Exercise as it relates to Disease/Effects of ROM and resistance programs on Cerebral Palsy

Definition
Cerebral palsy is a term given to a group of motor disorders that cause physical disability and impaired control of movement. Cerebral Palsy is technically not a disease or illness but a description of physical impairments that affect movement.

Classifications
Cerebral Palsy is classified based on the location and extent of brain damage, the body parts affected and the kinds of tone and movement difficulties present.

- Spastic: This is the most common form of Cerebral Palsy. 70% of people with Cerebral Palsy suffer from this form. Muscles can become tight, stiff and weak in areas meaning control over movement is difficult. Spastic Cerebral Palsy is further broken down into areas affected;
 * Diplegia- affects the legs (usually both) more than the arms.
 * Hemiplegia- affects one side of the body.
 * Quadiplegia- affects all four limbs.
 * Monoplegia- affects one limb
 * Triplegia- affects three limbs

- Athetoid (dyskinetic): Involves spontaneous and uncontrolled jerking movements. Posture and movement patterns are generally disrupted.

- Ataxic: Least common form and is characterised by a lack of balance and co-ordination. It is usually associated with shaky movements of the hands and feet called tremors.

- Mixed: A combination of two or more of the above types.

Causes of Cerebral Palsy
Cerebral Palsy does not have a single cause and is the result of damage to the brain before cerebral development is complete. Brain development continues during the first two years of life, so Cerebral Palsy can be the result of damage to the brain during the prenatal, perinatal and postnatal periods(1). The abnormal muscle tone and movement problems a person experiences depend upon which area of the brain is damaged. Damage to the motor cortex is likely to cause Spastic Cerebral Palsy as the motor cortex produces a persons desire to move and execute voluntary movements. The Basal Ganglia regulates motor movement, without information from the basal ganglia the motor cortex cannot direct motor movement. Similar to Parkinson's Disease, the pathways that provide feedback to the motor cortex are affected causing excessive inhibition or excitation of motor activity. This leads to the uncontrolled, writhing and twisting movements associated with Athetoid Cerebral Palsy. The Basal Ganglia also controls previously learned movements such as walking, sitting and eating, which can be affected by this form of Cerebral Palsy. Ataxic Cerebral Palsy is usually the result of damage to the cerebellum.As the cerebellum controls balance and co-ordination and fine motor movements, tremors and a lack of balance are associated with the ataxic form of Cerebral Palsy. Damage to the Brain before cerebral development is complete can be due to;
 * Low birth weight
 * Premature birth
 * Multiple births
 * Asphyxia (lack of oxygen)
 * Infection (mainly Meningitis and Encephalitis)
 * Cerebral bleeding
 * Drugs or other toxic substances
 * Physical Trauma

Clinical Diagnosis
Cerebral Palsy is a complex disability and diagnosis is not always an easy process. Most children with cerebral Palsy are born at full term and it is not until they do not meet the usual infant milestones that any form of disability is considered. In babies these milestones include; In toddlers these milestones include;
 * feeding or swallowing difficulties
 * Preference to use one side of their body
 * Can't sit up or independently roll over by 6 months
 * not walking by 12–18 months
 * not speaking simple sentences by 24 months

Parents are usually the ones who first become aware that something is wrong when their child is not reaching these developmental milestones. Doctors will take a full medical history and then monitor the child's movements and muscle tone. Some children will have relaxed and floppy muscles while others will have tight and stiff muscle tone. The child's general movements and posture is also examined to help with diagnosis. Parents can sometimes become frustrated with the process, as the diagnosis can take a long time. However, it is important to insure it is not a more serious progressive disorder before the diagnosis of Cerebral Palsy can be made.

Prevalence
Ongoing improvements in prenatal care have contributed to a decline in some types of Cerebral Palsy. However, Cerebral Palsy is still the most common physical disability in children, with 1 in 500 Australian babies being diagnosed with the disorder. There are approximately 34 000 people living with Cerebral Palsy in Australia and 17 million worldwide. The total cost of the disorder is estimated at $1.47 billion per year.

Range of Motion
Range of motion (ROM) refers to the degree of movement within a joint. There are two types or Range of motion
 * Passive - range of motion achieved by help from therapist or practitioner.
 * Active - range of motion achieved without assistance.

People suffering from Cerebral Palsy often experience limited range of motion in extremities. Spastic CP is associated with stiff and tight muscle tone, and consistently leads to decreased ROM. ROM or flexibility programs are very important in the treatment of CP and are widely regarded as the best form of treatment for people with CP. ROM programs are recommended from a young age and can help to maintain range of motion during development and growth, helping to facilitate movement throughout life. As children with CP develop decreased ROM and increased muscle weakness can occur if proper treatment is not provided(9). Much of the research involving ROM therapy targets the upper limbs as it is involved with daily task such as eating, cleaning and writing. A typical ROM program involves;


 * Arm Lifts - these work the shoulders throughout their range of motion. Arm lifts can be done seated and lying down, actively or passively. To perform this exercise actively, the patient sits up straight with arms relaxed at their side. The patient then raises one arm straight above their head as high as they can go. When performing this exercise passively, the patient sits with their arms relaxed and allows for someone else to raise their arm as far as it can go.
 * External hip rotation - this increases the range of motion of hips. To perform this exercise actively, the pateint lies on their back with legs straight while letting their legs to open outward. As a passive exercise, someone opens their legs outwards as far as possible.
 * Elbow Extensions - these aim to straighten the arms and is primarily a passive exercise. To do this exercise the patient will lie on their back with arms bent slightly and at rest by your side. The caregiver holds their upper and lower arm and gently straightens it. The exercise is repeated until the elbow is as straight as possible(10).

There are many ROM and flexibility programs for people suffering from cerebral Palsy. It is important to evaluate the individual and concentrate on areas most affected by their form of CP. ROM programs recommend that exercises be done at least once a day and up to twice a day when trying to recover lost ROM.

Resistance Exercise
Significant weakness has been identified in children with Cerebral Palsy and their motor function is affected. In order to increase motor control a certain amount of strength is needed. Although, strength training has been regarded as unnecessary and controversial due to concerns that it will increase abnormal muscle tone. Recent research however has shown that people suffering from CP can achieve strength gains without adverse affects. The most common types of resistance training for people with CP are isokinetic and free weight training. Both are now regarded as an important tool in the treatment of Cerebral Palsy and can improve the value of life for people with CP.

Treatment for people with Athetoid Cerebral Palsy often involves Whole Body Vibration Therapy. An 8 week resistance training program with WBV can increase gross motor performance without a negative effect on spasticity. However, walking distance in 6 minutes and balance in basic mobility is unlikely to change.

A resistance training program for spastic Cerebral Palsy has been shown to positively affect gait and improve free walking. A recent study showed that continuing a training program focusing on larger muscle groups of the lower limb, such as quadriceps and hamstrings improved walking cadence and velocity. Improving quadriceps strength at all angles of knee flexion can improve gait as the quadriceps are a major contributor in knee crouch. The major benefits to stride length and frequency are seen when resistance training is undertaken on both the hamstrings and quadriceps. The positive improvements in walking distance and self selected walking speed means that progressive resistance training can be viewed as a practical method for treating people suffering with Cerebral Palsy.

A typical resistance training program involves; 3 times a week with a minimum of one day rest between sessions

Weights used: Adjustable weight cuffs attached to patients ankles. Weight is highly specific to patient and should be tested to get the correct starting weight. Weight is then increased by increments of 0.25 kg and 0.75 kg each week

Program: Week 1: * 3x5 leg extension (quadriceps) * 3x5 leg flexion (hamstrings) * assisted squats (no weight) Week 2: Increase weight same program Week 3: Same weight as week 2 * 3x6 leg extension (quadriceps) * 3x6 leg flexion (hamstrings)

Program continues in these wave sets and generally builds up slowly due to the nature of the patients.

Recommended Readings
Cerebral Palsy Alliance - www.cerebralpalsy.org.au

A guide to understanding Cerebral Palsy - www.ethnomed.org

Cerebral Palsy Australia - www.cpaustralia.com.au

Centre for Cerebral Palsy - www.tccp.com.au