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Physiological
Benefits of Physical Activity for Children
with Cerebral Palsy
Chris Kroger, Undergraduate
student, College of Health and Human
Performance, University of Florida,
Gainesville, FL
Cerebral palsy (CP) is a disability
of muscle coordination and control caused
by pre or post natal brain damage. All
the known cases of CP result from one
of 4 types of brain damage: 1) damage
to the white matter (periventricular
leukomalacia [PVL]), 2) abnormal
development of the brain (cerebral dysgenesis),
3) bleeding in the brain (intracranial
hemorrhage), or 4) brain damage
caused by a lack of oxygen in the brain
(hypoxic-ischemic encephalopathy or
intrapartum asphyxia) (6).
The direct cause of cerebral palsy
is unknown, but there are numerous factors
that seem to increase the likelihood
of its development. These include disease
(rubella, herpes simplex), low birth
weight (less than 3.3 lbs.), maternal
ingestion of alcohol, tobacco smoke
or certain drugs, infections, Rh incompatibility,
premature birth, and multiple births
(5). It
should be noted that according to the
National Institute of Neurological Disorders
and Stroke, birth complications, including
asphyxia, account for only 5-10% of
babies with cerebral palsy (6).
The common signs to look for regarding
babies with CP include dragging one
leg behind the other, making spastic
uncontrolled movements, difficulty with
precise motor skills, walking on his/her
toes, incontinence, uncontrolled drooling
and difficulty swallowing, and having
seizures. Slow development of the ability
to smile, crawl, sit, and walk are all
common signs of a baby with this disability.
CP is not a progressive disability,
so progressive worsening of muscle function
is a sign that the condition is something
else. While right now there is no cure
for CP, there are some prevention tactics
that can be used. Some of these include
mothers being vaccinated for rubella,
testing for and controlling the effects
of Rh factor early in pregnancy, using
car-seats the correct way, having your
child wear a bicycle helmet, and supervising
baths at a young age.
Diagnosing CP can be difficult due
to its similarity to other disorders
that affect youth. Although a doctor
is usually able to diagnose CP before
the age of 2, sometimes mild CP can
go undiagnosed or misdiagnosed until
4 or 5. Doctors run a series of simple
tests to evaluate the motor skills of
the patient, while also looking for
any of the signs mentioned above. If
suspicion of CP is present, a cranial
ultrasound, a magnetic resonance imaging
scan (MRI), or a CT scan may be done
to rule out anything else.
Out of these 3 tests, the MRI is the
one preferred by most doctors because
it offers the finest level of detail
(6). It
allows the doctor to see different areas
of the brain in order to evaluate the
extent of damage. Cranial ultrasound
is used for high risk premature babies
because it is the least intrusive of
the 3, but it is also the least effective
at discovering brain damage. Sometimes
disorders, such as a metabolic syndrome
or a coagulation disorder, can be confused
with CP depending on the area of the
brain that is affected. Coagulation
disorders can cause strokes leading
to brain damage, and produce symptoms
similar to those of a patient with CP.
When this is the case, it is important
for a doctor to identify it quickly
and not misdiagnose it as CP, because
of the likelihood that another stroke
could cause more damage to the brain
(6).
There are several different treatments
for cerebral palsy, and the extent of
the treatments all depend on how severe
the individual's disability is. If an
individual has severe CP, it may require
surgery to correct any physical deformities
that hinder day to day activities. Spastic
muscles can not only limit functional
ability, but also be very painful; drugs
and muscle relaxants can be taken to
prevent this. A patient with CP may
require a slew of professionals to satisfy
all their needs: orthopedist, psychologist,
speech pathologist, a physical therapist,
and an occupational therapist. Along
with the team of professionals, a "team"
of instruments help make life easier.
Wheelchairs are used for transportation,
mechanical devices such as synthesizers
and computers are used to help communicate,
and various braces and orthotics are
often used to increase muscle control,
stability, and coordination (6).
One major problem that children encounter
with cerebral palsy is the contracture
of their muscles. If their muscles and
tendons are too spastic, the bones will
grow too quickly causing them to become
very rigid and distorted. This can become
an extremely painful condition, and
may sometimes require surgery and/or
the use of an orthotic to keep the muscle
stretched. However, we are finding more
and more that simple daily exercise
seems to be the most effective way to
prevent complications (6).
Lack of physical activity can lead
to many secondary conditions associated
with CP, such as chronic pain, fatigue,
and osteoporosis (2).
Because movement helps muscle growth,
muscle weakness is the number one problem
in children with CP. Evidence has revealed
that children with CP exhibit an increase
of co-activation of antagonist muscle
groups. This causes an overall loss
in net
torque produced at a joint, thus
resulting in a smaller force. A strength
training regimen has shown to increase
function.
Sometimes it has been difficult for
researchers to determine what is the
correct load to give a child with CP,
and thus gains have been indeterminate.
However, recently gains have appeared
to be more consistent with the ability
to calculate the load the patient should
move (2).
Therapists have moved to the water,
using swimming ad hydrotherapy to treat
many of their patients. Hydrotherapies
"… provide an opportunity
to improve physiological and psychological
achievements" (3,
pg.927). Water sports are often
a total body workout minus the pounding
your joints take on a solid surface.
Warm temperatures also help increase
muscle flexibility and thus the ability
to move around (3).
Exercise protocols have included underwater
lower extremity workouts with fins,
boots, and ankle weights; just like
any strength straining program, weights
were added accordingly as progress was
made. Results from these studies have
shown a positive influence on activity,
but it is difficult to determine how
effective they are functionally.
Increased cardiovascular function helps
decrease body fat and bad cholesterol,
thus decreasing risk for heart disease.
Evidence of a reduced peak VO2 and a
higher sub-maximal energy demand of
walking indicate that children with
CP have low cardiorespiratory fitness.
We can deduce that if a child with CP
is having other motor difficulties,
it is going to be difficult for him/her
to build strong cardiorespiratory fitness.
Two studies using cycle ergometers and
stationary bicycles have shown an average
8-12% increase in peak VO2. The longer
of the 2 studies ran for 16 months,
and conducted 3-20 minute sessions per
week. After 9 months, a 4 times/week
regimen of cycling, swimming, wheelchair
propulsion, running, and mat exercises
yielded a 35% increase in peak VO2 when
compared to a control. The control group
also showed an increase in body fat
during that same period (2).
A disability can hit hard at someone's
confidence, especially if the disability
leaves them distorted or disfigured
in some way. One common side effect
of CP is poor posture or a crouched
gait. The objective of a study in South
Africa was to determine how a strength
training regimen using relatively low
cost equipment would directly affect
gait and perceptions of body image.
Their study included a circuit of 8-12
weight training exercises with dumbbells,
free weights, wrist cuffs, and work
out balls. They allowed the subjects
to start by setting their own comfortable
resistance and monitored them closely.
As soon as any subject could complete
3 sets (or 12 repetitions) of any exercise,
the weight was increased. At the end
of the 12 week program all the members
in the experimental group had a more
upright posture resulting from a change
in joint angles at the ankle, knee,
and hip. Most of the subjects also reported
having an increase in their perceptions
of their body image and its ability
to perform certain tasks. The greatest
positive was that the teens were able
to build more confidence in what their
bodies could endure (4).
While it seems evident that exercise
is a phenomenal prevention factor for
people with CP, there is still a lot
of research that needs to be done in
the area. Most of the evidence supporting
physical activity relates only to spastic
CP. There are continuously new developments
for children born with neurological
disabilities, and they receive a lot
of support from the National
Institute of Neurological Disorders
and Stroke. Just recently in Taipei,
virtual reality testing was used to
affect reaching behavior in patients
with CP. A virtual exercise setting
was created that tested 4 kinematic
parameters as well as fine motor skills.
After short use with the system, 3 out
of 4 subjects showed improvements (1).
Hopefully, with more critical research
an innovative technique can be discovered
to help control CP even more.
references:
- Mei-Wun Tsai, Suh-Fang Jeng, Wen-Hsu
Sung. Use of Virtual Reality to Improve
Upper-Extremity Control in Children
with Cerebral Palsy: A Single Subject
Design. Phys Ther. Nov2007,
Vol. 87 Issue 11, p1441-1457.
- Eileen C Fowler, Thubi HA Kolobe,
Diane L Damiano, Deborah E Thorpe,
Don W Morgan, Janice E Bmnstrom, Wendy
J Coster, Richard C Henderson, Kenneth
H Pitetti, James H Rimmer, Jessica
Rose, Richard D Stevenson. Promotion
of Physical Fitness and Prevention
of Secondary Conditions for Children
with Cerebral Palsy: Section on Pediatrics
Research Summit Proceedings. Phys
Ther. Nov2007, Vol. 87 Issue
11, p1495-1510.
- Miriam Getz, Yeshayahu Hutzler,
Israel and Adri Vermeer. Effects of
aquatic interventions in children
with neuromotor impairments: a systematic
review of the literature. Clinical
Rehabilitation. 2006; 20: 927-936.
- Marianne Unger, Mary Faure, Annette
Frieg. Strength training in adolescent
learners with cerebral palsy: a randomized
controlled trial. Clinical Rehabilitation.
2006; 20:469-477.
- Cerebral
Palsy Columbia Encyclopedia; (AN
IXBcerebral)
- Cerebral Palsy: Hope Through Research
http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#88033104.
Feb 7, 2008.
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