Olaf Verschuren AusACPDM 1

-3-1 Exercise physiology and training in children and adolescents with cerebral palsy Training Training principles Training in children Program Training children with CP Practical considerations 197 Training in children Training Aerobic FITNESS Muscle Strength Physical training: The process whereby repeated systematic exercise leads to functional and morphological adaptations in the body. Anaerobic Training principles The PRINCIPLES of TRAINING are the rules to follow when using physical activity programs: Specificity Reversibility Adaptation/Supercompensation Specificity In order for a training program to be beneficial, it must improve the specific physiological capabilities required to perform a given sport or activity. Specificity Example, a goalkeeper needs to focus on reaction work in their training, in comparison to a midfielder who should focus on agility, stamina, speed etc. A runner who wants to improve his leg strength, should train differently to a cyclist. Both would need muscular endurance but the training method should be different!! Olaf Verschuren AusACPDM 1

-3-1 Reversibility Use it or lose it. When you stop training, the training effects can be reversed so don t quit! The training history will be an important factor. The longer you have trained the longer the effects will be present. Adaptation/Supercompensation In order to improve through training we need to apply greater demands on our body. This is the principle of OVERLOAD. The body will adapt to the new norm. Is it possible to train children? after training 16 1 1 6 2 Typically developing children children adults Payne VG, Morrow JRJ (1993) Exercise and VO2max in children: a metaanalysis. Res Q Exerc Sport 6:35-13. Training in typically developing children Little progression after training compared to adults (5-% vs. 1-15%) Program: carefully adapted to each individual s potential Baquet G, van Praagh E, Berthoin S. Endurance training and aerobic fitness in young people. Sports Med. 23;33(15):17-3. The three most important aspects of training 1. FUN 2. FUN 3. FUN Fitnesslevels in CP Low fitness High fitness How to develop a fitness training? lopers rolstoelrijders Olaf Verschuren AusACPDM 2

no CP level I level II 11 13 1 15 16 17 1 Height no CP level I level II 11 13 1 15 16 17 1 Height -3-1 Fitnesslevels in children with CP Muscle strength (HHD) Low compared to typically developing peers Muscle strength (HHD) Fitnesslevels in children with CP Aerobic Lundberg A 19 Strength 7 6 5 3 2 1 ILOP control hemiplegic diplegic RECT GLUT Damiano et al, 199 non dominant side ABD ADD HAMS QU 9 QU 3 muscle groups PF (E) PF (F) DF (E) DF (F) Strength 7 6 5 3 2 1 ILOP control hemiplegic diplegie RECT dominant side Testuitslagen GLUT ABD ADD HAMS QU 9 QU 3 muscle groups PF (E) PF (F) DF (E) DF (F) Percentage of predicted values Muscle strength right side (n=7) Fitnesslevels in children with CP Aerobic Verschuren et al. 2 (submitted) Fitnesslevels in children with CP Anaerobic Bar-Or et al 1996; Parker et al 1992 Fitnesslevels in children with CP Anaerobic Verschuren et al. 213 Female Male Typically developing Cerebral palsy (GMFCS I or II) Typically developing Cerebral palsy (GMFCS I or II) Mean Power 5 1 15 2 25 3 35 5 5 55 6 Mean Power 5 1 15 2 25 3 35 5 5 55 6 Fitnesslevels in CP Low fitness High fitness lopers rolstoelrijders % of the observation 6 55 5 5 35 3 25 2 15 1 5 children's play anaëroob Walking stairs, playing hide and seek, etc. aëroob Amusement Park, Sports, Cycling, etc. 3 6 9 15 1 21 2 27 3 33 36 267 duration of the activities (in sec.) Muscle Strength Aerobic Fitnesstraining FITNESS Anaerobic Muscle Strength Olaf Verschuren AusACPDM 3

-3-1 Training is?? Fitnesstraining Aerobic Muscle Strength Training is?? Cerebral Palsy Effect of aerobic training 3 RCTs: van den Berg-Emons et al. 1995, Unnithan et al. 27, Verschuren et al. 27 Trainingsprogram 2- à aerobic fitness of 1 22% Trainingsprogram -9 à aerobic fitness of 26-1% Cerebral Palsy Content aerobic training Duration of the training: 1-5 minutes 2 to times a week 3-9 Trainingsintensity between 6- % of HRmax. FITNESS Anaerobic Training is?? Typically developing Trainingsprogram weeks tot 1 à aerobic fitness of 5-1% Typically developing ACSM guidelines: Duration of the training: 2-6 minutes 3 times a week - Trainingsintensity between 55-9% of HRmax. Cerebral Palsy Effect of anaerobic training 1 RCT: Verschuren et al. 27 Trainingsprogram of 5 à anaerobic fitness of approx. 25% Cerebral Palsy Content anaerobic training Trainingsintensity maximal during exercises of 2-3 seconds Strength training in children with Cerebral Palsy Typically developing No clear evidence in current literature. Training seems beneficial Typically developing Guideline short-term and intermediate term anaerobic Trainingsintensity maximal during exercises of 1-3 seconds Different training modalities - Progressive Resistance Exercise - Electro stimulation Effect of resistance training on MUSCLE STRENGTH Lower extremity Upper extremity Electro stimulation Effect of resistance training on GMFM Lower extremity Electro stimulation What works? N= 119 Muscle strengthening is not effective in children and adolescents with cerebral palsy: A systematic review. Scianni A, Butler JM et al. Aust J Physiother 29; p1-7 N= 99 Muscle strengthening is not effective in children and adolescents with cerebral palsy: A systematic review. Scianni A, Butler JM et al. Aust J Physiother 29; p1-7 Olaf Verschuren AusACPDM

-3-1 Effect training on WALKING SPEED Lower extremity Electro stimulation Discussion Different methods in 1 review / metaanalysis If there is no effect on muscle strength or activity level à is training still worthwhile? Progressive resistance exercise is most oen used. N= 63 Muscle strengthening is not effective in children and adolescents with cerebral palsy: A systematic review. Scianni A, Butler JM et al. Aust J Physiother 29; p1-7 Is this method effec7ve? Effect of resistance training for the lower extremity in children and adolscents CP Dodd et al. 23 Liao et al. 27 Lee et al. 2 Scholtes et al. 21 Total NSCA guidelines Important ingredients according to the NSCA guidelines Warming- up (5-1 minutes) Type of exercise Intensity Frequency (2-3 7mes a week) DuraPon of the programme Progression during the programme Age of children N= 15 Verschuren et al. PT journal 211 Type of exercises Type of exercises: mostly functional based Result on muscle group level. Type RCTs in children with CP NSCA guidelines Dodd: multi-joint exercises (heel raises, half squats and stepups) multi-joint exercises Single-joint and Liao: multi-joint exercises (sit-to-stand) loaded (using weight vest) Lee: multi-joint exercises (squat to stand, lateral step up, stair up and down) loaded (using weight cuffs), Scholtes: multi-joint exercises (leg press) and loaded (using a weight vest) What is the trainingseffect on the muscle groups that were targeted? Muscle groups targeted in RCT s: Knee-extensors Hip-extensors Plantar flexors Study Dodd et al. Lee et al. Liao et al. Ankle plantar flexors Knee extensors Knee flexors Hip extensors Hip flexors Hip abductors Hip adductors - - - - - + - - - - Scholtes et al. - + - - - Be aware of compensapon during exercises! Olaf Verschuren AusACPDM 5

-3-1 Intensity of the programme RCTs in children with CP Intensity Dodd: 3 sets of - repetitions to fatigue Liao: 1 set of 1 repetitions at 2% 1RM 1 set of repetitions until fatigue at 5% 1RM 1 set of 1 repetitions at 2% 1RM Lee: 2 sets of 1 repetitions (low load and no progression) Scholtes: 3 sets of RM Only 2 of the studies are in line with the NSCA guidelines NSCA guidelines 1-3 sets of 6-15 repetitions of 5-5% RM Duration of the programme RCTs in children with CP NSCA guidelines -2 weeks Duration Dodd: 6 weeks Liao: 6 weeks Lee: 5 weeks Scholtes: 6 weeks ( week program) No study is in line with the NSCA guidelines Effect of resistance training of the lower extremity in typically developing children Significant relapon between durapon and trainingseffect: Behringer et al. Pediatrics Oct 25, 21 N= 172 Age of training Content of resistance training Recommendations RCTs in children with CP Age Dodd: mean 13.1, SD 3.1, range -1 years of age Liao: mean 7., SD 1.6, range 5- years of age Lee: mean 6.3, SD 2.5, range - years of age Scholtes: mean 1.5, SD 1.1, range 6-13 years of age NSCA guidelines Age 7 and onwards Variabels RCTs in children with CP NSCA guidelines Type Dodd: multi-joint exercises (heel raises, half squats and step-ups) Single-joint and multi-joint Liao: multi-joint exercises (sit-to-stand) loaded (using weight vest) exercises utilizing Lee: multi-joint exercises (squat to stand, lateral step up, stair up and down) concentric and eccentric loaded (using weight cuffs), single joint exercises contractions Scholtes: multi-joint exercises (leg press) and loaded (using a weight vest) Longer interventions with sufficient intensity, for example, weeks, may be needed to see significant or meaningful improvements in strength. In 3 out of the studies included children younger than the recommended 7 years of age. Intensity/ Dodd: 3 sets of - repetitions to fatigue volume Liao: 1 set of 1 repetitions at 2% 1RM 1 set of repetitions until fatigue at 5% 1RM 1 set of 1 repetitions at 2% 1RM Lee: 2 sets of 1 repetitions Scholtes: 3 sets of RM Duration Dodd: 6 weeks Liao: 6 weeks Lee: 5 weeks Scholtes: 6 weeks ( week program) Age Dodd: mean 13.1, SD 3.1, range -1 years of age Liao: mean 7., SD 1.6, range 5- years of age Lee: mean 6.3, SD 2.5, range - years of age Scholtes: mean 1.5, SD 1.1, range 6-13 years of age 1-3 sets of 6-15 repetitions of 5-5% RM -2 weeks Age 7 and onwards Verschuren et al. PTjournal 211 Recommendations Single-joint resistance training may be more effective for very weak muscles or for children or adolescents who tend to compensate when performing multi-joint exercises, or at the beginning of the training. Recommendations Depending on the complexity of the exercise and the level of motor impairment, children and adolescents with CP may need more than 1 minute of rest between bouts (perhaps up to 3 minutes). Recommendations Since strength training, as it is traditionally done, requires maximal effort and can include somewhat complicated activities, older children and adolescents, over 7 years old, are perhaps better suited to this intervention that younger children. Olaf Verschuren AusACPDM 6

-3-1 Recommendations Children or adolescents with more impairment might also benefit from strength training, but if it is difficult for them to contract voluntarily, methods such as electrical stimulation, mental imagery and biofeedback could be helpful. Training is effective Aerobic Fitnesstraining CP FITNESS Muscle strength Training can be more effective EXAMPLE STUDY Training is effective Anaerobic Aerobic FUNCTIONAL FITNESS Muscle strength Randomized Clinical Trial Goes Zwolle Breda Utrecht N=6 N=65 Randomized GMFCS level (I or II) Fitnessprogram 2 times a week for 5 minutes 2 physical therapists 2 groups 1. 7 - year 2. 13-2 year Anaerobic Experimental group N = 32 Control group N = 33 Trainingsscheme HRmax in children with CP Ingredients for training In the training we used standardized TASK- SPECIFIC aerobic and anaerobic exercises, which were based on walking activities, such as Running / Walking fast Step up and down Stepping over Bending Turning Getting up from the floor Olaf Verschuren AusACPDM 7

-3-1 Aerobic exercises The exercises Fitnesstraining guidelines Frequency: 2 days per week standardized exercises Intensity: Anaerobic exercises Aerobic 6 - % max. HR Duration: 5 minutes Activity:Rest: standardized exercises 1:1 Fitnesstraining guidelines Training Anaerobic Frequency: Intensity: Duration: 2 days per week maximal 3-5 minutes Activity:Rest: 1:3 1:5 1. Introduction Explain purpose of training and give children heart rate monitor 2. Warming-up 3. Training focus In circuit format (with 2 children in each group) for aerobic part (month 1-3) In group format for anaerobic part (month -). Closure of the training The effects of a functional fitness program in children and adolescents with Cerebral Palsy: a randomized trial Olaf Verschuren, Marjolijn Ketelaar, Jan Willem Gorter, Paul Helders, Tim Takken Aerobic FUNCTIONAL Muscle strength Experimental group (n=32) GMFCS I n=23 GMFCS II n=9 Randomization Control group (n=33) GMFCS I n=22 GMFCS II n=11 Objectives Primary objective; Study the effects on: aerobic (1-m Shuttle Run Test) anaerobic (Muscle Power Sprint Test) Secondary objective; Study the effects on: Functional muscle strength Agility Participation HRQoL FITNESS 11.6 (2.5) years Boys/girls 1/1.7 (2.7) years Boys/girls 23/1 Controlgroup: Baseline Follow-up: REGULAR PHYSIOTHERAPY Anaerobic Traininggroup: TRAINING + REGULAR THERAPY REGULAR THERAPY Olaf Verschuren AusACPDM

-3-1 Results Aerobic and anaerobic 1-m Shuttle Run Test Mean Muscle Power (MPST) Experimental group Control group Experimental group Control group 6 5 3 2 1-1 -2 6 5 3 2 1-1 -2 P<.1 P=. P-values: group(2) x time(3) interaction of repeated-measures analysis of variance For info 1-m SRT: Olaf Verschuren et al. Physical Therapy 26;6(6): 117-1117 For info MPST: Olaf Verschuren et al. Ped Phys Ther 27;19:1-115 Body Function and Structure Functional muscle strength Agility & improvement 3-sec Repetition Maximum Experimental group Control group 25 2 15 1 5-5 -1 1x5 meter sprint test Experimental group Control group 16 1 1 6 2 P<.1 P<.1 P-values: group(2) x time(3) interaction of repeated-measures analysis of variance Participation Children s Assessment of Participation and Enjoyment (CAPE) 1,6 Intensity 1,5 1, 1,3 1,2 control group 1,1 1 exp group,9,,7,6 + + Participation (intensity) Children s Assessment of Participation and Enjoyment (CAPE). Significant (p<.5) Skill-based activities (+2%) Physical activities (+2%) Overall activities (+27%) Not significant Recreational activities (+1%) Social activities (+%) Self-improvement activities (+6%) For info 1x5 meter:olaf Verschuren et al. Ped Phys Ther 27;19:1-115 P-values: group(2) x time(3) interaction of repeated-measures analysis of variance Health-related Quality of Life TACQOL-PF Conclusion Follow-up Aerobic and anaerobic 1 meter shuttle run test Experimental group Control group Significant (p<.5) Not significant 3 2 1 Basic motor functioning (+1%) Autonomy (+%) Cognitive functioning (+%) Pain and symptoms (+1%) Social functioning (+2%) Global positive emotions (+2%) Global negative emotions (+2%) Functionally based Easy to implement Effective and Fun -1 25 2 15 1 5 Mean Power (Watts) MPST Experimental group Control group -5 P-values: group(2) x time(3) interaction of repeated-measures analysis of variance Olaf Verschuren AusACPDM 9

-3-1 Follow-up Muscle strength and agility Functionele spierkracht (3-sec HM) Follow-up Participation Results of more studies 25 2 15 1 5-5 -1 16 1 1 6 2 Experimental group Control group 1x5 meter sprint test Experimental group Control group Intensity 1,6 1,5 1, 1,3 1,2 1,1 1,9,,7,6 + + follow-up control group exp group Exercise programs: What s the GOAL? Based on rationale for RCT s in published papers. Muscle Strength HEALTH related factors Dodd et al. Liao et al. Lee et al. Scholtes et al. End of training FOLLOW-UP CEREBRAL PALSY Berg-Emons et al. 199: after 3 17% Verschuren et al. 27: after 9 % Aerobic Muscle strength Body Mass Index Anaerobic Motor skill Agility / Speed HEALTH related problems and/or PERFORMANCE related problems GOAL Aerobic N= 15 Verschuren et al. PTjournal 211 Trainingsprogram 2- à aerobic fitness 1 22% Trainingsprogram - 9 à aerobic fitness 26-1% PERFORMANCE related factors PERFORMANCE related factors End of training FOLLOW-UP GMFM Anaerobic Trainingsprogram à anaerobic fitness 1% Trainingsprogram à anaerobic fitness 25% Verschuren et al. 27: aer Anaerobic 9 % Agility 5% Walking Speed Agility Trainingsprogram à agility % Trainingsprogram à agility 1% Olaf Verschuren AusACPDM 1

-3-1 Exercise programs: What s the effect? Only during the intervenpon What have we done?? follow- up too short HEALTH related problems and/or PERFORMANCE related problems No effect (at follow- up) Difficult to be acpve in daily life. Recent study LEARN 2 MOVE 7- Program designed to improve physical activity LEARN 2 MOVE 7- Group fitness training 3 x hh + LEARN 2 MOVE 7- Lifestyle intervention Motivational Interviewing A directive, client-centered counseling style to elicit behavior change by helping clients explore and resolve ambivalence. (Rollnick & Miller 1995) Training 16 weeks 1-2 times a week for an hour 2-5 children per group 15-2 seconds maximal! Motivational interviewing Olaf Verschuren AusACPDM 11

-3-1 Results Learn to Move The combination of counselling, homebased physiotherapy and fitness training was not effective in improving fitness, social participation in recreation and leisure, self-perception or quality of life. What have we done? Part 2. Are we satisfied when we become succesful in increasing PHYSICAL ACTIVITY? 3-6 min PHYSICAL ACTIVITY exercise continuum Regardless of Physical Activity Sitting and mortality Fitness level and mortality Van der Ploeg H et al. Arch Intern Med 2:172(6):9-5 Sedentary physiology in children with CP Uptime (Pirpiris and Graham 2) Sedentary pursuits (Maher et al. 27) Typically developing hemiplegia diplegia Mean hours per week Cerebral palsy CP Definitions of Sedentary Behavior Evolution of definitions of sedentary behavior: 21. Sedentary behavior should be defined as the muscular activity rather than the absence of exercise. 211. The origins of the word sedentary hint at a simpler, more workable definition. The word sedentary derives from the Latin verb sedere to sit. When sitting or lying, the majority of the body s largest muscle groups are under relaxation; in contrast, when standing, even if still, a large proportion of the body s musculature are under tension. Therefore any non-exercise activity that involves sitting or lying can be considered sedentary. 2. Sedentary behaviour is any waking behaviour characterized by an energy expenditure 1 5 METs while in a sitting or reclining posture. Important factors of Sedentary Behaviour Posture (sitting or reclining) Energy expenditure ( 1.5 METs) Muscular inactivity Low sedentary CP = Coach Potato High sedentary Olaf Verschuren AusACPDM

-3-1 What do we know about sedentary behavior in children with CP? EMG acpvity? Energy expenditure? Lying and sitting Standing? EMG acpvity? Energy expenditure?? EMG acpvity Energy expenditure Sitting Standing Energy expenditure (METS) GMFCS Rest Sit with support Sit without Standing level (lying) support (n=) 1. 1.1 ±.7 1.17 ±.1 1.5 ±.1 I (n=) 1. 1.1 ±.1 1.11 ±.17 1.53 ±. II (n=3) 1. 1.1 ±.9 1.1 ±.15 1.5 ±.19 III (n=6) 1. 1.21 ±.19 1.33 ±.25 1.6 ±.25 IV(n=2) 1. 1.3 ±.13 not possible 1.7 ±.6 V (n=1) 1. 1.2 not possible 1. Muscle activity GMFCS Rest Sit with support Sit without Standing level (lying) support (n=) 1. 1.33 ±.59 1.3 ±.2 3.77 ±.67 I (n=) 1. 1.17 ±.5.91 ±.21 2.35 ±1. II (n=3) 1. 1.1 ±.7 1.6 ± 1. 5.6 ±1.6 III (n=6) 1. 1.22 ±.7 1.69 ±.73.76 ± 3. IV(n=2) 1. 1.5 ±.6 Not possible. ± 2.6 V (n=2) 1..77 ±.57 Not possible 1.7 ± 1. Summary Children with CP have low fitness levels. Children with CP are able to increase their fitness levels. It is difficult to become and stay physically active. Even if we (or they) succeed, we are not doing enough. We need to get them less sedentary. Stand up for your health and ask a question? Take home message! Sleep Sedentary behavior* Light physical activity Moderate physical activity Intense activity cut down, replace by HEALTH ENHANCING PHYSICAL ACTIVITIES Wake up x Trip to and passive transportation* - walk or bike to school -brisk walk or bike fast to school from school sitting/reclining* - break up sitting every hour -PA lesson with Heart Rate > 6% HRmax School - active play (recess) sitting/reclining* - break up sitting every hour -moderate to vigorous activities After school screen time* - active play (out- or indoors) -play (competitive) sports Bed time x hours 15 hours 3-6 minutes 1 Olaf Verschuren AusACPDM 13

Beperkt uithoudingsvermogen Beperkte kracht/ verwacht krachtsverlies*** Beperkt krachtuithoudingsvermogen GMFCS I + II GMFCS III GMFCS I + II GMFCS III GMFCS I + II GMFCS III CP trainingsgroep Principes CP trainingsgroep individueel CP trainingsgroep Voor en/of na interventie**** POPEYE CP trainingsgroep POPEYE + Principes CP trainingsgroep individueel -3-1 Kind met een hulpvraag* Onderzoek** (oa. CP onderzoek, GMFM, krachttesten, GMFCS) * Kinderen met CP met een hulpvraag die gericht is op kracht en/of uithoudingsvermogen ** Meetinstrumenten volgens POPEYE- protocol *** Treedt vaak op pre- of postoperatief, na inactieve periode of tijdens Botox **** met interventie wordt hier bedoeld: Botox, SDR, of multilevel chirurgie Olaf Verschuren AusACPDM 1