Exercise Program to Increase Mobility for Children with Cerebral Palsy

by Phillip Conatser & Ulku Karabulut University of Texas

This workout program is designed to give physical educators the tools needed to increase mobility, strength, and endurance for children with cerebral palsy (CP). Suggestions about body characteristics, stretching ideas, and workout strategies will also be presented. We share four complete workout programs designed on a continuum from less able to higher functioning such as for children who use wheelchairs, walkers to crutches or canes.

As with any exercise program, intensity, duration, and frequency need to be optimized.
To help ensure the endurance component, children should maintain their heart rate at 60 to 80% of their max for 35 minutes.  Note: if students are exercising in a wheelchair or lying horizontal, reduce their maximum heart rate by 20 to 30 beats per minute.  For example, a girl 10 years old who uses a wheel chair, would have a target range of 220 - 20 or 30 = 190 or 180 x .6 to .8  = 114 to 152 or 108 to 144 beats per minute.  Exercises should be three or more times a week.  Remember, when doing weight lifting, move quickly from set-to-set or machine-to-machine to help maintain a higher heart rate.

Key Aspects to Remember and Look For

A.  The Body
1.  Primitive reflexes
      a.  Symmetrical tonic neck reflex: This will result in an extension of the arms and flexion of legs.
      b.  Mora reflex: Loud noises will result in extension of extremities.
      c.  Cross extension reflex: Fluctuation in muscle and/or movement of one limb reflex affects the other.
2.  Tendon reflexes are easily excitable and stretch reflexes are exaggerated.
3.  Agonist muscles strongly flexed; antagonist muscles usually stretched.
4.  Increased muscle tone, primarily in the antigravity muscles, resulting in abnormalities and muscle imbalance.
5.  Can have contractures in major or minor joints.
6.  Possible problems with spatial awareness, balance, and kinesthetic sense.
7.  Athetoid problems
     a.  Involuntary movement (keep extremities close to anatomical position; slow controlled movement)
     b.  Too little tone
     c.  All four limbs affected

B.   Stretching
1.  Generates heat in the muscle due to the metabolism of contraction and relaxation.
2.  Reduces the viscosity of muscular fluids and synovial fluid.
3.  Use active as well as passive stretching.
4.  Put the lower back on stretch first, then work out to extremities.
5.  Work to maintain symmetry and a mid-line position.  May also be used during the workout.
6.  Do not force a stretch by bouncing. 
7.  The stretching must be done gradually (on & off stretch).
8.  3 to 10 seconds on stretch release and repeat 3 times (1x relax-2x contract -3x relax).
9.  5 to 15 minutes on stretch.  If you are tying to stretch aggressively against the tone release and repeat 1 time.

C.  The Workout
1. Use your hands to interpret which muscle is being used to perform a movement.  Also, hands can be placed to maximize the desired motor response.
       a.  Facilitative input to a muscle (tapping or providing resistance to activate muscle response).
       b.  As a directional control.
       c.  Preventing an undesirable movement.  Ex:  Against pattern/tone.
2.  Do exercises in and out of pattern.
3.  Work exercises as a unit and independently.
4.  Tone activation (strength) should be considered to enhance a movement at first; then, to alleviate tone interference, put tone on stretch.
5.  Use proper alignment of the spine, pelvis, and lower and upper extremities (skill specific).
6.  Physically help the child perform a movement through the full range of motion on concentric contractions.
7.  Isometric contraction should be performed at maximum extension, flexion, abduction, plantar or dorsal flexion.
8.  Eccentric contraction in some cases is the first way to involve a muscle.
9.  While performing an exercise, the child should, at one time or another, have felt their muscle   contract/relaxed and if possible look at their muscle while performing the exercises.
10. Small muscle groups 1 to 3, set of 10; large muscle groups, 1 to 3, set of 20.
11. Intensity of workout and accurate documentation daily is a vital aspect for success.
12. Adaptive PE teachers, classroom teachers, doctors, PTs, OTs, and parents, all need to work congruently together.           
13. This workout program needs to be approved on an individual basis by the I.E.P. meeting.       

LEVEL 1: Workout for very physically challenged individuals

Warm-up:
The warm-up will need to be individualized and contain some type of movement for 8 to 10 minutes.  Suggestions include, rubbing/massaging the muscle, vestibular movements, weight-bear a muscle group or you physically manipulate a particular gross motor movement, activating primitive reflexes with physical prompting (this form of stimulating muscle contraction is only for people who have no active ROM).
Stretches:   (passive or active)
1.  Calf stretch
2.  Knee to chest
3.  1/2 back roll
5.  Ham stretch
6.  Quad stretch
7.  Sit and reach
8.  Half-mat hurdle stretch
9.  Butterfly stretch
10. Spinal twist
11. Shoulder stretch (subscapular tilt, maximum rotation on dislocates and inlocates)
12. Neck rotation
13. Arm and hand stretch, (supinate arm, fingers to neutral position then work thumb out)
14. 7-13 can be facilitated in 2 person sitting position

Suggestions for workout:
1.  Use simple key words to describe how the exercise mite feel or relate to.
      EX:  For leg curls say "pool" or for leg extensions say "kick"
2.  Use you hands to direct, stabilize, or stimulate muscle movement.
3.  When assisting an exercise, try to encourage them to do most of the work.
4.  Encourage any and all active r.o.m./dynamic movements.
5.  Some weights might be involved but gravity and or you will provide the resistance.
6.  Review the sections earlier concerning the body stretching and workout.

Workout M W F (1 set):
1.  Log roll, (front to back and back to front)
2.  Creeping
3.  Combed crawling
4.  Head control exercises
5.  Sit-ups (Assisted)
6.  Pull-ups (floor)
7.  Arm lifts (front, side, and front circle (clockwise and counterclockwise))
8.  Butterflies
9.  Arm curls
10. Forearm and finger grip exercises
11. Bench press
12. Pulls
14. Diaphragm exercises  
14. Lat pulls (rubber band)
15. Upright rows (one arm or both at a time, rubber band)
16. Any active range of motion (r.o.m.) or dynamic movement isolates and strengthens

Workout T TH SAT (1 set)
1.  Plantar and dorsal flexion
2.  Bent knee side to side
3.  Front leg lifts
4.  Leg curls
5.  Leg extensions
6.  Squats (possible concentric "+" contractions only)
7.  Knee walking and supine position walking.
8.  Knee or standing balance
9.  Back arches
10. Any active r.o.m. /dynamic movement isolates and strengthen

Equipment:
1.  Mat
2.  Ankle or arm weights
3.  Squeezable object

Activities TTh: 
1.  Nos. 2, 3, and 11 repeat
2.  Nos. 13 to 15 can be done on this day.
3.  Adaptive bikes or tricycle 5 to 8 minutes
4.  Walking with assistance (goal 130 yards) Note: Walk with deferent surfaces.
5.  Independent walking (goal 8 to 10 feet) Note: Walk with smooth surface.
6.  Walking with arm supports (goal 70 yards) Note: Walk with smooth surface.

LEVEL 2: Workout for Walker

Warm-up:   
Choose a particular exercise that will involve as many muscles as possible for 3 to 5 minutes (walking, etc.)

Stretches:
1.  1/2 back roll
2.  Knee to chest
3.  Right hand, left toe
4.  Spinal twist
5.  Butterfly
6.  Quad stretch
7.  Half-mat hurdle stretch
8.  Sit and reach
9.  Neck rotation
10. Shoulder stretch
11. Arm and hand stretch, (supinate arm, fingers to neutral position then work thumb out)
12. Calf stretch
13. Ham stretch

Workout MWF (2 sets):
1.  Knee or standing balance
2.  Knee walking and supine position walking.
3.  Squats; Hint: do not allow knees to adduct.
4.  1/2 squats
5.  Leg extensions (supine and sitting; legs together and independent)
6.  Leg curls (in and out of pattern, standing or prone)
7.  Hip flexor (prone and bent knee or doggy position)
8.  Front leg lifts
9.  Bent knee side to side
10. Plantar and dorsal flexion (sitting, bent knee or standing)
11. Sit-ups (knee bent at different heights)
12. Outer thigh
13. Push-ups
14. Forearm and finger grips
15. Arm lifts (front, side, and around to pocket)

Activities TTh: 
1.  Nos. 2, 3, and 11 repeat
2.  Nos. 13 to 15 can be done on this day.
3.  Adaptive bikes or tricycle 5 to 8 minutes
4.  Walking with assistance (goal 130 yards) Note: Walk with deferent surfaces.
5.  Independent walking (goal 8 to 10 feet) Note: Walk with smooth surface.
6.  Walking with arm supports (goal 70 yards) Note: Walk with smooth surface.

Consulting:
1.  Walker all time (school, home, etc.)

Equipment:
1.  Walker
2.  Bike
3.  Mats
4.  Ankle and arm weights
5.  Squeeze ball

Possible Braces:
AFO, KAFO, HKAFO

LEVEL 3: Workout for Arm Support

Warm-up:    
Walk with arm supports for 3 to 5 minutes

Stretches:
1.  1/2 back roll
2.  Knee to chest
3.  Right hand, left toe
4.  Spinal twist
5.  Butterfly
6.  Quad stretch
7.  Half-mat hurdle stretch
8.  Sit and reach
9.  Neck rotation
10. Shoulder stretch
11. Arm and hand stretch, (supinate arm, fingers to neutral position then work thumb out)
12.  Calf stretch
13.  Ham stretch

Workout MWF (3 sets):
1.  Standing balance (1 minute)
2.  Standing, locked knees (1 minute)
3.  Squats (1 set) Hint: do not allow knees to adduct.
4.  1/2 squats (4 sets)  *If possible with arm supports.
5.  Leg extensions (sitting; legs together and independent)
6.  Plantar and dorsal flexion (sitting, bent knee or standing)
7.  Leg curls (in and out of pattern, standing or prone)
8.  Front leg lefts
9.  Back arches
10. Bent knee side-to-side
11. Hip flexor (prone and bent knee)
12. Sit-ups (knees bent)
13.  Outer thigh
14.  Push-ups
15.  Forearm and finger grips
16.  Arm lifts (front, side, around to pocket)

Activities Tithe:
1.  Nos. 1 to 5, repeat 1 set
2.  Walking with arm supports (goal 130 yards under 10 minutes) Note: Be attuning to form, speed, and safety.
3.  Cruising, with 10 steps between objects. Note: Walk with smooth surface.
4.  Independent walking (goal 20 feet) Note: Walk with smooth surface.

Consulting:
1.  Arm supports all the time
2.  Walker only when necessary
3.  Cruising sometimes (desk to desk, home, very short distances)

Equipment: 
1.  Arm supports
2.  Walker
3.  Mats
4.  Ankle and arm weights
5.  Squeeze ball
Possible Braces:         
Short AFO, KAFO, HKAFO, part time or none, Loftstand crutches, Forearm Platform crutches, sticks

LEVEL 4: Workout for Walking

Warm-up:     
Cruising for 3 to 5 minutes

Stretches:     
1.  1/2 back roll
2.  Knee to chest
3.  Right hand, left toe
4.  Spinal twist
5.  Butterfly
6.  Quad stretch
7.  Half-mat hurdle stretch
8.  Sit and reach
9.  Neck rotation
10. Shoulder stretch
11. Arm and hand stretch, (supinate arm, fingers to neutral position then work thumb out)
12. Calf stretch
13. Ham stretch

Workout MWF (3 sets):
1.  Standing balance with locked knees (goal 3 minutes or more)
2.  1/2 squats (4 sets)
3.  Leg extension (sitting; legs together and independent)
4.  Plantar and dorsal flexion (sitting, bent knee or standing)
5.  Leg curls (out of pattern, standing)
6.  Front leg lifts
7.  Bent knee side-to-side
8.  Hip flexor (prone, 4 sets)
9.  Sit-ups
10. Outer and inner thigh
11. Push-ups
12. Forearm and finger grips
13. Arm lifts (front, side, around to pocket)

Activities TTh:
1.  Nos. 1, 2, and 3 repeat 2 sets
2.  Cruising (goal 130 yards) Note: Walk with smooth surface.
3.  Independent walking (goal 60 yards) Note: Walk with deferent surfaces.

Consulting:  
1.  Cruising -- independent walking all the time.
2.  Walking with arm supports only when necessary.

Equipment: 
1.  Mats
2.  Arm supports
3.  Ankle and arm weights
4.  Squeeze ball

Possible Braces:       
Short AFO, part time or none.  

Biography: Phillip Conatser is an Associate Professor, Department of Health and Human Performance, at the University of Texas, Brownsville. Read his biographical information here. http://www.utb.edu/vpaa/coe/Pages/PhillipConatser.aspx

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