Cerebral Palsy - Exercise Testing And Prescription

Question 1

If a patient report indicates that they have spastic or pyramidal cerebral palsy, what types of physical problems might you expect them to have?

How might each one affect your exercise testing/prescription?

Answer 1

1. Hyperreflexia - often associated with spasticity of muscles. Slow movements are better than fast in all forms of training [RT, endurance, skill practice,etc]
2. Clasp-knife rigidity - as above, hyperactive reflexes, velocity dependent.
3. Hypertonia - may affect strength measurements if hypertonia is in antagonist muscles, requires additional stretching exercise for optimum movement patterns and ROM, not velocity dependent.
4. Contracture - as above but is a permanent shortening so often surgery is used. Need to be aware of surgical procedures and how they might influence ex, so talk to the surgeon.

With all problems, must check wether surgery or meds have/are used in treatment.

Question 2

A patient report indicates that they have athetosis/extrapyramidal CP.

What types of medications might they be on? Name 4.

Answer 2

Botulinum [botox]
Baclofen
Clonazepam
L-dopa
Lorazepam
Valproate
Phenobarbital
Dantrolene

Question 3

What are some common side effects of these meds and how might they influence the design of a training session?

Answer 3

Drowsiness - a lack of strength might be associated with drowsiness, check with doctor to see if it’s OK to provide stimulant for training session.

Dizziness - will substantially affect balance and coordination, so many movements maybe difficult. Will need constant monitoring/spotting for safety.

Weakness and fatigue - realise there may be limits to loads lifted, even though higher loads might increase strength more. Fatigue will limit exercise, exercise in intervals separated by rest.

Ataxia - requires task practice, support/spotting, use simple rather than complex movements until movement control improves.

Dry mouth - keep water or weak sugar solution nearby, sip regularly.

Question 4

A patient comes to you with the following history:

22 yo male with no ACSM risk factors
Diplegic (lower limb) spastic CP but able to walk with crutches
2 min walk test result = 32m
Medications include - Botox and Baclofen
Had selective dorsal rhizotomy @ age 12 which was effective

To implement a RT program to increase walking speed - Given the patients history, what considerations might you note?

Answer 4

Lower limb diplegic, so often in wheel chair. Long term loss of bone mass, muscle strength are issues. Long term health problems with lack of exercise.

Due to spastic diplegia, which affects his lower limbs in this case, spasticity of the hip adductor might be a problem. This is exacerbated with fatigue, causing genu varum (knock knees), and should be monitored closely. Can increase the risk of falling in walk/run after training is completed.

Due to spasticity - movements should be performed slower rather than faster.

Medication effects already outlined.

Dorsal Rhizotomy - can lead to plantarflexor and hamstring strength reductions, which could affect walking performance. Regular testing of these muscle groups and specific training may be needed.
DR may also lead to back pain and spondylolysthesis, so physician should eliminate these possibilities before starting ex.
Low back pain and spondylolysthesis patients should then be referred to a physio who can guide early ex program.
Ex that places stress on spine should be avoided or performed at lower loads.

Sensory loss may occur, might not be possible for them to assess their own fatigue. RPE can be used, but good knowledge of ‘expected’ fatigue is req by EP. Thermoreg might also be impaired, so ex should be performed in a cool dehumidifies environment.
Swimming pools - provide ideal environment, as well as program variation and training benefits.
Urologic function may be affected. Meds used on Dr’s orders, and bladder should be emptied before starting ex.