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Muscle Strengthening in Cerebral Palsy Gill Holmes Gait Laboratory Manager Alder Hey Children’s NHS Foundation Trust

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Page 1: Muscle Strengthening & General Fitness

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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