercises. Significant increases in the number of heel
raises achieved were seen on both sides between baseline
and week 5 (p=0.002), baseline and week 10 (p<0.001), and
baseline and follow-up (p<0.001; Table I). No significant
change was seen between the other time intervals. Those
participants unable to perform any heel raises before train-
ing showed the least improvement in the number of heel
raises achieved.
Ankle range of motion
The mean ankle dorsiflexion range before training was
1.7 measured with the knee in extension and 8.7 mea-
sured with the knee in flexion. There were mild increases
in dorsiflexion range at week 5 (0.8 knee extended, 3 knee
flexed). These changes were maintained at week 10 and
follow-up; however, they were not statistically significant.
Muscle Volume after Training in Spastic CP Anne E McNee et al. 431
 14698749, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2008.03230.x by Cochrane Chile, Wiley Online Library on [30/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Table I: Median values (range) for functional measures at different points in the strengthening programme. Timed Up and Go scores expressed as
mean (SD)

Baseline Week 5 Week 10 Follow-up

Functional Mobility Scale 17 (4)18) 17 (8)18) 17 (8)18) 17 (5)18)

Gillette Functional Assessment Questionnaire 9 (2)10) 9 (2)10) 9 (7)10) 9 (8)10)
Timed Up and Go, s 5.6 (0.7) 5.5 (0.9) 5.63 (0.7) 5.37 (0.8)
Heel raises, n 1 (0)30) 4.5 (0)50)a 10 (0)50)b 9.5 (0)60)c
Participants, n 13 13 13 10

a
Significant difference between baseline and week 5 (p<0.05); bsignificant difference between baseline and week 10 (p<0.05); csignificant
difference between baseline and follow-up (p<0.05). Week 5, 5 weeks after commencement of the programme; week 10, at the end of the
10-week programme; Follow-up, 12 weeks after the end of the programme.

Table II: Mean (SD) of the absolute and normalized medial gastrocnemius (MG) and lateral gastrocnemius (LG) volumes at different points in the
strengthening programme

Baseline Week 5 Week 10 Follow-up

MG volume, ml 58.7 (26.0) 69.8 (32.3)a 72.5 (30.6)b 80.5 (38.4)c,d

LG volume, ml 42.3 (20.0) 46.6 (20.6)a 49.9 (21.5)b 50.9 (23.7)c
Normalized MG volume, ml ⁄ kg 1.6 (0.6) 1.7 (0.5)a 1.9 (0.7)b 1.7 (0.5)c
Normalized LG volume, ml ⁄ kg 1.1 (0.5) 1.2 (0.4) 1.3 (0.4)b 1.16 (0.5)
Limbs, n 26 26 26 20

a
Significant difference between baseline and week 5 (p<0.05); bsignificant difference between baseline and week 10 (p<0.05); csignificant
difference between baseline and follow-up (p<0.05); dsignificant difference between week 5 and follow-up (p<0.05). Week 5, 5 weeks after
commencement of the programme; week 10, at the end of the 10-week programme; Follow-up, 12 weeks after the end of the programme.

Muscle volume
Muscle volumes measured with the ankle in maximum
dorsiflexion and at rest were not significantly different. Vol- 3
Normalized Vol (ml/kg)

umes reported are from the maximum dorsiflexion angle. 2.5

b
Table II shows the change in absolute and normalized 2 a c
b
medial and lateral gastrocnemius volume over the assess- 1.5 a c
ment period, with changes in the medial gastrocnemius 1
volume displayed in Figure 2. Medial and lateral gastro- 0.5

cnemius volume increased by 16.6 and 13.5% respectively 0

between baseline and week 5 (p<0.003 and p=0.028). By
week 10, the volumes of the medial and lateral gastro-
cnemius were 23.1 (p=0.001) and 23.6% (p=0.006) greater
than at baseline. Although the mean levels of muscle
volume increased between week 5 and week 10 for both
the medial and the lateral gastrocnemius, these changes did
not reach significance. At follow-up, muscle volume was
increased by 30.5% in the medial gastrocnemius and
19.7% in the lateral gastrocnemius compared with baseline
measurements (p<0.001, p=0.007). There was no significant
change in muscle volume between week 10 and follow-up
(medial gastrocnemius: p=0.422, p=0.625). Muscle volume
was divided by body mass to account for the confounding
PreE Wk5 Wk10 FU Typically
Developing
Figure 2: Mean medial gastrocnemius (MG, black solid bars) and
lateral gastrocnemius (LG, grey and white striped bars) volume (SD 1
standard error) over the 10-week training period and at follow-up.
a
Significant difference between baseline (PreE) and week 5 (wk5)
(p<0.05); bsignificant difference between baseline and week 10 (wk10)
(p<0. 05); csignificant difference between baseline and follow-up 12
weeks after the end of the programme (FU) (p<0.05). Normalized MG
and LG volume in a typically developing group of 15 children (four
males, 11 females) are also illustrated on the right (age, mean 9 y
6mo; range 6y 4mo–13y 3mo; MG, grey solid; LG, grey striped).

432 Developmental Medicine & Child Neurology 2009, 51: 429–435


Table III: Mean (SD) gait parameters at different points in the strengthening programme
Knee flexion single support, 
Maximum ankle dorsiflexion, second half stance 
Cadence, steps ⁄ min
Walking speed, m ⁄ s
Time spent in single support, %
Participants, n
Week 5, 5 weeks after commencement of the programme; week 10, at the end of the 10-week programme; Follow-up, 12 weeks after the
end of the programme.
effects of skeletal growth. Normalized medial gastrocne-
mius muscle volume showed significant increases between
baseline and week 5 (p=0.003), week 10 (p<0.001), and fol-
low-up (p<0.002; Table II). Normalized lateral gastrocne-
mius volume showed a significant increase between
baseline and week 10 (p=0.014). No significant change in
normalized lateral gastrocnemius volume over any other
intervals was seen.
Spatio-temporal parameters
No significant change in self-selected walking speed, stride
length, or cadence over the assessment period was found.
No kinematic parameter selected showed significant
change (Table III). Three independently ambulant partici-
pants walked with greater than 15 of knee flexion in stance
at baseline and all showed a reduction in knee flexion at
week 10.
Functional performance
The functional scores increased slightly through the period
of the study although the differences failed to reach signifi-
cance (Table I).
DISCUSSION
We originally hypothesized that progressive plantarflexor
strengthening for 10 weeks would result in increases in
plantarflexor volume and would improve the gait pattern
and functional walking performance of a group of children
with spastic CP. Significant increases in plantarflexor vol-
ume were seen; although the indices of gait and mobility
improved they did not reach statistical significance. The
results presented here are similar to those of others, who
found that training led to substantial increases in strength
but moderate or undetectable changes in measured func-
tion.7–12
Limitations
Because only the plantarflexors were targeted in the
training programme, the potential improvement in
14698749, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2008.03230.x by Cochrane Chile, Wiley Online Library on [30/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Baseline Week 5 Week 10 Follow-up
14.3 (6.1) 16.1 (4.8) 13.4 (6.3) 14.5 (6.2)
11.7 (10.7) 12.6 (10.2) 12.0 (9.2) 10.7 (11.1)
117.9 (20.9) 120.1 (17.1) 119.6 (14.8) 121.8 (10.1)
1.03 (0.3) 1.08 (0.3) 1.06 (0.2) 1.12 (0.2)
38.7 (3.4) 39.0 (3.2) 38.8 (2.6) 39.4 (2.2)
13 13 13 10
function observed may have been limited compared
with a more comprehensive exercise programme. Wid-
ening the scope of our intervention to include other
muscle groups might have been of more functional
benefit to the participants.
At baseline, many of the children in this study showed
only mild gait deviations and scored close to the top of the
functional scales employed. Gait analysis performed in a
controlled environment such as the gait laboratory and the
functional measures used here may not be sensitive to any
genuine improvements in walking function that these chil-
dren achieved after training. Other measures aimed at test-
ing higher levels of function may better detect
improvements in more able participants.
This was a longitudinal study where participants acted
as their own controls. A randomized controlled trial may
account for the potentially confounding effects of growth
and natural history. However, when muscle volume was
normalized for body weight, percentage increases were
found to be similar to those using the actual volume mea-
surements (Table II).
Strength was not directly measured because of the poor
reliability reported for plantarflexor strength testing using
a hand-held dynamometer.22 The standing heel raise test
has been proposed as a better test of plantarflexor function
than dynamometry.17 Additionally, it is likely that the
participants in our study had improvements in motor unit
recruitment during the heel raise test over the training
period, but we did not measure muscular activation.
At follow-up, muscle bulk was maintained. Our results
may be confounded by some (four) participants electing to
independently continue with their exercises during this 12-
week period. However, Dodd et al.10 found lower-limb
extensor strength to be maintained 12 weeks after a 6-week
training programme. Darrah et al.9 also demonstrated
overall body strength to be maintained 10 weeks after
training.
The increases in muscle volume observed are greater
than those reported in healthy populations. Aagaard
Muscle Volume after Training in Spastic CP Anne E McNee et al. 433

et al.23 described a 14-week programme to strengthen the
quadriceps in a group of 11 adult male participants. They
showed a 14% increase in muscle volume measured by
magnetic resonance imaging. Others report an increase up
to 11.4% in the cross-sectional area of the knee extensors
in groups of elderly people after training.24 No study has
reported changes in plantarflexor muscle volume during
training. Perhaps the magnitude of change in muscle vol-
ume reported here is related to the plantarflexor muscle
group, the age of the participants, or the reduced volume
of the muscles before training.
One participant reported discomfort in the region of the
Achilles tendon insertion at week 5, the cause of which was
not believed to be programme-related. She rested for a
week and resumed training without discomfort. Another
participant described pain around the insertion of the
patella during exercising for the final 3 weeks of training.
The resistance he used was reduced, eliminating his dis-
comfort, and enabling him to continue training.
Ideally, the person conducting the assessment would
have been blinded to the training schedule for each partici-
pant. Because of funding limitations, one author (AM) was
involved in both training and assessment of participants.
Clinical implications
We have shown that the failure of muscle growth associ-
ated with spastic CP3 can be ameliorated by resistance
training. This is an important finding because it demon-
strates that strengthening interventions in spastic CP can
increase voluntary muscle strength by hypertrophy and not
by motor learning alone.
Superficially, there would seem to be little value in
conducting an intervention that results in limited imme-
diate functional gains. However, muscle conditioning
may have a longer-term positive effect on mobility.
Decline in functional performance in the elderly is
related to the loss of muscular strength and volume. In
old age, there appears to be a threshold for muscular
strength below which it is not possible to perform a
particular functional task.25 Function in the elderly can
be preserved and extended by resistance training. Is there
a lesson from research in the elderly that we may apply
to individuals with spastic CP? The natural history of
mobility in individuals with spastic cerebral palsy is one
of decline.26 It is probable that a deterioration of muscle
properties3-5 is responsible for the early loss of mobility
in this group. By maintaining muscular strength substan-
tially above the threshold required to perform key tasks
necessary for daily living, such as ascending and descend-
ing stairs, or walking between classrooms, it may be
possible for individuals with spastic CP to maintain their
mobility for longer.
434 Developmental Medicine & Child Neurology 2009, 51: 429–435
14698749, 2009, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2008.03230.x by Cochrane Chile, Wiley Online Library on [30/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CONCLUSION
Preservation of muscle function and mobility is one of the
primary aims in the management of children with spastic
CP, and intervention is often directed at the plantarflexors.
This is the first study to demonstrate that muscle hypertro-
phy is possible after progressive overload training in a pae-
diatric population. If it transpires that increases in muscle
volume result in maintenance of function for this patient
group, strengthening may turn out to be one of the most
important interventions available to ambulant individuals
with spastic CP.
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