Summary of the literature supporting strength training for sports performance in athletes with cerebral palsy

1. Strength training for sports performance
in athletes with cerebral palsy
Jennifer Fleeton, Ross Sanders, Ché Fornusek
Faculty of Health Sciences, The University of Sydney
Anatomy of Cerebral Palsy (CP)The Problem
Athletes with CP make up approximately 20% of all
athletes competing at the Paralympics, however to date
no training studies have been performed on this group.
Currently the potential success of training programs
must be inferred from studies conducted predominantly
with untrained children with CP and with able bodied
athletes.
What did we do?
MEDLINE, SportsDiscus, Ausport Med, CINHAL, Web of
Science, Scopus, AMED and Google Scholar were
searched for publications up to May 2018.
Keywords: “cerebral palsy”AND each of: strength
training, strengthening, strength exercise, weight
training, resistance exercise, resistance training, athlete,
athletic performance, performance, Paralympic, sports
performance.
What did we find?
• 26 training studies investigating strength
training in sedentary people with CP
• 20 articles relating to sports performance
for athletes with CP
Permanent, non-progressive disorder of movement and posture resulting from
injury to the foetal or infant brain. Affects 1:500 people.
Unilateral/ hemiplegic - 39% Bilateral/ diplegic - 38%
• Affects one side of the body • Legs more affected than arms
• 99% are ambulant • 98% are ambulant
Quadriplegic - 23%
• All four limbs affected
• Muscles of face, mouth & trunk also often affected
• 25% are ambulant, 75% are wheelchair users
Almost always accompanied by a range of associated conditions:
REFERENCES:
Aisen ML, Kerkovich D, Mast J, Mulroy S, Wren TA, Kay RM, and Rethlefsen SA. Cerebral palsy: clinical care and neurological rehabilitation. Lancet Neurology 10: 844-852, 2011
Colver A, Fairhurst C, Pharoah POD. Cerebral palsy. Lancet 383: 1240-1249, 2014
Kloyiam S, Breen S, Jakeman P, Conway J, and Hutzler Y. Soccer-Specific Endurance and Running Economy in Soccer Players With Cerebral Palsy. Adapted Physical Activity Quarterly 28: 354-367, 2011
Oliveira JA, Salvetti XM, Lira EB, Mello MT, Silva AC, and Luna B. Athlete's heart, oxygen uptake and morphologic findings in paralympic athletes. International Journal of Cardiology 121: 100-101, 2007
Patatoukas D, Farmakides, A., Aggeli, V., Fotaki, S., Tsibidakis, H., Mavrogenis, A.F., Papathanasiou, J., Papagelopoulos, P.J. Disability-related injuries in athletes with disabilities. Folia Medica 53: 40-46, 2011
Runciman P, Derman W. Athletes with brain injury: pathophysiologic and medical challenges. Phys Med Rehabil Clin N Am 29: 267-281, 2018
Runciman P, Tucker R, Ferreira S, Albertus-Kajee Y, and Derman W. Effects of induced volitional fatigue on sprint and jump performance in Paralympic athletes with cerebral palsy. American Journal of Physical Medicine &
Rehabilitation 95: 277-290, 2016
Yanci J, Los Arcos A, Grande I, Santalla A, Figueroa J, Gil E, and Cámara J. Jump capacity in cerebral palsy soccer players. Revista Internacional de Medicina y Ciencias de la Actividad Física y del Deporte 14: 199-211, 2014
Significantly greater strength, jump height, aerobic fitness & sprint times than those reported
for sedentary people with CP
1 in 3
has visual impairment
1 in 4
experiences incontinence
3 in 4
have daily pain
1 in 6
has hearing impairment
1 in 4
has a behaviour disorder
e.g. ADHD, autism, sensory processing disorder
1 in 3
is non-ambulant
1 in 2
has intellectual
disability
1 in 4
is non-verbal
(may use assistive technology)
1 in 3
has epilepsy
1 in 3
has hip dysplasia
Practical Applications
Results - Sedentary people with CP
43-90%
muscle strength vs.
able-bodied peers
energy expenditure
for a given task
21 studiesImproved strength following a resistance training intervention seen in
14 studiesBUT only showed functional improvements even in the presence of
With training...
• muscle cross-sectional area
• fascicle length
• rate of force development
• strength
• power
• muscle activation patterns
differential response to
training stimuli demonstrated
NO evidence that resistance
training worsens spasticity
Primary weakness a result of central neural
drive, agonist/ antagonist co-activation,
spasticity, hypertonia, impaired motor unit
recruitment and synchronicity, selective
voluntary motor control, poor coordination
and balance. Secondary weakness a result
of muscle atrophy and contracture. Worse
distally than proximally.
movement efficiency
strength.
Results - Athletes with CP
risk soft tissue injuries
compared to other
para-athlete groups
Ankle (36%) & knee (29%) = most common injuries
for CP athletes in running-based sports
Due to:
• altered gait mechanics
• strength asymmetry affected vs. less affected sides
• contractures & bony deformities secondary to spasticity
through adolescence
risk of BMD
(bone mineral density) due to failure
to accrue bone mass during childhood
Higher risk with increasing severity of CP
Severity of CP measured via the Gross Motor Function
Classification System (GMFCS) ranging from I - V. Those
classed as GMFCS III can ambulate with walking aides,
GMFCS IV & V require a wheelchair.
Athletes in non-weightbearing sports (e.g. swimming)
& junior athletes may be at risk
Athletes with CP are at risk of premature
osteoarthritis
Consider...
altered movement patterns
present even in elite
sprinters with CP
Motor planning & motor learning may be affected in
addition to peripheral muscle activation patterns
Altered pacing strategies demonstrated
In athletes with hemiplegia the ipsilateral
(i.e. “unaffected”) side also showed motor deviations
Slower reaction time & motor planning deficits
VO2 Peak
of 18 Paralympic level CP
football players & swimmers
48.3±6.7 ml·kg-1
·min-1
5.6±0.3 s 40 m sprint time of 6 Paralympic level track
sprinters
24.3±5.4 cm Countermovement jump height (via force plate)
of 13 players in the Spanish CP football team
993±397 m
Yo-Yo IR-1 distance of 14 players in the Irish CP
football team
Indication of potential for a response to long term training in athletes with CP
Based on current evidence there is potential for
sports performance to be improved through
resistance training for athletes with CP.
• Training to address primary deficit first
• An initial goal of increased total body strength &
hypertrophy
Addressing underlying strength asymmetry particularly
important in bilateral sports e.g. running, swimming, cycling
Athletes with CP may require longer training blocks to master a
skill or movement pattern, so give ample time to develop &
teach complex lifts
• Commence power training following initial strength
training block
Use a combination of unilateral exercises & compound
movements to facilitate addressing strength asymmetries
Transfer of movement skills between exercises may be reduced
compared to able bodied athletes
Athletes in high velocity sports may benefit from power training
year-round to maintain adaptations, coordination at high
movement velocities & technical mastery of complex exercises
• Reserving running loads for technical training
Utilize volume, intensity prescriptions when running
Use alternate training modes to achieve central adaptations
• Screening for low BMD in GMFCS II & III athletes
competing in high impact sports
e.g. snow sports
Movement
disorder
Definition Special considerations
Spasticity Velocity-dependent resistance of
a muscle to stretch
• Likely to have contractures
• Crouch gait common in diplegia
flexion moment arm about knee
risk knee injuries without major
traumatic event
Ataxia Impaired muscle coordination
poor balance, over-/ under-
shooting of movements & tremor
• Require spotting on all movements
due to impaired proprioception
• May have ‘wide-base gait’ pattern
due to instability falls risk
Athetosis Slow, constantly changing,
contorting or writhing movements
• Have difficulty maintaining voluntary
grip & moving limbs to a target
• May contraindicate use of free
weights
Dystonia Involuntary sustained or
intermittent muscle contractions
twisting, repetitive movements
&/or abnormal postures
• Fluctuate in severity, may vary with
position, task & emotional state
• May be more likely with unfamiliar
tasks
: jennifer.fleeton@sydney.edu.au
: @JFlee_83