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Exercise and Cerebral Palsy

Cerebral palsy (CP) patients with different degrees of severity have distinct impairments of muscle strength, coordination and balance[1] which makes them less physically active than the normal population[2]. CP is categorised into 4 major types, in which the most common one is the spastic type (70-80% of the cases) and the rest belongs to the athetoid, the ataxic and the mixed type[3]. Spastic CP patients always experience body stiffness, contracture, abnormal reflexes and gait (hypertonia), while other movement problems such as floppiness, tremors appear in other types of CP[4], which hinders the patients to exercise in various extent. The disease is also classified by the locations of the motor impairments, such as diplegia and hemiplegia[4]. It should be noted that a large variety of symptoms exists among CP patients, therefore, the conditions for different patients to exercise should be considered independently.

It is suggested that CP children to have one hour of physical activity (moderate to high intensity), five days per week[2]. Given that CP patients can attain a range of benefits through exercise, including boosted muscular strength and endurance, cardiorespiratory fitness and flexibility[5]. Exercise is important for CP patients to maintain health and motor movement.

Exercise Interventions

Aerobic Exercise

Aerobic exercise can improve cerebral palsy (CP) patients’ aerobic fitness[6] and general motor function[7]. CP patients can improve peak aerobic power[8], which refers to the muscle's ability to use oxygen to generate energy[9], by doing aerobic exercise, such as cycling, running, swimming. Another advantage of conducting aerobic training is that their muscle strength is enhanced and the energy required for CP patients to ambulate is reduced, which in turn assists them to cope with the motor impairments and activity restriction related to CP[6]. Though aerobic exercise promotes CP patients’ mobility and ability to execute daily tasks, they may have difficulties to exercise since cerebral palsy fatigue always resulted in poor movement economy[10], which means more energy is needed to achieve the same intensity of physical activity. These obstacles can be addressed by tailoring the type, intensity and duration of exercise to patients with different levels of the disease[10]. CP patients should also pay attention to proper head, trunk and joints position during the workout, since they are more subject to overuse injuries[10].

Aquatic Exercise

Aquatic exercise, which refers to the aerobic exercise in water, may overcome several problems associated with CP patients practicing exercises. CP patients with impaired balance, joint problems, together with instability, serious contracture are unable to perform some land-based exercises. On the other hand, in the water environment, the buoyancy could ease the effect of poor posture control and balance on the performance of exercise. And patients improve gross motor function, including flexibility and muscle strength, through aquatic workout[7].

Resistance Training

Resistance training can improve cerebral palsy (CP) patients’ muscle strength by working against a weight or force. The major benefits of this kind of exercise are improved neuromuscular performance (including the performance of muscles and the nerves serving them), as well as motor function[11]. These physical improvements, including enhanced strength, flexibility and fine-motor cooperation[11] enable the patients to perform better in daily activities[12]. In one case study, strengthening the knee extensor could support patients’ standing, walking, running and jumping[12]. In specific, resistance exercise particularly trains the weak muscle groups that oppose hypertonic muscle (excess passive tightness or stiffness) so as to balance the abnormal muscle tone through reciprocal inhibition[10]. Therefore, it is important to identify any asymmetrical weakness, through individual muscle group’s assessment, and training of weaker muscles could generate greater effort with more effective contraction. To protect the patients from potential hurt, appropriate warm-up, stretching and cool-down should be performed in slow, dynamic muscle strengthening exercises[10]. Stretching section before exercise could reduce muscle fatigue too[10].

Cardiorespiratory Endurance

Cerebral Palsy (CP) is known to be related to lowered cardiorespiratory endurance in CP patients[13], cardiorespiratory endurance is the ability of the lungs, heart, and blood vessels of delivering oxygen to the rest of the body[14]. CP increases the risk of cardiovascular disease and respiratory disease, including risks of angina, upper respiratory infections, and pneumonia[15][16] as it directly affects muscles that are crucial for heart and lung functioning. It is necessary for CP patients to improve their cardiorespiratory endurance in order to enhance own physical fitness, which directly affects the ability to carry out tasks without fatigue thus predict potential life quality[17].

Exercise is one of the ways to improve cardiorespiratory endurance. With CP, it is normal that patients have a lower threshold of exercise intensity, nevertheless, cardiorespiratory endurance is not about the intensity but the ability to sustain a moderate level of exercise. It is suggested that patients should set a goal depending on their heart rate in order to improve cardiorespiratory endurance. The target heart rate during an exercise should be kept between 40-85% of their maximal heart rate with a recommended duration of 10 minutes for cardiorespiratory fitness[18]. Heart rate should be monitored well during exercise for CP patients, a heart rate of too high is risky given that CP patients are more likely to develop heart failure[19], while a low heart rate is not effective in cardiorespiratory endurance training. It is important to note that CP patients are not suggested to do trainings that stimulates a sudden and immediate increase in heart rate, the pace should be slowly built[19]. Some suitable exercises for CP patients to train their cardiorespiratory endurance are jogging and biking, for patients with problems of using their legs, arm exercisers upper extremity ergometers which act same as a bike can be used instead, more will be explained in later sections. While it is also suggested that swimming program is effective in improving lung function and breathing efficiency by enhancing muscles involved especially in children, as they are in a critical stage of body development[16].

Others

Several new researches have suggested some innovative ways to help cerebral palsy (CP) patients through exercising, while dancing is one of them. Dancing requires good skills in balancing movements, effective strength usage, and endurance, while these are usually the weaknesses of CP patients as their muscles function decline with age. Through dancing, these weaknesses could be trained and improved, researches also proved that dancing helps improving neurorehabilitation for CP[20].

Yoga is also said to be a beneficial exercise for CP patients, and is commonly introduced to children with CP. One thing about yoga is that it can be modified according to each individual's needs and limitations[21], which is important for CP patients as they usually have different extents of physical limitations and weaknesses. It is stated that yoga improves respiration for CP patients by allowing a rhythmic and deeper breathing[22], it can also reduce muscle tone hence improving flexibility of patients, leading to an increase of range of motion, which plays an important role in mobility[21][22]. Stretching exercises have similar effects on CP patients, it relieves stiffness of muscles over time, benefit spastic CP patients the most[23]

Patient's Conditions

Age

Although both children and adults with cerebral palsy (CP) could promote health and adapt to normal daily life through exercise, the outcomes of exercise for different ages may be slightly different. For children, the ultimate goal of exercise would be enhancing bodily functions and performance, whilst adults could manage secondary conditions, referring to physical and mental health conditions resulted in paralysis, through exercise.

Children

Children with cerebral palsy have weakened muscle's strength and endurance, which are worsened by sedentary lifestyle and a lack of physical activity[24]. By doing different kinds of exercise, CP children could promote muscle fitness and joint range of motion[5] to tackle with everyday issues associated with physical disability. However, children who have uncontrolled epilepsy or severe osteoporosis should avoid physical activity[25].

Adults

Although cerebral palsy is a non-progressive disease, which means it would not worsen with age, physical discomfort and stress accumulate in the patient's body, which leads to pain and premature ageing in adults[26]. Great burdens are added on the body as CP patients spend extra energy for everyday tasks repeatedly, attributed to the fatigue and bodily weakness with the disease[26]. By doing exercise, pain could be eased[27] and the physical dysfunction could be mitigated[26].

Motor Level and Fitness

CP patients are advised to assess their motor level and fitness before designing tailored exercise programming, usually with the assistance of physicians[28]. A core set of tests (submaximum, maximum and anaerobic exercise tests) related to motor skills especially of CP patients is available[29]. For CP patients classified to the Gross Motor Function Classification System (GMFCS) level I and II, tests are related to walking and cycling skills. While, tests are related to arm cranking and cycling for CP patients of GMFCS level III and IV[29].

Assistive Technologies

Various types of technologies can be used to assist cerebral palsy (CP) patients during exercises.

Hip-extensor tricycle is a bicycle designed to strengthen hip extensor muscles, it works by applying different amount of extra weight thus controls the pressure of cycling and is more effective and safe in terms of muscle training[30]. It is commonly applied on children with CP to improve the gait, as walking impairment is one of the symptoms of CP, and the tricycle is said to be able to improve patients' gait thus walk movements through assisting motor control in gait[31][32]. Upper extremity ergometers are devices similar to hip-extensor tricycle that functions in a same mechanism except they are arm exercisers. These devices can be widely used by CP patients to improve limb muscles strength thus enhancing their mobility.

Barriers

Cerebral Palsy (CP) affects individuals in many ways and life aspects, causing different barriers that influence patients' ability to exercise.

Health Issues

The main symptoms of cerebral palsy are changes in coordination, strengths, and muscle tone[33]. Other than these symptoms, there are some extra health issues that can arise in CP patients, vary within cases, critical in affecting patients' ability to exercise. Epilepsy is one of these issues, the National Institute of Neurological Disorders defined epilepsy as a "spectrum of brain disorders"[34], people suffer from epilepsy are susceptible to unprovoked seizures repeatedly, results in occasional involuntary movements, for example, loss of consciousness[33][34]. Researches stated that around 40% of individuals suffering from CP experiences epilepsy[33][35]. These unpredicted seizures increase the risk of any type of exercise, it becomes hard for patients to exercise without supervision. In some severe cases, patients need support in maintaining body position, and to sit or stand[36], it is hard for them to perform voluntary movements and exercises.

Other than physical impairment, cognitive impairment is also associated with CP patients, causes them barriers in exercising. Around 40% of CP patients are cognitively impaired to different extents[37], leading to different outcomes including fatigue, attention issue, trouble in sensory information interpretation and movement control[37][38]. These outcomes make exercise more difficult for CP patients.

Caregivers' Capability

Since CP children and patients with higher level of motor impairment rely on the assistance given by the caregivers, the extent of CP patients' involvement in exercise would highly depends on their caregivers. However, the caregivers always have time limitation, high stress, financial and emotional burdens, attributed to the special needs of the patients[39]. Time and psychological state of the caregivers would be one of the factors determining their active level.

Social Factor

The society may not have significant acceptance and support for the CP patients. The sports clubs or communities may not welcome CP patients, due to the general undesirable attitude towards the disabled, or may not have the equipments to support this population[40]. Therefore, the opportunity for CP patients to get involved in exercise would be diminished.

Perspective

The Cerebral Palsy-International Sports and Recreation Association (CP-ISRA) classified cerebral palsy patients into 8 classes by their severity, patients suffer from various kinds and extents of symptoms might affect their abilities of performing different types of exercise[41]. Given this, exercise interventions and assistive technologies stated above are only some possible ways that help CP patients, before performing any type of exercise, it is important to consult with clinicians to personalize an exercise routine for patients according to their own needs and conditions. There are different ways of identifying beneficial exercise interventions for CP patients, for example, Cardiopulmonary exercise testing (CPET) can access patients' exercise tolerance by combining different test results. Clinicians can then evaluate the risks of unsatisfying health outcomes and benefits from different exercise interventions[42] through these procedures. Patients not accessible for exercise can keep active by moving as much as possible everyday[43], small movements make difference by preventing accelerated deterioration of the condition. The importance of exercising in CP patients, a high-risk population, must not be underestimated under any circumstances.

See also

Cerebral Palsy

Cerebral Palsy Sports Classification

Management of Cerebral Palsy

References

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  29. ^ a b Verschuren, Olaf; Ketelaar, Marjolijn; Keefer, Daniel; Wright, Virginia; Butler, Jane; Ada, Louise; Maher, Carol; Reid, Siobhan; Wright, Marilyn; Dalziel, Blythe; Wiart, Lesley (2011). "Identification of a core set of exercise tests for children and adolescents with cerebral palsy: a Delphi survey of researchers and clinicians". Developmental Medicine & Child Neurology. 53 (5): 449–456. doi:10.1111/j.1469-8749.2010.03899.x. ISSN 1469-8749.
  30. ^ Howell, Glade; Brown, Don; Bloswick, Donald; Bean, Jeffrey; Gooch, Judith (1993-02-01). "Design of a Device to Exercise Hip Extensor Muscles in Children with Cerebral Palsy". Assistive technology : the official journal of RESNA. 5: 119–29. doi:10.1080/10400435.1993.10132216.
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  34. ^ a b "Cerebral Palsy and Epilepsy". www.cerebralpalsyguidance.com. Retrieved 2020-04-04.
  35. ^ Mesraoua, Boulenouar; Ali, Musab; Deleu, Dirk; Hail, Hassan Al; Melikyan, Gayane; Haddad, Naim; Alalamy, Osama; Athanasios, Covanis; Asadi-Pooya, Ali A. (2019-05-08). "Epilepsy and Cerebral Palsy". Neurodevelopment and Neurodevelopmental Disorder. doi:10.5772/intechopen.82804.
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  39. ^ Majnemer, Annette; Shevell, Michael; Law, Mary; Poulin, Chantal; Rosenbaum, Peter (2012-07). "Indicators of distress in families of children with cerebral palsy". Disability and Rehabilitation. 34 (14): 1202–1207. doi:10.3109/09638288.2011.638035. ISSN 0963-8288. {{cite journal}}: Check date values in: |date= (help)
  40. ^ Verschuren, Olaf; Wiart, Lesley; Hermans, Dominique; Ketelaar, Marjolijn (2012-09). "Identification of Facilitators and Barriers to Physical Activity in Children and Adolescents with Cerebral Palsy". The Journal of Pediatrics. 161 (3): 488–494. doi:10.1016/j.jpeds.2012.02.042. ISSN 0022-3476. {{cite journal}}: Check date values in: |date= (help)
  41. ^ Alliance, Cerebral Palsy. "How does cerebral palsy affect people? | Cerebral Palsy Alliance". Retrieved 2020-04-03.
  42. ^ Verschuren, Olaf; Peterson, Mark D.; Balemans, Astrid C.J.; Hurvitz, Edward A. (2016-8). "Exercise and Physical Activity Recommendations for People with Cerebral Palsy". Developmental medicine and child neurology. 58 (8): 798–808. doi:10.1111/dmcn.13053. ISSN 0012-1622. PMC 4942358. PMID 26853808. {{cite journal}}: Check date values in: |date= (help)
  43. ^ "If Your Child Has Cerebral Palsy". WebMD. Retrieved 2020-04-03.
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