A friend of mine recently asked me to train her 14-year-old son [Sam] who has cerebral palsy. I will obviously consult with his heath care team, but I would also like some information from you. Sam uses a wheelchair but is able to walk with assistance for short distances. He has some spasticity on his left side, ataxia and produces involuntary writhing movements. He has no mental impairment. The questions I want to ask are:
- When a muscle becomes shortened, is this permanent? What changes take place in the muscle that would make this a permanent thing? I am assuming that most of the shortening occurs in the muscle itself, with a change in sarcomere length. Can this be reversed? How can I help him in this respect?
- He obviously has problems neurologically with muscle recruitment. I am assuming that training [repetition of movement] would improve his motor skills and improve his strength and quality of movement, even if his underlying condition is unchanged. Is this correct?
It is a great idea that Sam’s parents are interested in training with you. At age 14, Sam will be going through a critical growth period in his life as he is now physically maturing. The influence of regular exercise on his musculoskeletal and cardiovascular systems can have on-going benefits if he continues with it.
Cerebral palsy arises when there has been injury to the developing brain. The common sets of symptoms in children who have cerebral palsy are abnormal muscle tone and difficulty with muscle coordination and movement.
Therefore, in response to the first part of your question, at the age of 14, the physiological changes of the muscle are not permanent. But since there is no known cure for CP, the spasticity will continue, and the contractile elements of the muscle will be affected. Working with Sam’s medical team for guidance on which muscle groups to stretch and how to best stretch them would be prudent.
You are correct in that there will be a progressive change in the length of the sarcomeres. One of the goals of therapeutic stretching for people with CP is to decrease the reflex that feeds the spasticity. If flexibility is regularly addressed, structural changes to the muscle fibers can be reduced and/or slowed.
There has been research that shows resistance training does improve the quality of movement and does not increase spasticity of the involved muscles.
Rapid movements do increase reflex spasticity and co-contraction. Therefore, slower movements are recommended for people with CP.
The symptoms of CP are associated with earlier stages of neurodevelopment that the individual with CP did not progress beyond. And the earliest stages of neurodevelopment are learned in a cephalocaudal (head down) direction. Therefore, one strategy for training a person with CP is to begin with head positioning and trunk stabilization prior to asking them to perform exercises standing.
Finally, in my personal experience with the few CP clients I have trained, they have also responded extremely well to exercises that address their secondary movement compensations. These compensations are often necessary because of the neurological basis of their condition, but left unaddressed, the secondary compensations rapidly progress, leading to possible joint deformity, premature arthritis, scoliosis and increasingly uneconomical movement patterns.
- Dodd, K., Taylor, N., Damiano, D. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy Arch. Phys. Med. Rehabil 2002 vol. 83, page 1157.
- Dodd, K., Taylor, N., Graham, H. A randomized clinical trial of strength training in young people with cerebral palsy Dev. Med. Child Neurol 2003 vol. 45, page 652.