Authors: Naomi Sard (our Awesome Practical UNSW EP Student) and Mia J Kacen
The clinical condition, Cerebral palsy (CP) encompasses a group of disorders affecting the development of movement, muscle tone and posture (Patel, Neelakantan, Pandher & Merrick, 2020) causing activity limitations. This clinical condition is attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain (Olney, Doernbery & Yeargin-Allsop, 2014). In addition to the motor disorders of CP disturbances of sensation, perception, cognition, communication, behaviour, epilepsy and secondary musculoskeletal problems are also often present (Patel, Neelakantan, Pandher & Merrick, 2020).
Often classification of CP helps identification of risks of contracture, deformity and outcome interventions. However, there are several classifications of CP including;
2. Movement disorder
(Johari, Maheshwari, Thomason & Khot, 2016).
Classification & Information
Monoplegia (affecting one lower limb - is uncommon),
Hemiplegia (one side of the body),
Diplegia (affects involvement of the lower limbs maybe some fine motor deficiencies will still be present in upper limbs),
Quadriplegia (all 4 limbs and trunk are affected, upper limbs are equally or more affected than lower limbs)
(Johari, Maheshwari, Thomason & Khot, 2016).
Spastic, dyskinetic, ataxic, mixed (Gorter, Verschuren, van Riel & Ketelaar, 2009).
Spastic CP arises from motor cortex damage characterised by resistance to externally imposed movement increases with increasing speed of stretch which varies with direction of joint movement. In this form of CP the muscles appear stiff and movements jerky (Gorter, Verschuren, van Riel & Ketelaar, 2009).
Dyskinetic forms of CP are characterised by variable involuntary movements noticeable when a person attempts to move (Alliance, 2020). Some of these involuntary movements include; repetitive movements like twisting (dystonia), slow movements (athetosis), dance like and/or unpredictable movement (chorea) (Edwardo Ramos, Daniel Moon, K. Rao Poduri & Christina Marciniak, 2020).
Ataxia, “without order”
Is the inability to generate normal or expected voluntary movement trajectories, not attributed to weakness or involuntary muscle activity about the affected joints. Characteristically appears as clumsiness or instability that appears jerky, evident in movements such as walking or picking up something ) (Johari, Maheshwari, Thomason & Khot, 2016).
Gross motor function, upper limb function, communication.
(Johari, Maheshwari, Thomason & Khot, 2016.
Gross motor functional classification system (GMFCS)
Developed to create a systematic way to describe the functional abilities and limitations in motor function of children and adolescents with CP.
(Johari, Maheshwari, Thomason & Khot, 2016.
Another functional classification system is the Cerebral Palsy International Sports and Recreation Association Functional Classification System (CPISRA).
Although usage of this system in sports is now limited its functional classification maybe relevant to exercise prescription. This moves from those with most severe spasticity to least and functionally classes:
1-4 describe those who are wheelchair users and
Classes 5-8 as ambulatory
(Riebe, Ehrman, Liguori & Magal, 2018).
Upper limb function
This can be described using the manual ability classification system (MACS) as it describes how a person with CP uses their hands to handle objects in everyday daily activities.
Level 1 = handles objects easily and successfully
Level 2 = handles most objects but with somewhat reduced quality and/or speed of achievement.
Level 3 = handles objects with difficulty; needs help to prepare and/or modify activities.
Level 4 = Handles a limited selection of easily managed objects in adapted situations. Performs parts of activities with effort and with limited success.
Level 5 = Does not handle objects and has severely limited ability to perform even simple actions
(Johari, Maheshwari, Thomason & Khot, 2016.)
Can be assessed using, The Communication Function Classification System (CFCS) which classifies patterns of an individuals communication performance in one of five levels(Johari, Maheshwari, Thomason & Khot, 2016).
Level 1 = Effective Sender and Receiver with unfamiliar and familiar partners.
Level 2 = Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.
Level 3 = Effective Sender and receiver with familiar partners
Level 4 = Inconsistent Sender and/or Receiver with familiar partners
Level 5 = Seldom Effective Sender and Receiver even with familiar partners
Figure 1 copied from Edwardo Ramos, Daniel Moon, K. Rao Poduri & Christina Marciniak, 2020
Physical Therapy Treatment in CP
Though there is no known cure for CP, many treatments to improve a person's capabilities exist including the use of physical therapy.
Physical therapy usually begins in the first few years of a person's life or soon after diagnosis and includes activities to improve muscle strength, balance and motor skills ("Cerebral Palsy: Hope Through Research | National Institute of Neurological Disorders and Stroke", 2020)
Passive gentle range of motion exercises and stretches across major joints have been used to prevent or reduce joint contractures.
Low intensity regular progressive resistance exercise involving all major muscle groups to increase muscle strength, improve local muscular endurance, balance, posture control, gait and mobility (Patel, Neelakantan, Pandher & Merrick, 2020).
Functional strength training combined with plyometric exercises and balance training to improve function as plyometric exercises improve muscle power which includes strength and speed. Specifically a 12 week adaptive bungee trampoline program involving bouncing, hopping, heel jumping, jumping with eyes closed, sequence jumps and games such as dodgeballs, has been used to improve lower limb muscle strength (Patel, Neelakantan, Pandher & Merrick, 2020). 3-4 sessions per week over 3-4 months of treadmill training were documented to have led to improved gait velocity, stepping movements and independence of walking.
ACSM exercise prescription recommendations and considerations:
Generally the FITT principle recommendations for general population should be applied to individuals with CP however it is important to note that individuals with CP have decreased physical fitness levels compared with their peers without disability as well as decreased mobility with age and associated high pain and fatigue. Special considerations should be applied when adopting the general population prescription (Riebe, Ehrman, Liguori & Magal, 2018, p 317)
Aerobic exercise programs should start with frequent but short bouts at moderate intensity (40-50% oxygen uptake reserve or RPE 12-13 on our 6-20 scale) with recovery periods of intensity is exceeded. Progressively increase exercise bouts to reach 50-80% VO2R for 20 minutes.
If balance deficits are present- leg ergometry or recumbent stationary cycling for lower extremities or hand cycling for upper extremities can be used as they allow for wider ranges of power output and movements occur in a closed chain and is a minimal risk to injury from loss of balance control.
Recumbent stepping is feasible and safe in individuals with significant motor impairment and can often be performed without significant post exercise pain.
Fatigue is common due to poor economy of movement (because of altered movement control, energy expenditure is high even at low power output levels). Fatigue can deteriorate the voluntary movement patterns of hypertonic muscles. Exercise programs can be more effective when several shorter sessions are conducted, relaxation and stretching routines are included throughout the session and new skills are introduced early in the session.
Reduced muscular strength and endurance
Resistance training increases strength in individuals with CP without adverse effects on muscle tone. Emphasize the role of flexibility training with any resistance training program. Targeting weak muscles groups that oppose hypertonic muscle groups improve the strength of the weak muscle groups and normalise the tone in the opposing hypertonic muscle group through reciprocal inhibition.
Before open kinetic chain strengthening exercises (dumbbells, barbells, free weights) always check impact of primitive reflexes on performance (position of head, trunk, proximal joints of extremities) and if the individual has adequate neuromotor control to exercise with these.
Should be stretched slowly to their limits throughout the workout program to maintain length. Stretching for 30 improves muscle activation of antagonist group whereas sustained stretching for 30mins effectively, temporarily, reduces spasticity in the muscle being stretched. Ballistic stretches should be avoided.
Susceptible to overuse injuries because of higher incidence of inactivity
One of our incredible clients had the following procedure:
Tibial tubercle transfusion (osteotomy)
Tibial tubercle transfer (bony realignment, osteotomy), is a surgical procedure that involves moving a small portion of bone from the patella tendon and repositioning or transferring it to a location on the tibia. This procedure is designed to correct the underlying problem, instability, arthritis, cartilage defects affecting patellofemoral joint.
Exercises to address referral
VMO strengthening - Thanks to Physi Track Naomi has found some great exercises to help our clients strengthen their muscles.
Patel, D., Neelakantan, M., Pandher, K., & Merrick, J. (2020). Cerebral palsy in children: a clinical overview. Translational Pediatrics, 9(S1), S125-S135. doi: 10.21037/tp.2020.01.01
Olney, R. S., Doernberg, N. S., & Yeargin-Allsop, M. (2014). Exclusion of progressive brain disorders of childhood for a cerebral palsy monitoring system: a public health perspective. Journal of registry management, 41(4), 182–189.
Johari, R., Maheshwari, S., Thomason, P., & Khot, A. (2016). Musculoskeletal Evaluation of Children with Cerebral Palsy. The Indian Journal Of Pediatrics, 83(11), 1280-1288. doi: 10.1007/s12098-015-1999-5
Gorter, J., Verschuren, O., van Riel, L., & Ketelaar, M. (2009). The relationship between spasticity in young children (18 months of age) with cerebral palsy and their gross motor function development. BMC Musculoskeletal Disorders, 10(1). doi: 10.1186/1471-2474-10-108
Edwardo Ramos, M., Daniel Moon, D., K. Rao Poduri, D., & Christina Marciniak, M. (2020). Hyperkinetic Movement Disorders – PM&R KnowledgeNow. Retrieved 23 June 2020, from https://now.aapmr.org/hyperkinetic-movement-disorders-including-dystonias-choreas/
Alliance, C. (2020). Dyskinetic Cerebral Palsy | Cerebral Palsy Alliance. Retrieved 23 June 2020, from https://cerebralpalsy.org.au/our-research/about-cerebral-palsy/what-is-cerebral-palsy/types-of-cerebral-palsy/dyskinetic-cerebral-palsy/
Cerebral Palsy: Hope Through Research | National Institute of Neurological Disorders and Stroke. (2020). Retrieved 23 June 2020, from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Cerebral-Palsy-Hope-Through-Research
Riebe, D., Ehrman, J., Liguori, G., & Magal, M. (2018). ACSM's guidelines for exercise testing and prescription. Philadelphia: Wolters Kluwer.
Unknown. (2020). Tibial Tubercle Transfer - HSS.edu. Retrieved 23 June 2020, from https://www.hss.edu/conditions_tibial-tubercle-transfer.asp
Tibial Tubercle Osteotomy (TTO) Sydney | Knee Patella Alignment Kogarah. (2020). Retrieved 23 June 2020, from http://www.sydneyknee.com.au/tibial-tubercle-osteotomy/?fbclid=IwAR3lMe1yAlpuaddsl-A8XlZQchcHfTzTUo5b40lvRia0i232zfmfmwnfayo