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Special Populations

Cerebral Palsy: Physical Activity and Sport

Carroll, Kristen L. MD; Leiser, Jennifer MD; Paisley, Theodore S. MD

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Current Sports Medicine Reports: December 2006 - Volume 5 - Issue 6 - p 319-322
doi: 10.1097/01.CSMR.0000306437.21359.f7
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Abstract

Introduction

Health benefits from regular physical activity are well documented. The National Institutes of Health, Centers for Disease Control, American Heart Association, and American College of Sports Medicine support physical activity. These organizations recommend 30 minutes of moderate-intensity physical activity on most days of the week for all Americans [1•,2–4]. Inactivity, therefore, can be seen as a risk factor for the development of cardiovascular disease and diabetes. Patients with cerebral palsy (CP) have significant challenges in becoming and remaining physically active. They often struggle to maintain function and flexibility, and to perform activities of daily living. Physical therapy is a cornerstone of CP management, but little scientific evidence exists to prove efficacy and guide treatment [5]. Our challenge as providers is to assist this heterogeneous group of patients to maximize their health, functionality, and quality of life through enhanced physical activity. Sport is a natural extension of activity and should be utilized when practical.

Overview of Sports and CP

CP affects about 0.2% to 0.3% of children. CP has been defined as “a group of disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behavior, and/or by a seizure disorder” [6]. Patients with CP are heterogeneous in their abilities and in the medical complications of the disorder. About 80% of these children are born prematurely or are of low birth weight [3]. Several conditions common in this population affect the ability to participate in physical activity. Bronchopulmonary dysplasia (BPD) can decrease the respiratory adaptation to the rigors of exercise [4]. Spasticity can increase the risk of muscle strain and injury [7]. Spasticity also affects gait and balance. Decreased weight bearing can lower bone mass, increasing the risk of pathologic fracture. Seizure disorders affect nearly 40% of children with CP, and antiepileptic drugs can further reduce bone mass as well as affect concentration [1]. Coordination secondary to motor-cortex involvement can be reduced. Inactivity results in poor cardiovascular fitness.

Research shows that therapeutic interventions are effective for many of these problems. Cardiopulmonary function can be improved with aerobic training. In subjects affected with spastic CP, one study demonstrated an increase of 35% in peak aerobic power with weekly aerobic exercise sessions tailored to the child's ability [7].

CP has long been known to cause spasticity that requires stretching and/or surgical intervention to balance muscle forces. Recently, the weakness of antagonist musculature has been recognized. Even in highly functional individuals with CP, there is weakness of the major muscle groups compared with able-bodied, age-matched controls [8]. Studies have also looked at strength training and circuit training for children with CP [8,9]. They found isometric strength to be directly related to walking speed [10]. Strength training as few as two times per week increased walking speeds and improved strength 20% to 70% over 3 to 6 months. This improvement was maintained over a 3-month period after the cessation of treatment.

Patients with CP are at risk for development of osteoporosis due to disuse and lack of weight-bearing exercise. None of these studies directly investigated the effect of strength training on bone density in this population. Extrapolating from the normal population, bone density would be expected to increase with strength training. This may have a significant effect on quality of life during adulthood.

Horseback riding has recently been investigated as a beneficial activity for children with CP. This so-called “hippo therapy” has been shown to improve gait and coordination (Fig. 1) [11]. Patients in a horseback riding program showed 7.6% improvement in total gross motor function measure (GMFM) after 18 weeks of training, returning to baseline 6 weeks after concluding the training. Nonambulatory children improved with truncal balance primarily. Ambulatory children gained even more, with 100% having improvements with walking speed and balance after training [11]. Nonambulatory and partially ambulatory patients undergoing treadmill training with partial harness support showed 47% to 50% improvements in the GMFM score. The nonambulatory children had improvement in transfer, short walking with assistance, and walking with only verbal cues [12].

Figure 1
Figure 1:
“Hippo therapy” for a spastic quadriplegic patient with two assistants.

Sports Activity as an Alternative to Formal Physical Therapy

It is the experience of Dr. Carroll that formal physical therapy loses some of its impact with time. Many children tire of prolonged physical therapy from childhood into adolescence and adulthood. Therapy programs are simply abandoned due to boredom, expense, or lack of time. Sports and sports therapy offer an enjoyable alternative, providing children with CP skills for lifelong activity. They experience normal sports enjoyment and a sense of mastery. Family life may be more normalized as the children are able to participate in enjoyable activities. In the strength training studies cited above, the sports model of activity had a strong influence on the children's desire to participate and to continue participation after the study.

Case 1

A patient of one of the authors sent her the following letter: “My name is Rochelle and I am 14 years old. I have CP and I can't walk, but I sure do a lot of other stuff! I live in Aspen, Colorado, and I ski on weekends when I'm not at school. I have been skiing for about 8 years now and I can ski from the top of the mountain all the way down. At first I was scared to go skiing, but now I really like it. I even went cross-country skiing with my class last year. I can ice skate because I use cones to stand up on the ice. I go bowling and I have a special ramp to roll my ball. I have gone rafting a lot with Challenge Aspen. I started riding about 11 months ago, and have ridden in Special Olympics. This year I'll do even more events.

“I know that a lot of people don't think kids can do much if they have problems like me, but I can do about anything I want, I just have to try. I think that I kind of surprise a lot of people with all that I can do, but I think that if I try it I can do it.” (Fig. 2).

Figure 2
Figure 2:
Young woman with spastic quadriplegia on a fishing outing with the National Abilities Center.

Adult Function in Patients with CP

Function often decreases with age. Deficits from CP are not progressive. However, aging is often accompanied by a progressive spiral of inactivity leading to weight gain and decreased exercise tolerance [13]. The persistent underlying muscle weakness of CP results in decreasing ability to ambulate and participate in physical activity. Few studies address functional longitudinal outcomes in adults. By establishing a pattern of activity prior to adulthood, patients may avoid the health dangers of inactivity, be physically prepared to handle the aging process, and internalize the importance of activity and therapy. All three strength training studies cite the transition to adulthood as one of the major reasons to start weight or circuit training in childhood. Additional research is needed on longitudinal effects of sports and physical activity through the lifespan.

Case 2

A 69-year-old woman with CP has been ambulatory and independent in the community. She is the patient of one of the authors. At age 60 she suffered a stroke with residual right hemiparesis. She began using a wheelchair. While attending a day program at a community center, she began to walk with parallel bars. She gradually progressed from being wheelchair-bound, to ambulation with a walker, to being able to go up three flights of stairs. Physical therapy also helped her with problems of frozen shoulder and back pain from contractures. At age 66 she was admitted to a nursing home due to family circumstances. She continues in physical therapy and ambulates as much as possible. She used exercise and portion control to manage an initial 15-pound weight gain upon admission to the nursing home. She credits physical activity for helping her maintain relatively good health in spite of her disabilities.

Case 3

A 42-year-old woman with CP presented to the author's office for concern about weight gain. She is a resident of a group home with mild cognitive impairments. She has been ambulatory since age 7. However, about 2 years prior she began to use her motorized wheelchair more frequently. She also began to refuse physical therapy, going so far as to sit on the floor and refuse to get up. She developed poor eating habits and gained weight. This exacerbated her mobility problems. Conflict with her parents developed because she was no longer mobile in their home and they could not take her on family outings. Lack of weight bearing exercise and long-term Depo-Provera (Pfizer, New York, NY) use contributed to the development of osteoporosis. Her sociable personality led to a decision to enroll her in a commercial weight-loss program. She enjoys contact with other members and is learning better eating habits. She has lost some weight but is not back to her previous weight or activity level. She is able to transfer but no longer walks independently.

Sports Participation

Because of the heterogeneity of deficits in these patients, several organizations have developed classification systems so that children with CP can be placed in appropriate activities. A classification system can be used in competitive sports to allow fairly matched opponents. The United States Cerebral Palsy Athlete Association recommends an eight-level classification system (Table 1). The United Cerebral Palsy Association's website has a section dedicated to sports and adaptive physical education. Some of these sports include traditional events such as basketball, swimming, track and field, and cycling. There are others that are less intense, such as bocce and bowling, as well as those that utilize more adaptive equipment, including indoor wheelchair soccer. All of these facilitate participation, competition and general activity.

Table 1
Table 1:
Cerebral palsy eight-level classification system

Conclusions

Patients with CP benefit from physical activity as much as individuals without handicaps. Benefits include improved health, improved functioning and independence, and enhanced enjoyment of life. The clinician can foster this increased activity by an understanding of the needs and abilities of this special population.

At this time, it is difficult to find evidence-based recommendations for exercise prescriptions for patients with CP. Rimmer [14] points out that more research needs to be done in this area. He notes that public health guidelines do not include exercise modifications for patients with disabilities, and the body of literature is focused on children and adolescents. This makes extrapolation of potential methods and benefits to the adult population difficult. Additionally, he observes the “safest” mode of exercise is often described as walking, yet a patient with CP may either not be able to walk, or to walk at a high enough intensity to see cardiovascular improvement [14].

Given these limitations, a skilled multidisciplinary assessment of the patient's abilities will help define a sports and activity program that is safe and tailored to the patient's needs. Bone density should be assessed, especially if the patient is beginning a weight bearing or contact activity, or if the patient is wheelchair bound. Safe activities can then be suggested based on function, degree of spasticity, and current activity levels. Local resources can be identified and physical therapy or orthopedic consultations incorporated. A comprehensive plan can help the primary clinician provide guidance and exercise prescription appropriate to the patient.

Several websites provide resources for patients and clinicians:

  1. Disabled Sports USA' http://dsusa.org/
  2. Wheelchair Sports USA' http://www.wsusa.org/
  3. National Sports Ability Center for the Disabled'http://www.nscd.org/ (Fig. 3)
  4. Figure 3
    Figure 3:
    National Abilities Center in Park City, UT arranged for the Austrian National Downhill Team to assist in adaptive skiing.
  5. Boundless Playgrounds'http://www.boundlessplaygrounds.org/ (list of adaptive and accessible playgrounds)
  6. American Academy of Cerebral Palsy' http://www.aacpdm.org/index?service=page/Home
  7. Internet Relay Chat'http://www.irc.org (Internet resources for special-needs children)
  8. KidSource'http://www.kidsource.com (adaptive recreation for special-needs children)
  9. Winners on Wheels'http://www.wowusa.com (adaptive recreation for wheelchair ambulators)

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

1.• Thompson PD, Buchner D, Pina IL, et al.: Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity).Circulation 2003, 107:3109–3116.

Recent consensus statement with American College of Sports Medicine endorsement.

2. Pate RR, Pratt M, Blair SN, et al.: Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine.JAMA 1995, 273:402–407.
3. Physical activity and cardiovascular health. NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. JAMA 1996, 276:241–246.
4. US Department of Health and Human Services. Healthy People 2010 . Available at
5. Mayston M: Evidence-based physical therapy for the management of children with cerebral palsy.Dev Med Child Neurol 2005, 47:795.
6. Bax M, Goldstein M, Rosenbaum P, et al.: Proposed definition and classification of cerebral palsy, April 2005.Dev Med Child Neurol 2005, 47:571–576.
7. Damiano DL, Abel MF: Functional outcomes of strength training in spastic cerebral palsy.Arch Phys Med Rehabil 1998, 79:119–125.
8. Hebestreit H, Bar-Or O: Exercise and the child born prematurely.Sports Med 2001, 31:591–599.
9. Sterba JA, Rogers BT, France AP, Vokes DA: Horseback riding in children with cerebral palsy: effect on gross motor function.Dev Med Child Neurol 2002, 44:301–308.
10. Schindl MR, Forstner C, Kern H, Hesse S: Treadmill training with partial body weight support in nonambulatory patients with cerebral palsy.Arch Phys Med Rehabil 2000, 81:301–306.
11. Van den Berg-Emons RJ, Van Baak MA, Speth L, Saris WH: Physical training of school children with spastic cerebral palsy: effects on daily activity, fat mass and fitness.Int J Rehabil Res 1998, 21:179–194.
12. McDowell BC, Kerr C, Parkes J, Cosgrove A: Validity of a 1 minute walk test for children with cerebral palsy.Dev Med Child Neurol 2005, 47:744–748.
13. Durstine JL, Painter P, Franklin BA, et al.: Physical activity for the chronically ill and disabled.Sports Med 2000, 30:207–219.
14. Rimmer JH: Physical fitness levels of persons with cerebral palsy.Dev Med Child Neurol 2001, 43:208–212.
© 2006 American College of Sports Medicine