FIT ACTIVE HABITS FOR CHILDREN WITH CEREBRAL PALSY:INCREASING LEVELS OF FITNESS AND PHYSICAL ACTIVITY

Robyn Smith Department of PhysiotherapyUFS 2012

BACKGROUND Regular participation in physical activities is

important for all children to stay fit and healthy.

This is especially important for children with disabilities, who are often restricted in their activity options due to mobility problems.

Some of our children with CP show a deterioration in mobility, muscle strength and fitness related activities over their childhood years

BACKGROUND Current insights suggest that interventions for

school-age children with CP should focus more on promoting an active lifestyle and increasing physical fitness.

Should this be changing our approach to intervention?

WHAT DO WE MEAN WHEN WE SAY EXERCISE PROGRAMME?

Planned and structured activities involving repeated movement of skeletal muscles that result in energy expenditure and seeks to improve or maintain levels of physical fitness above the intensity required for activities of daily living

Activities of daily childhood life consist of well-balanced aerobic, anaerobic, and muscle strength components

Studies have shown that achieving an active lifestyle between 9-18 years determinesprospects for an active lifestyle in adulthood

Motivation of child & parental support andInvolvement are KEY!

EXERCISE FOR CHILDREN WITH CP? Exercise in children with CP has often been avoided

because of the concern about the negative effect of such effort on muscle spasticity and children’s movement patterns.

Has been a shift in perspective in recent years about the use of exercise in children with CP.

Studies done to data evaluating the effect of exercise on children with CP reported no adverse effect on patterns of movement flexibility or spasticity.

Much research regarding exercise in this population still needs to be done (best practice, measuring etc)

WHY IS EXERCISE A CONCERN AND GROWING FOCUS IN THE CP POPULATION? People with cerebral palsy are less physically active

than their unimpaired peers (sedentary lifestyle)

Due to their sedentary lifestyle children with CP greater risk of developing secondary health problems including cardiovascular disease, osteoporosis, obesity and type II diabetes pain

Inactivity can also contribute to social isolation and depression and poor self image/perception.

OUR INTERVENTIONS SHOULD THEREFORE ALSO FOCUS ON .... Enhancing levels of physical activity , especially in school

aged children with CP

There is preliminary evidence to suggest that structured exercise programmes increase habitual physical activity levels in children CP

Practicing and carryover of mobility related activities in daily environments is paramount.

BENEFITS OF EXERCISE FOR CHILDREN WITH CP Numerous well documented benefits of exercise in this

population:

Improves CVS fitness and endurance Improves muscle strength and endurance Improves balance/agility Help control body weight Improves flexibility and helps maintain ROM Improves psychological wellbeing Increases participation in individual and community activities Improves bone density Reduces risks of several chronic diseases

CHALLENGES FOR PHYSIOTHERAPISTS..... Changing the mindset to our rehabilitation practices

Lack of a knowledge base regarding physical activity interventions and aspects of lifestyle, fitness and mobility in children with CP

Little research regarding the application and measurement of these parameters outside the laboratory setting

Physiotherapists knowledge and training regarding exercise fitness

Little knowledge regarding the effects of exercise programme’s in this population e.g. Overuse or musculoskeletal injuries

Formal Exercise/Fitness

Programme

Group intervention

recommended

Measure improvements in endurance,

strength, exercise

tolerance, activity and

anthropometricmeasures

Lifestyle intervention

Counselling parents/child

Evaluating and changing

attitudes to exercise and

activity

Home based Physiotherapy Practice mobility related aspects in

home environment

Encourage participation in sport/ community activities

Regular Physiotherapy

sessions

Programme needs to be

adapted child’s individual

abilities and requirements

Value of electronic games e.g. Wii

FITT PRINCIPLES CAN BE USED IN DEVELOPING A STRUCTURES EXERCISE PROGRAMME

FITT principle based training programme contain theFollowing components:

F Frequency I Intensity T Type of exercise T Time

These are principles that can be used in compilinga programme for a physicallychallenged child

SO HOW DO GO ABOUT DEVELOPING AND

IMPLEMENTING AN EXERCISE PROGRAMME FOR CHILDREN

WITH PHYSICAL DISABILITIES ?

UNIVERSAL EXERCISE PRINCIPLES COUNT......

FREQUENCY Literature suggests that the child participate in a

formal exercise programme 3-5 times per week is indicated

In studies done to date most of the children participated in formal exercise programmes between 2 and 4 times per week

INTENSITY Aerobic capacity at 60-75% maximal HR Calculation max HR =220-age Some data suggest even exercising at ≥ 40% of

max.HR is beneficial

TYPE OF TRAINING Individual or group circuit training in combination

with specific exercises

Stations of relatively intense periods of activity e.g. Cycling followed by lower-impact stations e.g. Resistance training

CONDITIONING PROGRAMME

Any exercise programme should commence withwarm up.

Duration of the war-up should be approx. 10- 15Minutes and should include low impact dynamic

movements using large muscle groups : e.g. slow walking/ cycling on stationary bike or arm

ergonomter Can also include 2-5 min stretches of large muscle

groups at the end of the warm up

Warm up serves as preparation for the heightened levelof physical activity to follow

CONDITIONING PROGRAMMEAerobic conditioning

Aims improve CVS fitness & endurancePerformed over longer periods time

20-30 minutes per session

NB monitor HR of child and allow resting stations as well if indicated

CONDITIONING PROGRAMME

Aerobic continued...

Can include any of the following exercises Waking with walking frame counting number of step/ distance/

covered and time taken (speed) to increase progressively Cycling on a stationary bicycle/arm ergonometer (resistance

set and distance covered/time monitored) Supported walking on treadmill ( speed/incline can be

adjusted as progression) Swimming Endurance can even be improved by means of wheelchair

rides of progressive lengths Rowing machine Arm ergomenter/static cycle

CONDITIONING PROGRAMME Anaerobic capacity improved by activities require a

sudden burst of energy over shorter periods.( 30s)≺

Can be Achieved by of task specific activities: Running Playing with ball Cycling arm ergonometer/static cycle

MUST be at maximal intensity 15-20 seconds Can progress by increasing duration and decreasing

the rest period between spurts.

CONDITIONING PROGRAMME Strength or resistance in order to improve strength

training may include:

use of free weights e.g. ankle/wrist weight or dumbbells or

Weight machines Functional strengthening e.g. loaded sit to stand;

forward/lateral stepping, heel raises (start with body weight progress to a weighted vest) 3 sets 12 repetitions

Two or three sets of 8-12 repetitions.

CONDITIONING PROGRAMME

Cool down allowing time to gradually reduce the level of activity and aims to improve /maintain flexibility:

self or assisted stretches of key muscle groupsMay also include slow walking/cycling/wheeling

TIME/DURATION

Exercise programme to should be started gradually (progressive programme gradually increasing the frequency, duration and intensity of the training) and under the supervision of a physiotherapist.

Can start at 15 minutes and progressively increase to 45 minute sessions.

CARRY OVER INTO DAILY LIVING Encourage the child to become involved in sport for

physically challenged and participation in community sporting events with family and friends

Heightened activities with daily living

HEALTH AND SAFETY CONSIDERATIONS Adequate hydration Appropriate clothing and footwear Safe execution of activities

REFERENCES Bania, T. 2010. Increase habitual physical activity levels in

people with cerebral palsy. Clin Rehabil April 2011 vol. 25 no. 4 303-315

United Cerebral Palsy (UCP). Exercise Principles and Guidelines for Persons with Cerebral Palsy and Neuromuscular Disorders

Verchuren, O; Ketelaar, M.; Takken, T.;Helders, P.J.M. & Gorter, J.M. 2007. Exercise programs for children with cerebral palsy. A systematic review. American journal of Physical Medicine and Rehabilitation

Van Wely,L; Becher, J.G.; Reinders-Messelink, H.A.; Lindeman, E.; Verchuren, O.Verheijden, J & Dallmeijer, A.J. 2010. Learn 2 Move 7-12 years: A randomised controlled trial on the effects of a physical activity stimulation program in children with cerebral palsy. BMC Pediatrics

Rimmer, J.H. 2001. Physical fitness levels of persons with cerebral palsy. Developmental medicine & child neurology

How to exercise with Cerebral Palsy WCPT 2011: focused symposia. Fit active habitds

measuring fitness and physical activity in cerebral palsy