Programming for Cerebral Palsy

Cerebral Palsy is a term used to describe a group of chronic disorders impairing control of movement that appear in the first few years of life and generally do not worsen over time; however, secondary conditions such as muscle spasticity can develop and may get better, worse or remain the same over time. The term cerebral refers to the brain’s two halves, or hemispheres, and palsy describes any disorder that impairs control of body movement.

The different types of Cerebral Palsy depend on the type and degree of movement problems. The types include:

• Spastic: The individual has above normal tone or stiffness of muscles. This is the most common type of Cerebral Palsy.
• Athetoid: There is damage to the part of the brain that influences and modifies electrical impulses sent from the brain to the muscles; damage to this system can cause movements such as tremors, jerks or writhing movements.
• Atonic: The individual is weak, lacking normal muscle tone.
• Mixed: A combination of any of the above.

Causes

Cerebral Palsy is not caused by problems in the muscles or nerves; instead it is caused by cerebral dysfunction that occurs during gestation, birth or the neonatal period. Faulty development or damage to motor areas in the brain disrupts the brain’s ability to adequately control movement and posture. This can happen before birth, at the time of birth, or in early childhood. Recent studies have shown that difficulties during the birth process itself are not a common cause of Cerebral Palsy. The etiology of cerebral palsy includes developmental deficits, vascular accidents, infections, toxins (e.g., chemical abuse by mother), trauma and genetic factors. Cerebral palsy is not is not a disease and should not be referred to as such. Although cerebral palsy is not "curable" in the accepted sense, training and therapy can help improve function.

Symptoms

Symptoms of cerebral palsy lie along a spectrum of varying severity and are unique to each client. An individual with cerebral palsy may have difficulty with fine motor tasks, such as writing or cutting with scissors; experience trouble with maintaining balance and walking; or be affected by involuntary movements, such as uncontrollable writhing motion of the hands or drooling. The symptoms differ from one person to the next, and may even change over time in the individuals. Some people with cerebral palsy are also affected by other medical disorders. Depending on which part of the brain that has been damaged and the degree of involvement of the central nervous system, one or more of the following may occur: seizures, spasms, mental retardation, disturbance in gait and mobility, and impairment of sight, hearing, or speech. Contrary to common belief, however, cerebral palsy does not always cause profound handicap. While an individual with severe cerebral palsy might be unable to walk and need extensive, lifelong care, an individual with mild cerebral palsy might only slightly awkward and require no special assistance. Cerebral palsy is not contagious nor is it usually inherited from one generation to the net. Although, at this time it cannot be cured, thanks to modern medicine, many children with cerebral palsy who would not have survived in the past are now able to lead productive lives.

Terms Used for the Location of the Movement Problems:

• Monoplegia: One arm or one leg is affected.
• Hemiplegia: The arm and leg on the same side are affected.
• Paraplegia: Only the legs are affected.
• Diplegia: Major movement problems with the legs and minor problems with the arms.
• Quadriplegia: Arms, legs and spine are affected.

Importance of Exercise

In addition to improving overall health, cardiovascular fitness, range of motion, and flexibility, exercise can help an individual with cerebral palsy help prevent the weakening or deterioration of muscles that can follow lack of use (called disuse atrophy) and avoid contracture, in which muscles become fixed in a rigid, abnormal position.

General Types of Training:

• Cardiovascular - To improve respiratory system and increase stamina.
• Strength - To improve function, help prevent contractures, muscle imbalance and atrophy.
• Flexibility - To increase range of motion and maintain joint flexibility.
• Breath - To reduce tension/stress, strengthen respiratory system, increase body awareness and encourage/facilitate making a mind body connection.
• Coordination, balance and functional - To challenge the body’s proprioceptive system, improving trunk stabilization and walking and weight transfer movements.

Programming Focus

It is very important to keep in mind the appropriateness of training from one client to the next. As the needs for a child will be different from an adult, focusing training to meet each individual’s needs will be crucial to successful development of a personalized training program. For example, the skills a 2-year old needs to explore the world are very different from those that a child needs in the classroom or an adults needs to become or stay independent. Therefore, training for clients with Cerebral Palsy should be tailored to reflect these changing demands.

However, regardless of the client’s age and which type of training is used, it is crucial to work toward these important goals:

• Muscle strength and endurance - To prevent atrophy and muscle imbalance.
• Improving flexibility - To avoid muscle contracture.
• Improving balance and coordination - To improve gait and to help avoid falls.
• Strengthening core stabilization - To improve postural alignment and control.

Addressing these goals will improve function, which provides an opportunity to maximize and maintain the highest level of mobility and function.

General Cardiovascular Training Guidelines

• Set an exercise pace that feels good to your client. Rate level of exertion by the Rate of Perceived Exertion scale (4-6 is a good target zone; range 1-10 where 1 is very very light, and 10 is very very hard) and or a heart rate monitor (heart rate monitors are ideal for clients who take medications that effect heart rate or for clients with mental challenges).
• Utilize the principal of interval training to challenge clients and to also allow for recovery/rest periods during cardiovascular training periods.
• Vary cardiovascular training principals and modalities (appropriate to ability level and training goals) to prevent boredom, avoid muscle overuse and imbalance.
• Depending on an individual’s level of physical health clients with Cerebral Palsy can typically follow general cardiovascular exercise guidelines. Cardiovascular exercise can be done daily and is recommended at least 3-4 days/week and 20-60 minutes/session. (As per the American College of Sports Medicine (ACSM). Deconditioned clients should begin with 5-15 minutes sessions, 2-3 times a week and gradually progress accordingly.

Examples of beneficial cardiovascular training are:

• Elliptical Machines
• Swimming/Aquatic fitness classes
• Stationary recumbent or upright bicycle
• Walking
• And other forms of continuous movement that allow for individuals to safely work at their own pace. (Keep in mind to used forms of cardiovascular training that minimize impact on skeletal system, challenge coordination and provide support for individuals with balance problems)

General Strength Training Guidelines

• Begin strength training at 70 percent of a 10 repetition maximum. This is 70 percent of the weight that one can perform an exercise 10 times. When this weight can be performed for 25 repetitions for two consecutive sessions, increase the weight 10 percent.
• Training should be performed two to three times a week for two to three sets, eight to 12 repetitions/exercise, 10 to 15 minutes/session (depending on mobility of client).
• Keep in mind that as effective as traditional weight training exercises can be, other forms of training can also provide excellent forms of strength training (Pilates, yoga, play/recreation activities, etc.) Choose the type of program that will encourage, motivate and best suit your client’s needs and goals.
• Don’t forget to focus on addressing muscle imbalance, weakness and areas that are most susceptible to atrophy.
• A variety of equipment can be used, depending on the levels of strength, balance, flexibility and coordination.
• Free weights
• Medicine balls
• Isokinetic machines
• Resistance bands
• Sand or water filled equipment
• Buoyancy/ aquatic specific equipment
• Exercise balls (air filled)

General Flexibility and Breath Training Guidelines

• Ideally training should be performed daily for at least 10 to 15 minutes.
• Flexibility training should be performed before and after every cardiovascular and strength session (rhythmical/active flexibility training before exercise and static flexibility training after exercise).
• Adequate time and focus should be placed on muscles groups being utilized during weight and/or cardiovascular training.
• Address greater focus to areas that are more susceptible to contracture and spasticity (i.e., pectorals, hamstrings and gastrocnemius).
• Choose an environment that encourages relaxation of muscles and focus of breath patterns.
• Utilize breath techniques to enhance benefits of flexibility work and to cultivate awareness throughout training sessions (believe it or not, even a two-year-old can grasp the idea of breath work).

Recommended activities that address flexibility:

• Restorative forms of yoga (i.e., Hatha Yoga)
• Feldenkrais
• Exercise balls (air filled)
• Swimming
• And other types of activities that allow for controlled, gentle lengthening of muscles, ligaments and tendons.

General, Coordination, Balance and Functional Training Guidelines

• Incorporate exercises, movements and activities that require your client to utilize the muscles that stabilize the trunk and challenge the proprioceptive system during and throughout the strength, flexibility and cardiovascular training sessions.
• Utilize tools that target trunk stabilization. Example, stability/balance boards, foam rods, exercise balls and air filled disks, etc.
• Maximize activity training by creating variables. Example, changing resistance, timing, buoyancy, planes of movement, support base (standing on one leg vs. two), use of senses (closed/open eyes), etc.
• Use exercises/activities that mimic daily living activities. Especially those that require weight shifts and contra lateral movement.
• Teach/coach correct structural alignment and utilizing activities that help to improve reaction speed. This focus will impact all area of training and will help minimize the changes of falling.

Recommended activities that address coordination, balance and function:

• Walking
• Bike riding
• Stair climbing
• Games
• Aquatic fitness (movement in water while body is in a vertical plane)
• Tai Chi
• Other activities that safely address the training guidelines above. Asistive devices may be necessary to minimize risk of injury (i.e., a walker, training wheels on a bike, double railing on stairs and padding on floor, etc.)

For specific programming details, contraindications and condition specifics, consult your client’s physical/occupational therapist and physician/specialist. It is crucial to utilize other professionals that your client is working with as they are the best source of information and can help you to best meet the physical needs of your client. In doing so, you will benefit from their expertise as much as they will from yours!