Week 1 & 2: Neuroanatomy Review (Part 1)

Recall the functions of the central nervous system

1. Sensory input
– Information gathered by sensory receptors about internal and
external changes
2. Integration
– Interpretation of the sensory input
3. Motor output
– Activation of effector organs (muscles and glands) produces a
response

Ability to describe the roles of different parts of the peripheral nervous system

Central and Peripheral Nervous System

• The central nervous system (CNS) is the integrative and control centre of the nervous system
• Consists of the
– Brain
– Spinal cord
• The peripheral nervous system (PNS) is composed of all the nervous structures located outside
of the CNS
• The PNS consists of
– Spinal nerves
– Cranial nerves

Motor (efferent) Division of PNS

1. Somatic (voluntary) nervous system
– Conscious control of skeletal muscles
2. Autonomic (involuntary) nervous system (ANS)
– Visceral motor nerve fibers
– Regulates smooth muscle, cardiac muscle,
and glands
– Two functional subdivisions
• Sympathetic
• Parasympathetic

Role of each division

• Sympathetic
– Mobilizes the body during activity; is the “fight-or-flight”
system
– Promotes adjustments during exercise, or when
threatened
• Parasympathetic
– Promotes maintenance activities and conserves body
energy
– Its activity is illustrated in a person who relaxes, reading,
after a meal
Recall the 4 lobes of the brain hemispheres and discuss regions of major significance
Frontal lobe
• Primary motor cortex
– Allows conscious control of precise, skilled, voluntary movements
– Motor homunculi: upside-down caricatures representing the motor innervation of body
regions
• Pre-motor cortex
– Controls learned, repetitious, or patterned motor skills
– Mirror neurons fire during goal-directed actions as well as the observation of similar
actions
• Brocas area
– Is active as one prepares to speak

Parietal lobe
• Somatosensory cortex
– Receives sensory information from the skin, skeletal muscles, and joints
– Capable of spatial discrimination: identification of body region being
stimulated
• Somatosensory association cortex
– Integrates sensory input from primary somatosensory cortex

Occipital lobe
• Its primary function is the processing, integration, interpretation, etc. of vision and
visual stimuli.
• Primary visual (striate) cortex
– Receives visual input from the retina via optic nerve
• Visual association area
– Uses past visual experiences to interpret stimuli

Temporal lobe
• Primary auditory cortex
– Interprets information from inner ear as pitch, loudness, and location
• Auditory association area
• Hippocampus
– Major component of the brains of humans and other mammals
– Part of the limbic system
– Implicated strongly in memory
• Wernicke’s Area
– Language comprehension
– Located on the Left Temporal Lobe

Describe the structures of the diencephalon, specifically the main functions of the hypothalamus
Diencephalon (Tween brain)
• Thalamus
– Gateway to the cerebral cortex
– Sorts, edits, and relays information
– Mediates sensation, motor activities, cortical arousal, learning, and memory
• Hypothalamus
– Autonomic control center for many visceral functions
– Center for emotional response
– Regulates body temperature, food intake, water balance, and thirst
• Epithalamus
– Contains pineal gland
 Diencephalon - The hypothalamus
• The hypothalamus is involved in pituitary gland function, emotional and homeostatic
regulation
• Secretes several important hormones
– Anti-diuretic hormone (ADH) + oxytocin
– Growth hormone-releasing hormone (GHRH)

Recall the brain regions which are parts of the brainstem and describe their features

The Midbrain
• Located between the diencephalon and the pons, minimal differentiation
• 2 bulging cerebral peduncles on the ventral side of the midbrain
– Contain descending fibers that go to the cerebellum via the pons
– Descending pyramidal tracts
• The roof of the aqueduct (the tectum) contains the corpora quadrigemina
– 2 superior colliculi
– 2 inferior colliculi
• On each side, the midbrain contains a red nucleus and a substantia nigra

The Pons
• Wedged between the midbrain and the medulla
• Contains
• Sensory and motor nuclei for 4 cranial nerves
• Respiratory nuclei
– Apneustic & pneumotaxic centers work w/ the medulla to maintain respiratory rhythm
• Nuclei & tracts that process and relay info to/from the cerebellum
• Ascending, descending, and transverse tracts that interconnect other portions of the CNS

Medulla Oblongata
• Contains choroid plexus of the fourth ventricle
• Just above spinal cord-medulla junction fibers cross over (decussation of the pyramids)
• Cranial nerves VIII, X, and XII are associated with the medulla
• Autonomic reflex centers
• Cardiovascular center
• Respiratory centers
Ability to describe the functions of the cerebellum.
The Cerebellum
• Dorsal to the pons and medulla
• Subconsciously provides precise timing and appropriate patterns of skeletal muscle contraction
• Sensory feedback on movements compared with intended movements
• Signals continuously “inform” the cerebellum of the body’s position and momentum
• A “blueprint” of coordinated movement is sent to the cerebral motor cortex and to brain stem
nuclei
• Plays a role in word association and puzzle solving

Explain how sensory and motor nerves are associated travel within the spinal cord
Functional divisions of the cerebellum
• Vestibulocerebellum
– It collects inputs from the visual and vestibular system
– Consists of flocculus and nodulus
• Spinocerebellum
– Collects information from the muscle and skin carried by the spinal cord
– Sends efferent output through extrapyramidal system
• Cerebrocerebellum
– Input comes from the area of the cerebral cortex controlling sensory and motor
functions.

Cerebellar ataxia
• Can result in affected movement from the trunk to the limbs
• Results in clumsy speech patterns, affected eye movements and affected gait
• Bleeding, MS or infections can all be a cause of cerebellar ataxia
• All cerebellar lesions do not manifest in ataxic motor syndromes

Describe the major motor pathways and their function

• Corticospinal tract – Voluntary motor
• Dorsal columns/medial lemniscus – Discriminative touch + Conscious proprioception
• Spinocerebellar tract (dorsal and ventral) – Unconscious proprioception
• Spinothalamic tract – Pain/temperature
 Describe the different ascending sensory pathways, the structures involved and their specific functions
• The nonspecific and specific ascending pathways send impulses to the sensory cortex
– These pathways are responsible for discriminative touch, pain, temperature, conscious
proprioception (body position sense) etc.
• The spinocerebellar tracts send impulses to the cerebellum and do not contribute to sensory
perception

Dorsal column medial lemniscal pathway

• Detect discriminative touch and body position
• Sensory nerve endings in the skin etc. relay to sensory neurons
• Reach DRG and fibres run only in dorsal column (posterior funiculi)
• Topographically organised spinal cord dorsal columns
• Sensory decussation in medulla, relayed to VPL nucleus prior to input to somatosensory cortex

Trigeminothalamic pathway
• Cutaneous mechanoreceptor information from the face sent via this pathway
• Branches of trigeminal nerve (CN V) carry information
• Terminate in appropriate region of the trigeminal brain complex before relayed to thalamus

Spinothalamic pathway
• Afferent fibres of nociceptors are lightly myelinated or unmyelinated
• Pain has been divided into a sharp or more diffuse type of pain
• Include the lateral and anterior spinothalamic tracts
• 1st order neuron: sensory neuron
• 2nd order neuron: interneurons of dorsal horn; synapse with 3rd order neuron in thalamus
• 3rd order neuron: carry impulse from thalamus to postcentral gyrus

Spinocerebellar pathway
• Plays a role in reflex and perception
• No conscious sensation
• Transmits information about trunk and lower limb muscles to cerebellum
• Afferent fibres bifurcate and branch in spinal cord
• Afferent fibres synapse at Clarke’s nucleus and then ascend
 Week 3: Motor Control Theories
“The ability to regulate or direct the mechanisms essential to movement.”
Involves the integration between:
1. Physiological
2. Perceptual
3. Cognitive

Recall the three different motor control theories

Systems Model
Movement results from the interaction of multiple systems working in synchrony to solve a motor
problem.
Advantage: accounts for adaptability of a variety of environmental conditions
Functional goals, environmental & task constraints play a major role in determining movement.
Example: Patient A
• Sustained a brain injury. Their goal is to attempt to put on a shirt while seated.
• To be successful at performing this task BOTH Internal and External factors must be considered
“What are some internal & external factors?”
Internal Factors:
– Strength - Balance
– Flexibility - Cognition
– Coordination - Motivation
– Pain Level
External Factors:
– Type of Shirt
– Surface of the seat
– Availability of assistance devices
– External distractions

Generalized Motor Program Theory

Central control of movement.
- States there is a neural storage of generalized motor programs for a large class of similar actions
- GMP are NOT muscle specific however contain variant & invariant features
Example: Patient A
- During initial learning –Manipulate the environment in which the patient practices the
movement (changeable feature!!)
Begin: Seated on a hard stable surface with options for balance support (reduce risk of falling)
Progress: unstable surface

Dynamical Systems Theory

Dynamic self-organisation of multiple sub-systems to control movement.
- Proposes there is a neural storage of a sequence of motor steps
- Physical movement is constrained by:
- Individual: Cognition, Motivation etc.
- Environment: Light, Gravity etc.
- Task: Goals, Rules etc.
- While certain movement patterns are preferred they are NOT set. Therefore, new patterns of
movement can emerge.

Describe these theories and state how they can be applied in a rehabilitation setting
Dominant theories summary:
 BOTH theories = movement outcome is stored or represented as a motor plan, distributed at
different levels of the CNS.
o Learning or Re-learning è interaction of multiple systems è develop strong neural
connections è viewed as a representation of movement.
Recall the various stages of skill learning & the type/method of feedback most appropriate across each
stage.
Stages of Skill Learning
• Skilled or Learned actions are those that demonstrate:
– Consistency: Repeatable performance
– Flexibility: Adaptability of movement
– Efficiency: Capabilities of the system to perform over various durations
• These vary dependent upon the different skill levels

1. Cognitive
- Early identification & understanding of the skill
- Focus is on “what to do”
- Simple instruction, keep motivation high, feedback is key!
- Creating an environment with emphasis on the key aspects of the movement = positive learning
environment.

2. Associative
- Emphasis is practice “how to perform” the skill
- Longest stage of skill learning
- Errors become less frequent as the synchronization of the mind and muscle occurs
- Demonstrate greater flexibility in performing the skill under multiple environmental conditions.

3. Autonomous
- Task is executed automatically with minimal thought
- Rates of improvement during this stage are smaller
- Learning is still occurring through new strategies to perform the movement

Learning Style
• Learning occurs through two processes:
– Implicit (passive process): New information acquired through exposure
– Explicit (active process): Seek new information through structure that is presented.
• Occur at different stages and overlap during the learning process

Explicit Learning
Example: Patient A
- Cognitive stage of learning must understand the movements that can be performed with ê ROM
& Strength
- Simple cues should be provided as patient navigates through problem solving
- Explicit learning: Movement patterns constantly adapted by the patient
Implicit Learning
Example: Patient A
- Associative stage of learning = merging of successive movements & regulation of internal factors
(e.g. force) required for the task.
- For example: amount of force & muscle activation required to balance on the chair
- Implicit learning: Modulation and recognition of internal mechanisms within the movement &
environment

Measurement of Learning
Assessed in three ways:
1. Acquisition - Initial practice of skill
2. Retention - Ability to demonstrate attainment of skill
3. Transfer - Performance of a skill with slight variation (e.g. timing and force)
“Skill is not learned until transfer is demonstrated”
Recall the various types of practice  Specifically mental practice.
– Whole: Performing the movement/task as a whole
– Part: Breaking the task into segments to practice
– Massed: Practicing the task in one whole block
– Distributed: Separating practice into multiple sessions throughout the day
– Constant: Task is performed the same way each time
– Variable: Each repetition of the task is altered slightly
• Specificity & Location: Environment or task may need to be modified to ensure some early level
success is achieved
– E.G: Using a foam cup (easier to grasp) instead of glass
• Role of Mental Practice: Cognitive rehearsal & imagery of the task without physically performing the
task (visualize & feel the movement)
– Research shown a combination of mental & physical practice results in greatest improvements
in motor output.
Mental Practice
• Blood flow experiments show mental practice stimulates same areas of brain as does performance
of actual movement
– Pre-frontal areas, supplementary motor cortex, basal ganglia & cerebellum
– Mental practice leads to same plastic changes in cortical output maps as does actual practice

Week 10: Neuroplasticity

Define neuroplasticity
The ability for the brain to change itself
General term; implicated in:
Development, learning, post-injury
• ‘Structural’ AND ‘Functional’
• Scaleable
• Applicable to rehab

Understand Herbs rule of synaptic plasticity  “Axons that fire together wire together”
Hebb’s postulate
 Hebb's postulate of learning (or simply Hebb's rule) (1949), is the following:
“Axons that fire together wire together”
 This rule forms the basis of much of the research on role of synaptic plasticity in memory and
learning
 Has been generalised to include decreases of strength when neuron A repeatedly fails to be
involved in activation of B and generally look at the correlation or covariance of activities of pre-
and postsynaptic neurons

Recall associative and non-associative learning

Learning: the process by which new information is acquired by the nervous system
Allows us to adapt our behaviors to the environment
Non-associative learning
• Non-associative learning results when the animal is exposed once or repeatedly to a single type of
stimulus
• Habituation
– The decline in the tendency to respond to an event that has become familiar through repeated
exposure
• Sensitization
– An increase in the tendency to respond to an event that has been repeated; is more likely when a
repeated stimulus is intense
Associative learning
Classical conditioning
– Innate reflex can be modified by association of triggered stimulus with unrelated stimulus
– Pavlov and his dog
Operant conditioning
– Associating a stimulus with a reward
• Both of these forms of learning require repetitive training prior to change in behaviour
• Learning speech/language can be an example of complex conditioning

Understand the role exercise can play in neuroplasticity and relearning.

The role of exercise
• Exercise increases growth factors in brain making it easier to grow new connections
• Mice that ran on a wheel had twice as many new brain cells as mice housed in standard cages.
• As a comparison, provided mice with other “enriched” environments (e.g., “free swim”) yet only
running produced the effect.
• Growth was in the hippocampus (learning and memory)
What effect does exercise have?
• Preliminary results are encouraging
• Significant improvements in fitness over very short periods of time
• Aerobic exercise has shown improvements in fitness, cognition and motor skills
PARKINSONS
Diagnosis (pathophysiology)
 Second most common neurodegenerative disease
 QoL= Non-motor symptoms > motor decline
 Cognitive impairment: unpredictable and undertreated

Ideopathic Parkinson’s disease (IPD):

Most common for of Parkinson’s (75-90% of all cases). Cause of IPD is unknown.
Secondary Parkinsonism:
Display similar symptoms as IPD but damage is the result of certain medicines, nervous system disorder
or other illness
Parkinsonism-plus syndromes:
Cause Parkinson’s related syndromes due to multiple system degenerations

Symptoms
Primary Signs and Symptoms
1. Tremor at Rest
- Slow and rhythmic
- Starts on one side of the body slowly spreads to other areas
- External or Internal tremor
1. Rigidity
2. Bradykinesia
- Slow movement
- Decrease in fine motor skills and coordination
3. Gait Impairments
- Decrease in natural arm swing
- Shuffling
- Freezing of gait (feet appear glued to the ground)
4. Balance & Posture Impairments

Secondary Signs and Symptoms

• Increased risk of dementia
• Autonomic dysfunction: drooling, constipation, urinary problems, erectile dysfunction,
excessive sweating, hypohydrosis (lack of sweating)
• Neuropsychiatric problems: hallucinations, delusions, cognitive decline, depression
• Sleep disorders: difficulty falling or staying asleep, restless leg syndrome, REM sleep disorders
• Sensory disorders: pain, difficulty staying still, loss of smell

Assessment/screening tools
• Symptoms & Severity
• Hoehn & Yahr Scale of Disability
• Independence
• Parkinson’s Disease Questionnaire - 39
• Self-assessment Parkinson’s Disease Disability Scale
• Unified Parkinson’s Disease Rating Scale
• Functional Capacity
• Gait
• Aerobic
• Strength
• Balance
• Timed Up and Go
Exercise Testing
• Dynamic balance test: sitting and standing, functional reach (reach for object), Berg Balance
Scale, etc.
• Gait observation: stride length and frequency, heel-toe, obstacle avoidance, turn time
• Aerobic tests: Treadmill not a good option when balance and gait difficulties - use bicycle or arm
crank (sub-maximal)
• Strength tests: often done by dynamometers and isokinetic equipment
• Little research, so no clear guidelines for testing… patient specific!

Adverse signs & symptoms during exercise

 Episodes of decreased movement/ freezing during walking
 Increased difficulty getting through doorways or narrow spaces
 Difficulty getting into and rising from bed or getting out of a chair
 Need for assistance with dressing and bathing
 Repeated demonstrations along with written and visual cues are needed to ensure adherence
 Large number of repetitions to develop procedural skills
 Environment to be clutter free to avoid freezing episodes
 Observe for fall risks and changes in neuromuscular control during session
 Display exaggerated and blunted cardiovascular response
 Perform exercise 45-60 mins after medication during peak drug levels

Programming principles

Special considerations
Safety considerations
• Weight assisted treadmills, use of harness
• Recumbent bike, arm ergometer
• Begin with exercises that make the individual feel safe and offer greatest reward
• Monitor HR
• BP cuff with stethoscope
• Climate controlled environment

Contraindications to exercise
Contrindications
1. Emotional state – Depression, anxiety, fear of falling, low confidence
2. Cognitive state – Can they comprehend what it is you want them to do?
3. Physical state – Are there balance and coordination deficits and gait instability? *Depending on
stability, choose either standing or seated exercises
DEVELOPMENTAL COORDINATION DISORDER
Diagnosis (pathophysiology)
“Developmental coordination disorder (DCD) is children experience with posture, movement and
coordination, without there being a specific medical reason for these difficulties. These difficulties are
severe enough to adversely affect their everyday function and school activities.”

Pathophysiology
Research suggests due to a immaturity of neuronal development in the brain affecting they way new
skills are learned & performed
– The way information is received
– Using this information to organization a specific motor task
= movement appearing awkward & difficulty performing new motor tasks.

• Cerebellum: Develops later compared to other cortical areas = vulnerable to developmental

disorders
• Basal Ganglia: Responsible for force control & motor sequencing
• Parietal region: Considered to be involved with visuospatial processes during motor skill learning.
• Appears to be multifactorial and often observed with other developmental conditions:
• ADD
• Dyslexia (reading difficulty)
• Asperger's Syndrome

Diagnosis
• Requires comprehensive assessment that includes a valid and reliable evaluation of a child's motor
skills.
• There is no ‘gold standard’ test or screening measure that can be solely used to identify DCD.
• American Psychiatric Association documents the essential features of DCD under four criteria, all of
which should be met for a diagnosis of DCD to be made.

Criterion A: Performance of daily activities require motor coordination is below average given persons
age & mental intelligence.
Criterion B: Poor motor coordination interferes with academic achievements &/or ADL.
Criterion C: Not due to other medical condition (e.g. cerebral palsy, muscular dystrophy).
Criterion D: If other mental condition is observed motor difficulties in are excess then what is typically
observed.

Symptoms
Signs & Symptoms
• Difficulties controlling their posture & proprioception.
• Poor timing
• Impaired Balance
• Difficulty sequencing movements
• Left to Right confusion
• Poor Proprioception
• Impaired dexterity and manipulation
• Poor Handwriting
• Difficulty performing daily life activities
• Speech Impairment (childhood apraxia of speech) and uncontrolled salivation
• Children with DCD can suffer from severe, long term consequences
– Poor social competency
– Academic and behavioural problems (inattention)
– Low self-esteem
– Withdrawal from social situations
– Anxiety
Assessment/screening tools
Fitness Assessment Tools (not limited to):
• Leger’s 20m Shuttle Run
• Incremental Treadmill or Cycle Ergometer Protocol
• 6 Minute Run
• Half mile Run
• 1-RM
• Grip Strength
• Curl Up Test
• Push Up Test
• Ball Throw Distance

Programming principles
Prescription
1. Resistance Training
• Strength and power may be underlying deficits that contribute to motor difficulties.
• Recommended minimum of one set of 8 to 10 repetitions, focusing on both multi and single
joint exercises
• Rest intervals of 30 to 120 seconds
• Twice a week training frequency, allowing rest days
• Session should run for at least 20 – 40 minutes, including a warm up and cool down.
• At least, for a 12 week period.
2. Aerobic Training
• Children with DCD often have low cardiorespiratory fitness
• Demonstrate decreased aerobic power compared to their peers
• Implement aerobic exercises that are enjoyable for the child
• Hydrotherapy – reduces any joint/loading pain, increases mobility, assists in developing muscle
power
• Recommended 2-3 times a week for 30-60min
3. Other Modalities
• Implementing technology – promote skill learning and increase stability, balance and aerobic
capacity
– Wi-Fit
• Neuromotor Task Training – Involves function skill training to assist the development of ADL’s

Special considerations
Movement Patterns
– Does the child appear weak at the “core”?
– Walk with normal heal to toe action with symmetrical arm swing?
– Run or jump with explosive muscle power?
Postural control
– Rise from a supine position without the use of hands?
– Can maintain 4-point kneeling while moving one limb?
Action Sequence
– Carry out a series of actions?
Assess ability to perform unilateral vs. bilateral actions

Contraindications to exercise
Safety Considerations
• Each child has different presentations and progressions
• Use machine weights rather than free weights
• Avoid any action/activity that may harm the child
• Ensure before loading the muscle, the child can execute the exercise with the proper technique
• Judge progression based on level of fatigue.
STROKE
Diagnosis (pathophysiology)
 Ischemia: lack of circulating blood deprives the neurons of oxygen and nourishment
 Haemorrhage: extravascular release of blood causes damage by cutting off connecting
pathways, resulting in local or generalized pressure injury
 Stroke: occurs when blood flow to the brain is interrupted by a blocked or burst blood vessel
- Rapidly developing clinical signs of focal or global disturbance of cerebral functions
- Symptoms lasting 24 hours or longer, or leading to death, with no apparent cause other than a
vascular origin

Symptoms
 Weakness or numbness of the face, arm or leg on one side of the body
 Loss of vision
 Loss of speech, difficulty talking or understanding what others are saying
 Sudden or severe headache with no known cause
 Loss of balance, unstable walking, usually combined with another symptom

Methods Measures End Point of Test

AEROBIC
Cycle Ergometer (5- 12 lead ECG
10W/min) and/or HR Volition Fatigue
SBP > 250 mmHg Useful for
Arm + Leg Ergometer DBP > 115 mmHg prescribing
Seated Stepper BP, HR, RPE Ischemic exercise intensity
Threshold
Arm Ergometer
ENDURANC 6 or 12 min walk Distance walked
E Useful for clients
Arm + Leg Ergometer Time of exercise Volition Fatigue with and without
above 60% peak assistive devices
power

Assessment/screening tools
Endurance Exercise Testing
• Normally have lower VO2 due to hemiparalysis/paresis and loss of muscle mass
• Ramped/progressive testing can still be performed on treadmill (with safety harness), bike, arm
ergo
Strength Exercise Testing
• Strength can be assessed using standard machines, free weights or dynamometers (e.g. grip
strength)
• Proper instruction on technique important – remember patients may have hearing,
comprehension, language or learning difficulties
Methods Measures

STRENGTH
Manual Muscle Test • Force generated on
dynamometer
Isokinetic/Isometric
• Peak torque Only valid if the
Dynamometer
normalized to BW client can isolate
Weight machines/cables • Kilograms normalized movement
to BW
• Number of repetitions
Adverse signs & symptoms during exercise
• VO2 max – Approximately half that of age-matched health counterparts
• Breath harder when under exertion (reduced V02 and reduced lower maximal HR)
• Fatigue approximately 2.5 times more rapidly than health aged-matched individuals
• Lack of endurance & fatigue = sedentary lifestyle increase the risk of other co-morbidities

Programming principles
Aerobic Exercise Prescription
• May need to monitor blood pressure during exercise
• Consider aquatic activities, under supervision
• Use of heart rate to set loads may be problematic if:
Goal:
- Improve ADL’s and increase independence
- Increase walking speed
- Decrease associated cardiovascular health risks
Various modes of activity including:
- Upper & lower body Ergometer
- Cycle Ergometer
- Treadmill
- Seated Stepper
40-70% V02peak
3-5 days per week
20-60mins per session (can break the time up across multiple sessions)

Strength Exercise Prescription

• Strength of knee extensors, ankle plantar flexors and hip flexors correlated with gait
performance in stroke patients
• Should progress slowly to reduce DOMS
• Isometric and water resistance exercises a good start
• Good evidence that strength training significantly improves gait re-training

Nature of Strength Post Stroke

1. Strength measures obtained from different muscle groups
- Tend to correlate
- Have internal consistency
- Represent a common underlying factor
2. Muscles on the non-affected side may also be weaker post stroke (60% less compared to pre-
stroke)
- Greater impairment proximal than distal
3. Muscles of the trunk may also be impaired post stroke – therefore can greatly affect functional
activities.
Goal:
- Improve ADL’s and increase independence
- Improve gait and balance
Various modes of activity including:
- Isometric exercises
- Weight machines (pins and cables)
- Free weight (later stages)
3 sets (8-12 reps)
2 days per week
Muscle fatigue may be a factor that limits the number of stets and reps. Progress accordingly

Special considerations
Exercise Considerations/Safety Guidelines
• May hold stretches for up to 20 min for contractures
• Balance and stability a key issue – progress to unstable surfaces under supervision

• Heart rate monitors could be worn in all sessions

• Blood pressure should be monitored before and after training (supervise if BP high after
training)
• Psychological interventions (for depression), goal setting, social environments, etc. may help
exercise adherence
Think about accessibility (may not drive, etc.) and enjoyment/social interaction

Contraindications to exercise
 Vasodilators may increase the cool-down period required after exercise to prevent post exercise
hypotension.
 Medications that limit cardiac output by reducing heart rate may cause lower peak heart rates.
 Diuretics reduce fluid volume and may alter electrolyte balance, causing dysrhythmias.

Constraint Induced Therapy

• Repetitive actions with unaffected arm in a sling.
• 5 days a week, 6 hours a day, for three weeks – improvement in raising affected arm and holding
an object steady
• Perform simple tasks such as building blocks, board games, pick-up-put-away
• This massed practice of skills with affected arm is likely responsible for the increase in cortical
reorganization
• Results indicate that:
• Larger shifts of the centre of motor cortical output map
• Enlargement of excitable cortical areas

Role of mental practice

• Imagery of movement which activates the same/similar brain areas that are activated when
movements are actually executed.
• Passive observation of movement has been shown to activate cortical motor areas.
• Imagining movements -> stimulate restitution & redistribute brain activity, which accompanies
recovery of motor function.
• Twelve, 45 min sessions 3 x per week mental imagery training.
• Study reported no enhanced improvement in outcome measures:
• Grip strength
• Hand function (manual dexterity)
• ADL’s (Barthel Index)
SPINAL CORD INJURY
Diagnosis (pathophysiology)
SCI: usually from trauma, results in compression, contusion or severance of spinal cord or
arteries

Medical/pharmacology intervention
Antispasticity (baclofen/diazapam)
– Side effects include tachycardia, hypotension, CNS/CV depression, sedation/weakness
Anticoagulants (warfarin)
– Side effects include haemorrhage, increased bruising
Antibiotics (Bactrim)
– No important side effects
Neurogenic bladder treatment may require alpha-blockers
– Hypotension

After SCI, serotonin (5-HT) and noradrenaline (NA) levels greatly reduce brain stem-derived descending
neuromodulatory pathways.
Lack of NA would normally reduce motor neurone excitability, but after some weeks spasticity increases.

What is Spasticity?
Velocity dependent increase in muscle tone or muscle stiffness as a result of increased reflex activity.
Can Result in:
- Involuntary muscle contractions/spasms
- Stiffness or tight muscles when trying to move limbs
 - Pain and Weakness
Symptoms
Reflex testing:
• Most of the pathways that descend the spinal cord have a inhibitory effect on spinal reflexes.
• Damage of the descending tracts = facilitation of reflexes that are mediated at level of the spinal
cord = hyperactive
• After acute damage, spinal reflexes often pass through an initial stage of hypoactivity.
5+ Extremely hyperreflexive, sustained

4+ Very brisk, hyperreflexive

3+ Brisker, more reflexive

2+ Normal

1+ Low, diminished

0.5 + A reflex only elicited with reinforcement

0 No Response

• Peripheral Nerve: Stretch reflexes are depressed, usually out of proportion to weakness (which
may be minimal).
• Spinal cord and brain stem: Stretch reflexes are hypoactive at the level of the lesion and
hyperactive below the level of the lesion.

Assessment/screening tools
Endurance:
• University of Toronto Arm Crank Protocol – Submax protocol to predict max VO 2
o Perform 3 x 5-min stages with 2-min rests
o Predict max VO2 from 12-min wheelchair propulsion test
o Measure RPE & HR
• Stretching prior to exercise testing may help achieve appropriate ROM & warm up increase
aerobic metabolism

Strength:
• Can use standard strength testing procedures
• May need to watch for stability, pressure sore problems
• May need trunk stabilisation or securing of hands to handles
• Empty bladder prior to maximal performance

Exercise testing considerations:

• May need trunk or limb stabilisation (straps, etc.)
• Skin protection (seat cushion and padding)
• Prevent bladder over-expansion (empty before test)
• Environmentally controlled or cool area to compensate for impaired thermoregulation/sweating
• Use incremental protocols that allow monitoring of HR, BP, RPE and exercise tolerance
• Care for post-exercise hypotension – rest,
recline, leg elevation, fluid ingestion

Adverse signs & symptoms during exercise

• Inability to stimulate
autonomic/cardiovascular systems: lack of
adrenaline & thermoregulation difficulties
• Exercise hypotension
 • Autonomic dysreflexia – extreme hypertension (>300/200 mmHg), headache, flushing, goose
pimples, sweating/shivering, nasal congestion
• Chronic pain, spasticity, depression, obesity, urinary tract infections and pressure sores
• Dependence on upper extremities (wheelchair/crutches) predisposes overuse injuries, joint
degeneration
• Severe spasticity reduces range of motion
• Standard health issues with inactivity
• ~70% of SB patients have allergic hypersensitivity to latex (natural rubber)
• Exercise, clinical or research equipment with latex (e.g. rubber bands, rubber-coated dumbbells,
latex gloves, blood pressure cuffs)
• Causes allergic symptoms, including wheezing, itching, hives and life-threatening anaphylaxis

Programming principles
Aerobic Exercise
 3-5 days/week
 40-90% VO2R
 20-60mins each session
 exercises using arm ergometer, wheel chair ergometer, wheelchair treadmill, free wheeling, arm
cycling, seated aerobics, swimming, wheelchair sports, and electrical stimulation leg cycle
ergometry

• Normal progression requirements, but focus on work large muscle groups where possible
• Heart rate may be hard for patient to record, and may not predict muscle fatigue.
• Be aware of overuse injuries (shoulders) – vary exercises from normal daily movement patterns
• Increases in power output expected, but increases in max VO 2 harder to obtain
• 3-5 days per week, 20-60min per session

Resistance Training
 2-4 days/week
 not specified
 2-3 sets, 8-12 reps
 exercises using free weights, machines and dumbbells

• Strength training in spastic muscles may help manage contractures

• Muscles respond better to slow, controlled movements. Eccentric training so time under load in
stretch
• Increase exercise capacity leads to cardiovascular benefits and fatigue resistance for daily
movement
• Standard rules of progression, overload and specificity apply
• Target shoulders, upper arms, back and postural muscles to aid movement capacity
• Ensure bladder is empty before heavy lifting as increased intra-abdominal pressure may cause
damage
• Supervision (for falls, autonomic dysreflexia, etc.) important at all times
• May train balance and coordination with strength training, under supervision
• 2-3 sets of 8-12 reps, 2-4 days per week

Flexibility Exercise
• Twice-daily stretching sessions concentrate on shoulder and upper back (thoracic) flexibility
• Normal stretches held for 15 s (or 30 s), but contractures or postural stretches for up to 20 min
• Continual activity helps maintain ROM, and may also stretch after exercise
• May require special equipment to help improve ROM
Special considerations
 Exercise modes should be varied week to week to prevent overuse injury
 People with tetraplegia should use an environmentally controlled, thermoneutral gym
 Empty bladder or urinary collection device before exercise to prevent autonomic dysreflexia
 People with hypotension should use supine postures and wear support stockings and an
abdominal binder to maintain BP

Contraindications to exercise
 Initially aerobic exercise should consist of short 5-10min bouts of 40-50% VO2R (moderate)
alternating with 5 mins of active recovery. This may progress to 10-20mins of 85%-90%
VO2maxR (vigorous)
 Strength training should be performed from both seated position in the wheelchair and non-
wheelchair exercise and should include all trunk stabilizing muscles
 Avoid repetitive strain injuries by working to lengthen the anterior shoulder muscles and
strengthen the upper back and posterior shoulder muscles
 Avoid triggers for heat intolerance, including dehydration, glycogen depletion, sleep deprivation,
alcohol, infection, and lack of acclimatization
TRAUMATIC BRAIN INJURY
Diagnosis (pathophysiology)
• A TBI occurs when an outside mechanical force is applied to the head and affects brain
functioning.
– The physical force can consist of a blow to the head (such as from an assault, a fall, or
when an individual strikes his/her head during a motor vehicle accident) or a rapid
acceleration-deceleration event (like a motor vehicle accident).
– It is possible for the brain to become injured even if the head has not directly struck or
been struck by another object.
– The brain can become injured whether or not the skull is fractured.
• The most common causes of TBI:
– Falls (28%)
– Motor vehicle-traffic crashes (20%)
– Being struck by or against an object (19%)
– Assaults (11%)
– Blasts are a leading cause of TBI for active duty military personnel in war zones

Pathology/Pathophysiology of TBI
• Primary brain injury secondary to trauma:
– Cerebral contusions
– Lacerations
– Hemorrhage (sometimes considered secondary)
– Diffuse axonal injury
• Secondary injury to brain tissue:
– Intracranial hypertension
– Brain shift and herniation
– Biochemical processes
– Swelling
– Cerebral ischemia

Pathology/Pathophysiology of TBI
Cerebral contusions: typically in tips/bases of frontal lobes and tips/bases/lateral surfaces of T lobes.
Lacerations: less frequent but associated with penetrating TBI
Hemorrhage: may be epidural, subdural, subarachnoid, intraparenchymal
Diffuse axonal injury (DAI): occurs due to widespread shearing and stretching of axons and myelin
sheaths in white matter. DAI is best correlate with prolonged coma after TBI.
Intracranial hypertension: most common cause of death from TBI from those surviving initial injury due
to brainstem herniation compromising vital functions.
Brain shift: Pressure effects from bleeds, edema can cause mass effect or brain shift leading to additional
damage to brain tissue.
Brain swelling: can occur due to increased cerebral blood volume or cerebral edema. Swelling may be
localized adjacent to contusions, diffuse within a cerebral hemisphere, or diffuse throughout both
hemispheres.
Cerebral ischemia: can occur even without increased intracranial pressure and may relate to vascular
disruption and vasospasm.

Medical/pharmacology intervention

Symptoms

Assessment/screening tools
Components of the exam include:
1. Mental Status
 Level of consciousness (may occur during acute stage)
 Orientation (level of disorientation related to severity of the injury)
 Attention & Concentration (often seen in patient with injuries to frontal lobe)
 Memory (long term and short term memory can be affected)
 Calculations (damage to parietal lobe affect mathematical skills)
 Speech & Language (due to damage of the dominant hemisphere)
 Spatial orientation/perception (result from focal injuries to non-dominant parietal lobe)
 Affect (external facial expressions), mood (internal emotional state), behaviours

2. Cranial Nerves
 Damage or impairment to the 12 cranial nerves directly impact the structure they innervate.
- Balance
- Vision
- Speech
- Facial expression
Cranial Nerve Innervation

1: Olfactory Sensory Nerve (Smell)

2: Optic Sensory Nerve (Vision)

3: Oculomotor Motor Nerve (Moves Eyes)

4: Trochlear Moto Nerve (Moves Eyes)

5: Trigeminal 1. Opthalmic (Tears/Sensory)

2. Maxillary (Upper Teeth/Sensory)
3. Mandibular (Chewing/Sensory,Motor)

6: Abducens Motor Nerve (Moves Eyes)

7: Facial Motor Nerve (Facial Expression)

Sensory Nerve (Taste)

8: Vestibulocochlear Sensory Nerve (Vestibular, Cochlear)

9: Glossopharyngeal Motor Nerve (Pharynx)

Sensory Nerve (Tongue)

10: Vagus Motor Nerve (Speech)

11: Accessory Motor Nerve (Cranial & Spinal)

12: Hypoglossal Motor (Tongue)

3. Motor Assessment
 Muscle Bulk: Muscle atrophy after a period of disuse or coma
 Muscle Tone: Often observed increases in spasticity
 Muscle Strength: Hemiparesis and tetraparesis common following TBI
 Abnormal Movements:
o Dystonia
o Dyskinesia
o Tremor
o Myoclonus

4. Sensation
- Dependant upon the location of the injury
- Thalamus = impairment of all sensory function to the contralateral face and body
- Parietal lobe = Retain pain and temperature but UNABLE to locate this sensation
 - SENSORY NEGLECT – Non-dominant parietal lobe is injured

FUNCTIONAL CONSEQUENCES include:

- Inability to detect pain/soreness as a result of injury or fatigue
- Diminished joint position sense may affect individuals ability to perform ADL’s

5. Coordination
Modulated by:
 Corticospinal tracts = Muscle weakness slowing of fine & gross motor tasks
 Basal Ganglia = Slowed initiation of movement & Braykinesia
 Cerebellum = Tremors and inability to gauge speed, force etc. required for given task
 Sensory pathways (posterior columns) = Ataxia due to impaired proprioception
Can be assessed by simple tests including finger to nose and heel to toe walking

6. Reflexes
 Assessment helps to identify the brain region affected
 Hyperactive reflexes is common with corticospinal tract injuries (also associated with muscle
weakness and spasticity)

7. Posture and Gait

Spasticity, contractures and muscle weakness may result in:
 Weak hip flexors & ankle dorsi flexors = impaired swing through and toe clearance during
gait
 Decreased arm swing = due to impaired coordination
*Basal ganglia injury = stooped posture & shuffling gait

Exercise Testing Aerobic

• Following TBI individuals only able to achieve 60-74% of age predicted VO 2 max
• Measured by submaximal progressive protocols including:
• Use bicycle, arm/leg ergo or stair climb
• 20-m progressive shuttle
• 12-min run (although typically hard to self pace)
• Treadmill (may need harness to prevent falls
• VO2 max estimated from heart rate, distance travelled (during a set time period) or workload

Exercise Testing Strength

• Standard dynamometer tests useful
• Some individuals may have movement limitations (e.g. may only be able to extend knee if hip is
also extending)
• May demonstrate increased fatigue due to muscle weakness
• 1-min sit-up test shown to be reliable and requires little coordination
• Timed pull-up, arm flexion, etc. useful and shown reliable in this population

• Important for addressing muscle weakness

• May need to adapt movement patterns for postural stability issues
 • Consider use of Velcro straps if weak grasp
• Follow standard guidelines for strength programming, but may need to progress slower and
target single large muscle groups
• ACSM =

Exercise Testing Flexibility & Balance

• Arthritic complaints more common in individuals with TBI
• Lesser range of motion
– Multiple joint trauma in addition to brain injury
– Reduced mobility in acute phase of injury (bed rest)
– Heterotopic ossification
– Muscle weakness and hypertonia
– Can often use standard flexibility tests (with goniometer), but may need to support
patient

Adverse signs & symptoms during exercise

Cardiovascular changes:
• Postural hypotension
• Loss of aerobic capacity
• Reduction in cardiac output persists past one month
Musculoskeletal:
• Up to 40% loss of muscle strength: loss is more pronounced in the lower limbs versus upper
limbs:
• Decrease in bone density
• Shortening of soft tissues/contractures
• Effects on respiratory system, balance, cognition, sleep, psychiatric function

Exercise programming might be affected by

– Deficits in judgement, memory/learning, apathy, easy frustration, loss of inhibition (particularly if
frontal lobe)
– Loss of selected, isolated movement patterns
– Loss of synergy patterns to perform functional movements
– Muscle weakness
– Hypertonia or resistance to muscle stretch
– Hyperactive deep tendon reflexes
– Sensory/perceptual changes (including special senses)

Programming principles
Aerobic
 3-5days/week
 40-70% VO2max
 20-60min each session (or multiple 10 min sessions)
 upper and lower body ergometry, cycle ergometry, seated stepping, treadmill exercise

Strength
 2 days/week
 3 sets of 8-12 reps
 weights, free weights, isometrics exercises

Flexibility
 2 days/week (before or after aerobic or strength activities)
Neuromuscular
 2 days/week (same days of strength activities)
 coordination and balance activities

Special considerations
 individuals who need conditioning should start with aerobic intensity at 40-50% VO2max and
work up
 duration of aerobic activity should be gradually increased to an amount of expending 300kcal
 duration should be increased slowly (every 4-5weeks)
 time of day for both exercise and medication should be kept as constant as possible

Cardiovascular changes:
• Postural hypotension
• Loss of aerobic capacity
• Reduction in cardiac output persists past one month

Musculoskeletal:
• Up to 40% loss of muscle strength: loss is more pronounced in the lower limbs versus upper
limbs:
• Decrease in bone density
• Shortening of soft tissues/contractures
• Effects on respiratory system, balance, cognition, sleep, psychiatric function

Contraindications to exercise
• Exercise programming might be affected by
– Deficits in judgement, memory/learning, apathy, easy frustration, loss of inhibition
(particularly if frontal lobe)
– Loss of selected, isolated movement patterns
– Loss of synergy patterns to perform functional movements
– Muscle weakness
– Hypertonia or resistance to muscle stretch
– Hyperactive deep tendon reflexes
– Sensory/perceptual changes (including special senses)
MULTIPLE SCLEROSIS
Diagnosis (pathophysiology)
• Disease of CNS with multiple areas of inflammatory de-myelination, and damage to axons
• T- cells to attach to capillaries in brain and activate macrophages to attack and digest myelin
• Lesions representing focal areas of inflammatory demyelination seen in cerebral hemispheres,
brainstem and spinal cord
• Diagnose by neurologic deficits and MRI scanning

Medical/pharmacology intervention
 Anti-seizure medication: fatigue, drowsiness, dizziness, double vision, lack of coordination 
 Anti-parkinsonian medication: dizziness, agitation, low blood pressure, nausea, confusion 
 Anti-spasticity medication: drowsiness, weakness, dizziness, nausea, lightheadedness
 Antidepressants: headaches, nausea, dizziness, agitation, aggressiveness, increased heart rate,
drowsiness
 Antipsychotics: low blood pressure, seizures, muscle spasms 
 Anti-anxiety medication: nausea, drowsiness, dizziness 
 Psychostimulants: agitation, weight loss, insomnia

Primary signs and symptoms

• Fatigue and lack of motivation
• Decreased heat tolerance, blurred vision
• Other symptoms include facial numbness and
pain, loss of taste, swallowing difficulty, loss of
coordination of lower limbs before upper
• Bladder control (excessive urination) and
constipation a problem

Secondary signs and symptoms

• Loss of strength and mass
• Poor balance, postural stability
• Osteoporosis and weight gain from medications
• Diabetes
• Watch for thermoregulation difficulties and lack
of pain feedback because of poor afferent
conduction
• Spasticity common

Assessment/screening tools
Screening tools
1. Functional System Scores (FSS) & Expanded Disability Status Scale (EDSS)
 Based on a standard neurological examination, the 7 functional systems:
o Pyramidal
o Cerebellar
o Brain Stem
o Sensory
o Bladder & Bowel Control
o Visual & Mental Function
 These ratings are then used in conjunction with observations and gait assessments are used to
rate the EDSS.
 FSS - Scale of 0-9 (0 = normal)
 EDSS – Scale 0 (normal neurologic examination) to 10 (death due to MS) in half-point
increments.
2. Multiple Sclerosis Functional Composite (MSFC)
 MSFC is a three-part, standardized instrument for use in clinical studies & trials of MS.
 The MSFC was designed to fulfil three criteria:
o It should be multidimensional to reflect the varied clinical expression of MS across
patients and over time
o The dimensions should change relatively independently over time.
o One component should be a measure of cognitive function. The three components of the
MSFC measure leg function/ambulation, arm/hand function, and cognitive function.

3. Trunk Impairment Scale

• To measure the motor impairment of the trunk through the evaluation of static and dynamic
sitting balance as well as co-ordination of trunk movements.
• Scores range from a minimum of 0 to a maximum of 23.
• If patient scores 0 on the first item, the total score on the TIS is 0.
4. Functional Independence Measure (FIM)
5. Berg Balance Scale
6. Manual Muscle Testing
7. ROM Testing
8. Gait Assessment

Adverse signs & symptoms during exercise

 Reverse pedalling with resistance improves hip and ankle flexor strength for walking
 Harness or partial support of body weight facilitates longer exercise duration and reduces fear
while walking
 Void before and during exercise to reduce incontinence
 Non weight-bearing exercise should be reserved for those individuals with poor balance, lower
extremity sensory loss, or significant orthopaedic issues
  Depression is common and may affect adherence
Mode
Aerobic
Strength
Flexibility
Special considerations
Sensory loss and balance
deficits
Fatigue
Severe Spasticity
Thermo sensitivity and
reduced sweating response
Higher energy cost of walking
(2-3 times greater)
Daily variations in symptoms
Urinary incontinence
Cognitive deficits
Exacerbation of symptoms
Unco-ordination in upper
and/or lower extremities
Contraindications to exercise
Goals Frequency
Increase aerobic capacity & 60-70% V02 max
endurance 3-5 days per week
30 min per session
Improved muscle strength and 1-2 sets 8-12 reps
power 2 days per week
50-70% 1RM
Improve ROM Daily
Precautions
Perform resistance training, aerobic exercise and flexibility training in a
seated position; Avoid excessive joint range and muscle spasticity
aggravation. Careful progression based on the individuals responses to
exercise & avoid excessive fatigue
Perform resistance training on non-aerobic exercise training days
Avoid excessive joint range and muscle spasticity aggravation. Work to
correct imbalances & rest at least 1 day between sessions
Encourage adequate hydration, keep exercise room temperature between
20-22 degrees Celsius. Use cooling fans & exercise in the morning when
body temperature is lowest
Adjust workloads to maintain desired heart rate and check HR, BP & RPE
frequently.
Provide close exercise supervision and make daily adjustments to exercise
program variables. Careful progression based on an individual’s abilities.
Ensure adequate hydration and schedule exercise in close proximity to
restrooms
Provide written instructions, diagrams, frequent instructions and verbal
cues
Discontinue exercises and refer client to their physician. Resume exercise
program once symptoms are stable and client is medically cleared to
continue
Consider using a synchronised upright or recumbent arm/leg ergometer to
ensure balance and safety
CERBRAL PALSY
Diagnosis (pathophysiology)
 Characterised by:
o Limited ability to maintain posture & balance
o Changes in muscle and spinal reflex

Category Site of injury Presentation

Pyramidal Cortical region Spastic, Hyperreflexia,
Hypertonia
Extrapyramidal Basal Ganglia & Cerebellum Ataxia, Rigidity
Mixed Combination of above Combination of above

Diagnosis
 Severe CP can be predicted* after birth
o MRI
o Cranial Ultrasonography
o Other imaging techniques

 Mild to Mod. Early warning signs

o Delayed motor milestones
o Seizures
o Decreased rate of head growth
o Persistently fisted hand

Medical/pharmacology intervention
Pharmacology interventions
 Anticholinergics (uncontrolled body movements)
o E.g. Benztropine
 Anticonvulsants (seizure medications)
o E.g. Gabapentin
 Antidepressants (depression medication)
o Side Effects: Dizziness, Fatigue, Nausea, Dry mouth, Blurred vision
 Antispastic (muscle relaxants)
o E.g. Baclofen
 Anti-inflammatories (pain medication)
o E.g. Aspirin
Surgical interventions
 Orthopedic Surgry
 Botox
o Injected into the muscle to weaken them by interrupting the connection between the
nerves & muscle
o Lasts 3-6 months
o Research found = Decrease in muscle stiffness allows greater ROM and ability to
perform motor tasks
o Side Effects: Blurred vision, loss of strength, fatigue, nausea, respiratory problems
 Selective Dorsal Rhizotomy (SDR)
o Involves cutting of some of the sensory nerve fibres that come from the muscles and
enter the spinal cord (typically lumbar region)
o Side Effects: Back pain, sensory loss, weakened hamstring muscles

Symptoms
Signs and symptoms
 Depends on the type of Cerebral palsy
 Baby:
o Slow or delayed development (such as holding their heads up or sitting up later than
other babies)
o Unequal movements across their bodies (such as taking no notice of one hand)
o Muscle spasms or feeling stiff when you try to move their joints.
o Some babies with cerebral palsy might have been sick or premature when they were
newborns.
 Children:
o Problems with feeding, pain, sleep and communication
o Intellectual disability or learning disabilities in about 45% of children
o Behaviour difficulties in about 25% of children
o Epilepsy

Assessment/screening tools
MODE Measures/ comments
Aerobic Arm Cranks ECG, HR, BP, RPE
Wheelchair Use slow cadence if
Cycle ergometer (mild CP) spasticity is a concern
6/12min walk/push test Use incremental protocols
Strength Free Weights Record # of RM’s
Machine Weights # of Reps in 60 seconds
Limited by ROM & Spasticity
Flexibility Goniometry ROM limited by pain and/or
spasticity

Neuromuscular Gait\Balance Useful to assess to identify

limitation in motor
performance

Adverse signs & symptoms during exercise

Exercise considerations
 “Children with cerebral palsy are likely to also have other impairments in addition to their motor
disability”
 Spinal and hip abnormalities
 Epilepsy/ seizure – medications
 Vision and/or Hearing impairment
  Intellectual/ behaviour disability
 Chronic pain
 Communication issues
 Fatigue
 Secure hands and feet where necessary

Programming principles

Mode Goals Frequency

Aerobic Increase aerobic capacity & 40-85% V02 max
endurance 3-5 days per week
20-40 min per session
Emphasis Duration over
intensity
Strength Improved muscle strength 3 sets 8-12 reps
2 days per week
Following rules of
progression
Flexibility Improve ROM Before and after aerobic
exercise

Special considerations
Secondary considerations and consequences
 Chronic pain, spasticity, obesity, urinary tract infections and pressure sores
 Dependence on upper extremities (wheelchair/crutches)
 Severe spasticity reduces range of motion, may affect breathing
 Standard health issues with inactivity
 Inability to perform large muscle group exercise exacerbates problems

Lecture 7:

**know this slide** and the interaction between healthy mind, body and brain and peoples perception
of their pain response