muscle strengthening & general fitness
TRANSCRIPT
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Muscle Strengthening in
Cerebral PalsyGill Holmes
Gait Laboratory Manager
Alder Hey Children’s
NHS Foundation Trust
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Plan.
Historical background. Treatment strategies.
Alder Hey work.
Research ideas.
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What Is Muscle Strength?
‘the ability of a muscle or group of muscles toproduce tension and a resulting force in onemaximal effort, either dynamically or statically,in relation to the demands put upon it (Burton,
2002)’
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Why the Focus onStrengthening?
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Historically..
Despite weakness being clinically recognized -terms ‘cerebral palsy’,’-plegia.’
Phelps (1950s) advocated resisted exercise todevelop 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 co-
ordination.
Impaired selective control prohibitedperformance of strengthening activities.
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However..
Evidence supports the fact that strength isdeficient in CP.
Weakness directly related to functionalperformance.
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Why Muscle is Weak inCerebral Palsy.
Damage to CNS affects motor development and
maturation (Leonard,Hirschfeld& Forssberg 199,1Dietz & 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
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Effect of Spasticity
Biomechanical changes.
Clinically pts with spasticity have increased jointstiffness – 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.
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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’ - (Pimm1992)
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Effect of AgeingHarridge & White (1993) Eur J Apply Physiol
0
20
40
60
80
100
120
Angular Velocity (rads -
1)
t o r q u e (
N m )
elderlyyoung
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Effect of Interventions
Negative effect of surgery – similar changes toimmobilisation
Orthopaedic surgery
Neurosurgery - dorsal rhizotomy
Intrathecal baclofen
Botulinumtoxin
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Summary
The effect of brain lesion (CP) alone has profound effecton muscle development and function in developingchildren.
Activity or lack of activity further affects muscle function.
Growth and physical maturation.
Imposed treatment strategies whilst aiming to improvethe situation may in fact be making situation worse.
Lack of understanding as to the effects on muscle indifferent spastic aetiologies e.g. dystonia, ataxia etc.
Effect of age at which spasticity is acquired.
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Summary
Primary inability of agonist to produce force.
Restriction of agonist i.e. Muscle imbalance, co-contraction, spasticity.
Inappropriate muscle length i.e. too long / too short.
Reduced activity level.
Changes in muscle properties (stiffness / atrophy).
Poor selective motor control.
Hypotonia.
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Effect of Exercise onSpasticity
Miller & Light 1997 - strength
training in 9 adult right-sidedhemiplegics.
Findings - spasticity unchanged.
Level of co-contraction greaterbefore exercise.
Appeared to improve agonist
recruitment. Sahramann & Norton 1977.
Colebatch 1986.
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Is It Possible toStrengthen?
Damiano 1995 - progressive strengthening programme14 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.
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Patterns of Weakness
Wiley & Damiano 1998 - patterns of muscle weaknessin 30 community ambulant CP children.
Distal weakness more prevalent.
Difficulty moving out of synergy.
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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
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General Exercise / PhysicalFitness
Promotion of personal fitness in the generalpopulation.
Offset decline in function due to ageing.
Assist in maintaining physical independence.
Evidence to show that people with disabilitiesalso benefit (Rimmer 2001,Andersson 2001).
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Benefits of MuscularStrength & Endurance
Increased fat-free mass & resting metabolicrate.
Increased bone mass.
Improved glucose tolerance.
Reduction in injury from falls & lower back pain.
A greater ability in activities of daily living.
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Summary
Children with CP have true muscle weakness
Strength directly related to function
Children have the ability to get stronger - muscle hasnormal ability to respond to training
Rate of strength increases are similar to that for muscleweakness not due to UMN lesion
Strengthening has functional benefits
Strengthening does not increase spasticity
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Which Treatments Do WeUse?
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Treatment Strategies
Variety of methods.
Progressive resistance weight training.
Isometric training.
Isokinetic training.
Weight-bearing exercises.
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Treatment Strategy
Dependent on pre-treatment evaluation
Physical exam – particularly strength ratiosacross a joint
Identification of functional goal –– GMFCS level i.eGMFCS level i.e
level of impairmentlevel of impairment
Patient specificPatient specific
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4 Main Principles
Overload Specificity
Individuality
Reversibility
(McArdle,2001;Bruton,2002)
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Muscle Strengthening
Strategies
Which muscles to bestrengthened?
Strengthen antagonistse.g hip extensors,
quadriceps, ankledorsiflexors
Lengthen spasticagonists
Concentrate on powerproducers for the task
Identify the goal
Strength training shouldbe prescriptive
Minimise joint stress –
hydrotherapy
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Muscle Strengthening
Strategies
Types of resistance.
Isotonic – fixed loadstressing parts of rangedifferently machines /weights.
Elastic – increases withlength.
Isokinetic – constant
velocity withaccommodatingresistance throughoutrange - cybex.
Weakness end of ranges
– isotonic
Weakness throughoutrange – isokinetic
Difficulty with quickmovements – isokinetic
Eccentric weakness –
isokinetic
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What Type of TrainingProgramme?
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).
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Muscle Strengthening
Strategies
General Principles
Load
Repetitions
Frequency
Duration
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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 withrest
Damiano
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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 alifetime.
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Muscle Treatment
Strategies - Summary
Loading muscles
exercise
stretching
casting under tension
electrical stimulation
general fitness
Muscles made to work
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But Unfortunately !
We usually have to usethe following techniques
unloading muscles
immobility & disuse
muscle & tendonreleases
casting without tension
but not without cost !
Muscles made not to
work
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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.
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North West RegionPaediatric Muscle
Strengthening Group 2 Collaborative projects
Physiotherapists: Alder Hey and NWRegion – clinical expertise
Researchers:Evidence-based ChildHealth Unit – methodological expertise
USE OF MUSCLE
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USE OF MUSCLE
STRENGTHENING IN CHILDRENWITH CEREBRAL PALSY
SURVEY OF PHYSIOTHERAPISTS
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Aims of project
A survey of paediatricphysiotherapists in the NW of England was carried out to ascertain
current clinical practice with regardsto use of muscle strengthening programmes in children and young
people with cerebral palsy.
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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
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Method – target population Paediatric physiotherapists in NW England
Region comprises 24 paediatric physiotherapy bases (dataobtained from the north west regional Primary CareTrusts)
Questionnaires, covering letters and stamped addressed
envelopes sent to the managers of each centre for
distribution amongst all their staff
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Method - analysis
Data entered into SPSS (v13) – double checked
Frequencies calculated
Responses from open-ended questions tabulated to
facilitate qualitative assessment
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Results
90 paediatric physiotherapists within the region submittedcompleted questionnaires.
37 respondents chose to identify their place of work,revealing that submissions were obtained from at least18/24 surveyed centres.
Proportion using
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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 musclegroups” (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 toworkload.
• caseload does not include children with CP.
69/90 (76.6%) responders reported using strengtheningprogramme.
M l t th i
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Muscle strengthening
methods used:
Functional exercises (eg sit-to-stand) 67/69(97.1%)
Individual’s own body weight or gravity 61/69(88.4%)
Resistance ‘devices’ (eg theraband, freeweights or manual)
39/69 (56.5%)
Gym equipment (eg treadmill, bike) 26/69(37.7%)
Hydrotherapy 50/69 (72.5%)
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Frequency: Pre and Post
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Frequency: Pre and Post-
op.Frequency Pre & Post Operative
0
10
20
30
40
50
60
70
80
Pre-
surgery
2-6 wks
post
surgery
7-12 wks
post
surgery
3-6 mths
post
surgery
6-12 mths
post
surgery
12+ mths
surgery
%
Daily
2/3 times p/wk
Weekly
Other
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Frequency - Post Botox
Frequ ency - Post Bo tox
0
10
20
30
40
50
60
70
80
Daily Three times
p/wk
Weekly Other
%Post-Botox - 2-6wksPost-Botox 7-12wks
Post-Botox - 3-6mtns
Frequency Weakness
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Frequency -Weakness
Identified
Frequ ency - Weakness Iden tif ied
0
10
20
30
40
50
60
70
80
Daily Three times
p/wk
Weekly Other
%
Weakness Identified - 2-6wks
Weakness Identified - 7-12wks
Weakness Identified - 3-6mths
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Frequency - Serial Casting
Frequency - Post Serial Casting
0
10
20
30
40
50
60
70
Daily 2/3 times
p/wk
Weekly Other
%
Serial Casting - 2-6wks
Serial Casting - 7.12wks
Serial Casting - 3-6mths
Frequency: qualitative
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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
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Progression- methods
25%
19%
11%
21%
20%
4%Increase reps
Increase holds
Increase w eight
Change starting
position
Change way muscle
w orks
Other
Treatment discontinued
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Treatment discontinued
when:
Goals reached 68.1%
Poor compliance78.3%
No improvement
55.1% Plateau of function
49.3%
Advice given on
cessation
Gym attendance28%
Activity clubs 58%
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Cochrane review:Muscle strengthening
for children and adults with
cerebral palsy
A well formulated question
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should include a descriptionof:
P – Initially children & adolescents 4-19 years with adiagnosis of cerebral palsy – expanded to include adults. I – Muscle strengthening including: graded resisted
exercise, progressive resisted strengthening, weightbearing exercise with added load, isokinetic training,
isotonic programmes, eccentric & concentric trainingprogrammes, electrical stimulation, functional strengthtraining.
C – any of above e.g. eccentric versus concentric, loadversus 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
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used to assess the efficacy of therapyor intervention.
Systematic Review of Randomised Controlled TrialsConfirmed Randomised Controlled Clinical Trials
Single Randomised Controlled Clinical TrialNon Randomised Controlled clinical Trial
Case Controlled Observational StudiesAnalysis of large computer databasesCase Series with Historical Controls
Case Series, Literature ControlUncontrolled Case SeriesAnecdotal Case
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Objectives:
To determine the effectiveness of any
form of muscle strengthening programmein children and adults with cerebral palsy.The effectiveness will be considered in
terms of both measures of musclefunction and muscle physiology/structure.
Sources Searched to Identify
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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 tosee if they are aware of any additional studies not already
identified by our review.
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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/ skillbased activities but not social or recreational activities.
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Research Ideas Intensive training over longer period – 1 year.
Intensive training v conventional physiotherapyfollowing multi level surgery.
Working together with sports scientists.
Muscle Strengthening
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Muscle Strengthening
Conclusions.
Muscle recruitment & co-activation problems are life-
long soft tissue management issues (Cusick 2002) Effect of immobility on general health and
independence
World-wide there is a move to guided treatments ratherthan 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
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Thank you!
Determinants of Muscle
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e e a s o us e
Force. Muscle fibre alignment
Physiological cross-sectional area
Motor unit recruitment
Muscle fibre type and length
Number of sarcomeres