DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Effectiveness of functional progressive resistance exercise strength

training on muscle strength and mobility in children with cerebral
palsy: a randomized controlled trial
VANESSA A SCHOLTES 1 | JULES G BECHER 1 | ANTON COMUTH 2 | HURNET DEKKERS 3 | LIESEKE VAN DIJK 4 |
1
ANNET J DALLMEIJER

1 Department of Rehabilitation Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands. 2 Adelante, Valkenburg,
the Netherlands. 3 Rehabilitation Centre Heliomare, Wijk aan Zee, the Netherlands. 4 Mytyl and Tyltylschool and Rehabilitation Center Amsterdam, the Netherlands.
Correspondence to Dr Annet J Dallmeijer, at VU University Medical Center, Department of Rehabilitation Medicine, PO Box 7057, 1007 MB Amsterdam, the Netherlands. E-mail: a.dallmeijer@vumc.nl

PUBLICATION DATA AIM To evaluate the effectiveness of functional progressive resistance exercise (PRE) strength
Accepted for publication 17th November 2009. training on muscle strength and mobility in children with cerebral palsy (CP).
Published online 28th January 2010. METHOD Fifty-one children with spastic uni- and bilateral CP; (29 males, 22 females; mean age
10y 5mo, SD 1y 10mo, range 6y 0mo–13y 10mo; Gross Motor Function Classification System
LIST OF ABBREVIATIONS levels I–III) were randomized to the intervention group (n=26) or the control group (n=25, receiving
LSU Lateral Step-Up test usual care). The intervention group trained for 12 weeks, three times a week, on a five-exercise
PRE Progressive resistance exercise circuit, which included a leg-press and functional exercises. The training load progressively
STS Sit-To-Stand test increased based on the child’s maximum level of strength, determined by the eight-repetition
maximum. Muscle strength (measured with hand-held dynamometry and a six-repetition maxi-
mum leg-press test), mobility (measured with the Gross Motor Function Measure, two functional
tests, and a mobility questionnaire), and spasticity (measured by the appearance of a catch) were
evaluated before, during, directly after, and 6 weeks after the end of training by two blinded
research assistants.
RESULTS Directly after training, there was a statistically significant effect (p<0.05) on muscle
strength (knee extensors +12% [0.56N ⁄ kg; 95% confidence interval {CI} 0.13–0.99]; hip abductors
+11% [0.27N ⁄ kg; 95% CI 0.00–0.54]; total +8% [1.30N ⁄ kg; 95% CI 0.56–2.54]; six-repetition maxi-
mum +14% [14%; 95% CI 1.99–26.35]), but not on mobility or spasticity. A detraining effect was
seen after 6 weeks.
INTERPRETATION Twelve weeks of functional PRE strength training increases muscle strength up
to 14%. This strength gain did not lead to improved mobility.

Cerebral palsy (CP) describes a group of disorders in the
development of movement and posture, causing activity limi-
tation, that are attributed to non-progressive disturbances
that occurred in the developing brain.1 It is the most com-
mon cause of movement disability in childhood. Children
with CP may experience a variety of impaired muscle func-
tions, such as spasticity, muscle weakness, and loss of selective
motor control. Although all impaired muscle functions limit
the performance of daily life activities and participation in a
child with CP, a recent study has shown that muscle weak-
ness showed a stronger association with mobility limitations
in children with CP than spasticity.2 Strength training for
these children is, therefore, expected to improve or maintain
their mobility.
Until recently, strength training in children with CP was
discouraged as it was assumed that it would increase spastic-
ity. However, this was not supported by the results of earlier
uncontrolled studies which showed that strength training can
improve lower-limb muscle strength in children with CP
without increasing spasticity.3,4 Although studies have shown
there to be sufficient evidence for its effectiveness on muscle
strength, these effects are probably overestimated because of
the low methodological quality of the studies.5,6 The few
uncontrolled studies that have evaluated the effectiveness of
strength training on mobility outcomes in children with CP
have reported limited effectiveness.3,7 Three recently pub-
lished randomized clinical trials8–10 evaluated both muscle
strength and mobility in children with CP, but conflicting
results were reported.11,12 One of the explanations for these
conflicting results could be the high variability in training
characteristics, such as type of training, training intensity, and
training period. To be successful, strength training must be
individualized, and involve a progressive increase in intensity,
thereby stimulating strength gains that are greater than those

ª The Authors. Journal compilation ª Mac Keith Press 2010 DOI: 10.1111/j.1469-8749.2009.03604.x e107
associated with normal growth and development (i.e. ‘over-
load’). This is known as progressive resistance exercise (PRE).
According to the US National Strength and Conditioning
Association, children should be trained at an 8- to 15-repeti-
tion maximum, which is the number of repetitions that can be
completed before fatigue.13 To stimulate strength progres-
sion, the amount of resistance should be increased as strength
increases. Most previous strength training studies did not
present full details of their training programme, or used insuf-
ficient intensities. Adequate interpretation of study results is
not possible when key principles of the PRE are not followed.
Further, earlier reported training programmes lasted 5 to
8 weeks but some have argued that a 6-week training pro-
gramme may not be long enough to induce functional adapta-
tions.14 Therefore, the purpose of this study was to evaluate
the effectiveness of a sufficiently long and intensive 12-week
functional PRE strength training programme, by applying
current guidelines.13 We hypothesize that this training would
improve muscle strength and, subsequently, lead to improved
mobility in children with CP, without increasing muscle
spasticity.
METHOD
Participants
Ambulatory children with spastic unilateral or bilateral CP1
were pre-selected by a paediatric physiatrist. The inclusion
criteria were (1) age between 6 and 13 years, (2) able to
accept and follow verbal instructions, (3) able to walk inde-
pendently indoors, with or without walking aids (Gross
Motor Function Classification System [GMFCS] levels I–III),
and (4) able to participate in a group training programme.
The exclusion criteria were unstable seizures, any treatment
for spasticity or surgical procedures from 3 months (for botu-
linum toxin type A injections) to 6 months (for surgery)
before the study (or planned during the study period), any
change in medication expected during the study period, and
suffering from any other diseases that interfered with physical
activity.
Study design
This study, performed between April 2007 and May 2008, had
a single-blind randomized controlled design. It was conducted
at three special schools for children with physical disabilities
in the Netherlands (Amsterdam, Wijk aan Zee, Valkenburg).
The study protocol was approved by the medical ethics com-
mittee of the VU University Medical Center in Amsterdam.
Full written informed consent was obtained from all parents
and 12-year-old children before enrolment. Randomization
was performed for each school separately by one independent
physiatrist. The children were pre-stratified according to three
stratification variables: sex, GMFCS level (I, II–III), age
(youngest: 6–9y; oldest 10–13y), and subsequently randomized
to one of two groups using sealed envelopes. Parents, thera-
pists, and schoolteachers were notified about the randomiza-
tion group by letter. Two independent research assistants
performed all assessments and data entry. They were blinded
for treatment allocation. Assessments were at baseline (T0),
e108 Developmental Medicine & Child Neurology 2010, 52: e107–e113
What this paper adds
• Insight into the true effectiveness of strength training in children with CP, using
a blinded randomized controlled study.
• It evaluates the effectiveness of a strength training program in which appropri-
ate guidelines for strength improvements are applied, based on the key ele-
ments of PRE.
• It shows that PRE based strength training is effective on muscle strength
improvement, but not on mobility improvement.
during training (T1; a subset of outcomes), directly after train-
ing (T2), and at the 6-week follow-up (T3). The measurement
points of main interest were T2 and T3.
Intervention
The control group continued their conventional physical
therapy programme. Children in the control group received
one to three sessions a week. The training group followed a
12-week progressive functional strength-training programme
for the lower extremities. This replaced their conventional
physical-therapy programme. Training was given three times
a week for 45 to 60 minutes at school in small groups (four
or five children). Each training session consisted of one
exercise on a child-adapted leg-press (Enraf Nonius, Delft,
the Netherlands) and three functional exercises (sit-to-stand,
lateral step-up, half knee-rise), loaded with a weighted vest.
During the training, intensity progressively increased, based
on repeated estimation of the eight-repetition maximum. A
detailed description and characteristics of the PRE training
programme can be found elsewhere.15
Outcome measures
The primary outcome, ‘mobility’, was measured with the 66-
item version of the Gross Motor Function Measure (GMFM-
66), the Sit-To-Stand (STS) test, and the Lateral Step-Up
(LSU) test. The GMFM-66 is a standardized observational
instrument, based on interval scaling.16 It reports on the
child’s level of capacity, and has been internationally validated
for evaluating change in the gross motor activities of children
with CP. The STS test assesses the number of repetitions (full
movement from standing up to sitting down) that the child
can perform in 30 seconds on a child-sized chair with a
height-adaptable seat (no backrest, no armrest). The LSU test
assesses the number of repetitions (full movement from step-
ping up to stepping down) that the child can perform in
30 seconds on a 21cm (GMFM I–II) or 11cm (GMFCS III)
step. Subjectively reported mobility was assessed with the 28-
item version of the Dutch mobility questionnaire (MobQues-
28), which measures caregiver-reported mobility limitations.
It was found to be valid and reliable in a recent study in a
Dutch population.17
The secondary outcome, ‘muscle strength’, was measured
with (1) a six-repetition maximum test on a leg-press and (2)
isometric strength tests of the hip flexor ⁄ abductor, knee
flexor ⁄ extensor, and ankle plantar flexor muscles of the most
affected leg, using a hand-held dynamometer (MicroFet; Bio-
metrics, Almere, the Netherlands). At T1 only a subset of
these outcomes were tested: the STS, LSU, and six-repetition
maximum.
 The control outcome measure was spasticity, quantified on
a scale of 0 to 5, calculated as the sum of a catch in response to
a fast muscle stretch (0, no catch; 1, catch) in five leg muscles
(adductor, rectus femoris, hamstrings, soleus, gastrocnemius).
Scholtes et al.15 give detailed descriptions of all outcome mea-
sures and measurement protocols.
Muscle soreness was scored weekly on a Likert scale (no;
mild; moderate; severe; extremely severe).
Statistical analysis
Baseline characteristics were analysed with the Student’s t-test
for continuous normally distributed data, a v2 test for dichoto-
mous data, and a Mann–Whitney U test for ordinal data. A
two-tailed value of p<0.05 was considered to be statistically
significant.
To investigate the effect of the strength training, we used
generalized estimating equations for longitudinal analysis of
continuous outcomes and log linear generalized estimating
equation analysis for ordinal outcomes. This method takes
into account the dependency of within-patient observations
and the fact that not all children are assessed at each measure-
ment point (missing data). All analyses were performed in
SPSS, version 15 (SPSS Inc., Chicago, IL, USA). In the
primary generalized estimating equation model, the outcome
variable (e.g. GMFM-66, LSU, STS, hand-held dynamome-
ter, six-repetition maximum, MobQues-28, or spasticity) was
analysed as a dependent variable, with treatment allocation (1,
training; 0, control) as the key independent variable adjusted
for time. To evaluate whether the two groups differed in
change over time, the interaction term (group*time) was added
as an independent variable. We had four measurement points,
so time was included as a dummy variable (reference was base-
line), and three interaction terms were analysed (group 1*T1;
group 1*T2; group 1*T3). All models were corrected for the
school attended. We also analysed whether sex (1, male; 0,
female), age, body mass index, limb distribution (1, unilateral;
0, bilateral), GMFCS level (dummies for levels I–III; refer-
ence, I), puberty onset (Tanner stages, dummies for early
[stages 1–2], middle [stages 3–4], or late adolescence [stage 5];
reference, early), and problem behaviour (Strength and Diffi-
culties Questionnaire,18 dummies for normal [scores 0–10],
borderline [scores 11–13], or abnormal behaviour [scores
14–40]; reference, normal) were confounders of the training
effect. A two-tailed value of p<0.05 was considered statistically
significant.
Study power
This study had a power of 87% in detecting a difference in
improvement of 5% on the GMFM-66 between the interven-
tion and the control group, with an alpha of 0.05.
RESULTS
Sixty-one patients were asked to participate; four turned out
to be ineligible. Of the remaining 57 eligible patients, six did
not give consent. The remaining 51 children were random-
ized. Of these, one dropped out before T0 (GMFCS level III,
female, age 13y 1m, training) owing to a hip injury that made
pretesting and training impossible, and one was lost to follow-
up at T1 (GMFCS level II, female, age 12y 1mo, training)
owing to an unexpected long-term stay abroad.
Analyses were performed for 49 participants (Fig. 1). Per-
sonal characteristics of the participants are presented in
Table I. There was no statistically significant difference
between the groups for personal characterstics.
Training compliance and intensity
Of the 36 scheduled training sessions, three to six sessions
were cancelled because of school-related activities. After cor-
rection for these, the mean compliance was 92.3% (range 71–
100%). A mean of 32 training sessions (range 30–33) were
attended. Reasons for absence were illness (41.4%), medical
appointment (8.6%), vacation (6.9%), or other ⁄ unknown
(43.1%).
Every 2 weeks, starting from week four, eight-repetition
maximum tests were performed for leg-press and loaded STS
exercises. Based on these eight-repetition maximum test values
the training load progressed. During the last 8 weeks of train-
ing, the mean eight-repetition maximum strength increased
from 116 to 149% on the leg-press, and from 28 to 41% on
the loaded STS.
Each week, one to six children reported mild to moderate
muscle soreness.
Outcome measures
Table II presents the mean values at all measurement points
for all outcome measures. Some children could not be moti-
vated to complete all tests at each occasion; therefore, a vari-
able number of observations is shown.
At baseline, the intervention group achieved statistically sig-
nificantly more STS repetitions, had statistically significant
greater ankle plantarflexion and total isometric muscle
strength, and had statistically significant greater six-repetition
maximum leg-press strength than the control group.
The estimated intervention effect, corrected for baseline
differences, is presented in Table II. The intervention had no
statistically significant effect on the primary outcome mobil-
ity, measured with the GMFM-66, STS, LSU, and Mob-
Ques-28 (Fig. 2a–d). There was a statistically significant
effect on the secondary outcome for the total isometric
(1.30N ⁄ kg, 8%), knee extensor (0.56N ⁄ kg, 12%), and hip
abductor (0.27N ⁄ kg, 11%) muscle strength, and the six-repe-
tition maximum strength (14%; Fig. 2e,f). There was no
effect on spasticity.
Confounders
None of the investigated variables confounded on the training
effect. Table II and Figure 2 present the results of the final
regression models.
DISCUSSION
This study hypothesized that a 12-week functional PRE
strength training programme, in which appropriate guidelines
for increasing muscle strength are applied,13 improves muscle
strength in children with CP, and subsequently leads to
Strength Training for Children with CP Vanessa A Scholtes et al. e109
 Patients asked to participate
n = 61

Patients ineligible
n=4 (4× planned for surgery)

Patients eligible to participate

on basis of inclusion criteria
n =57

Patients who did not give informed

consent. n =6 (4× no interest;
2× too busy)

Randomized patients
n =51

Functional strength training Usual care group

group n=26 n =25

Patients who dropped out.

Before T0 n=1(hip-injury)
Before T1 n=1 (long-term stay abroad)

Patients who completed follow Patients who completed follow

up n=24 up n=25

Figure 1: Patient flow chart.

Table I: Personal characteristics of participants (n =24)

Intervention Control
Personal characteristics group (n=24) group (n=25) p value 95% CI

Sex (females ⁄ males) 8 ⁄ 16 12 ⁄ 13 0.30

Age (y:mo), mean (SD) 10:4 (1:10) 10:3 (2:3) 0.96 )1.2 to 1.2
Height (cm), mean (SD) 141.4 (13.6) 139.1 (13.1) 0.55 )9.9 to 5.4
Body weight (kg), mean (SD) 38.8 (11.2) 34.49 (10.4) 0.17 10.5 to 1.9
Limb distribution (unilateral ⁄ bilateral) 7 ⁄ 17 10 ⁄ 15 0.43
Gross Motor Function Classification System Level (I ⁄ II ⁄ III) 13 ⁄ 8 ⁄ 3 12 ⁄ 9 ⁄ 4 0.64
Orthoses (yes ⁄ no) 12 ⁄ 12 14 ⁄ 11 0.67
Puberty onseta (early ⁄ middle ⁄ late adolescence) 16 ⁄ 7 ⁄ 0 16 ⁄ 7 ⁄ 2 0.57
Problem behaviourb (normal ⁄ borderline ⁄ abnormal) 10 ⁄ 5 ⁄ 7 6⁄9⁄7 0.46

Data are number of patients, unless otherwise indicated. aDerived from the Tanner stages of sexual maturation. bDerived from the Strength and
Difficulties Questionnaire. CI, confidence interval.

improved mobility, without any adverse effect on muscle spas-
ticity.
This 12-week functional PRE strength training resulted in
statistically significant larger improvements (8%) in total
hand-held isometric muscle strength in the training group
than in the control group. Isolated significant improvements
were found in the knee extensors (12%) and hip abductors
(11%), but not in the knee, hip, and ankle plantar flexors. This
seems to underline the importance of specificity in strength
training; i.e. the exercise must be specific to the working of the
muscle. Because the circuit training specifically targeted
strengthening knee and hip extensors (with the leg-press, STS,

e110 Developmental Medicine & Child Neurology 2010, 52: e107–e113

 Table II: Estimated effect of intervention on mobility, muscle strength and spasticity according to generalized estimating equation analyses

Values at measurement points Effect of intervention

Intervention Control
Regression coefficient
T n Mean (SD) n Mean (SD) (95% CI) p value

Primary outcomes
GMFM-66 (0–100) T0 24 76.1 (12.8) 23 71.8 (12.5)
T2 24 76.1 (11.8) 24 73.1 (12.4) )0.56 ()2.11 to 0.99) 0.48
T3 24 76.6 (13.0) 24 72.7 (12.8) 0.26 ()1.23 to 1.76) 0.73
STS test (reps) T0 24 12.9 (2.8) 23 10.8 (3.0)a
T1 24 13.3 (3.2) 24 12.1 (4.2) )0.47 ()2.28 to 1.33) 0.61
T2 24 13.6 (3.0) 24 12.7 (4.3) )0.75 ()2.21 to 0.72) 0.32
T3 24 14.3 (2.9) 23 12.7 (4.6) 0.03 ()1.43 to 1.49) 0.97
LSU test (reps) T0 23 15.6 (4.0) 23 13.3 (5.4) 0.95
T1 24 15.2 (3.9) 24 13.7 (4.3) )0.05 ()1.87 to 1.77) 0.63
T2 24 17.0 (5.1) 23 15.4 (4.3) 0.48 ()1.45 to 2.40) 0.9
T3 24 17.5 (4.8) 24 15.8 (6.6) 0.13 ()1.84 to 2.10)
Secondary outcomes
Isometric muscle strength (N ⁄ kg)
Knee extensors T0 24 4.78 (1.12) 23 4.36 (1.05)
T2 24 5.39 (1.10) 24 4.48 (1.21) 0.56 (0.13 to 0.99) 0.01
T3 23 5.20 (1.04) 24 4.46 (1.20) 0.35 ()0.16 to 0.85) 0.16
Knee flexors T0 24 2.73 (0.79) 23 2.25 (0.96)
T2 24 2.76 (0.75) 24 2.27 (1.02) 0.05 ()0.25 to 0.36) 0.71
T3 24 2.67 (0.86) 24 2.33 (0.90) )0.10 ()0.43 to 0.24) 0.58
Hip flexors T0 24 3.96 (0.75) 23 3.76 (0.99)
T2 24 4.43 (0.99) 24 4.12 (0.99) 0.16 ()0.22 to 0.55) 0.41
T3 24 4.46 (0.90) 24 4.43 (0.86) )0.12 ()0.50 to 0.27) 0.55
Hip abductors T0 24 2.66 (0.76) 22 2.41 (0.74)
T2 24 2.78 (0.85) 24 2.28 (0.70) 0.27 (0.00 to 0.54) 0.05
T3 24 2.90 (0.99) 24 2.45 (0.94) 0.23 ()0.10 to 0.56) 0.17
Ankle plantar flexors T0 24 3.90 (1.43) 23 3.11 (0.87)a
T2 24 4.53 (2.16) 23 3.54 (0.94) 0.23 ()0.47 to 0.93) 0.51
T3 24 5.01 (2.26) 24 4.38 (1.49) )0.16 ()1.01 to 0.69) 0.72
Total T0 24 18.04 (3.52) 22 15.94 (3.57)a
T2 24 19.88 (4.13) 23 16.65 (4.11) 1.30 (0.56 to 2.54) 0.04
T3 23 20.39 (4.49) 24 17.80 (4.01) 0.40 ()1.02 to 1.83) 0.58
Six-repetition maximum on leg- T0 23 112.78 (21.28) 23 93.76 (20.18)a
press (% body weight) T1 24 119.38 (26.61) 23 100.80 (23.72) 1.97 ()8.45 to 12.41) 0.71
T2 23 135.63 (31.87) 22 102.88 (26.76) 14.17 (1.99 to 26.35) 0.02
T3 24 129.90 (32.15) 23 111.99 (26.17) 3.42 ()8.62 to 15.46) 0.58
MobQues-28 (0–100) T0 22 68.42 (20.93) 22 64.77 (26.26)
T2 23 67.51 (24.58) 23 66.43 (25.93) )0.46 ()6.00 to 5.07) 0.87
T3 21 70.03 (23.49) 17 67.49 (20.33) )2.22 ()7.88 to 3.43) 0.44
Control outcome Median (SD) Median (SD)

Spasticity (0–5) T0 24 1.00 (1.32) 23 2.00 (1.32)

T1 23 2.00 (1.41) 22 2.00 (1.39) 0.02 ()0.99 to 1.02) 0.97
T2 23 2.00 (1.11) 24 1.50 (1.10) 0.46 ()0.34 to 1.26) 0.26
T3 22 1.00 (0.87) 24 1.00 (0.87) )0.22 ()0.92 to 0.49) 0.55

a
Statistically significant baseline difference between the two groups. T, measurement point; T0, baseline; T1, 6 weeks; T2, 12 weeks (end of
training); T3, 18 weeks (follow-up); n, number of individuals; GMFM, Gross Motor Function Measure; STS, Sit-to-Stand test; LSU, Lateral Step-Up
test; reps, repetitions; MobQues-28, mobility questionnaire; CI, confidence interval.

forward step-up, and half-knee-rise exercises) and hip abduc-
tors (with the lateral step-up exercise), improvements in these
target muscles were, therefore, to be expected. Unfortunately,
isometric hip extension strength was not assessed, owing to
this assessment’s low reliability, as found in a pre-pilot study.
Two other randomized studies have evaluated isometric mus-
cle strength, and found similar results, either in total muscle
strength9 or isolated (targeted) muscle strength.8 The training
also resulted in a statistically significant improvement (14%)
in six-repetition maximum leg-press strength, compared with
the control group. To our knowledge, no other study has
assessed this outcome measure in a similar patient group, so it
is impossible to compare these results with others. However,
one randomized study10 did use the one-repetition maximum
STS as an outcome. When adjusted for body weight, the
strength increase in favour of the intervention group was com-
parable (approximately 15%).
The results of this study show that training with a sufficient
intensity, e.g. with a training load at which no more than 8 to
12 repetitions can be completed before muscular fatigue,
results in increases in muscle strength. With this result we
hope to fill the gap that was recently addressed in a literature
discussion19 on the effectiveness of strength training on
muscle strength, and stressing the need for new randomized

Strength Training for Children with CP Vanessa A Scholtes et al. e111

 Lateral step up (repetitions)
90 20 20

Sit to stand (repetitions)

a b c
GMFM 66 (0–100) 85
15 15
80
75 10 10
70
5 5
65
60 0 0
0 6 12 18 0 6 12 18 0 6 12 18

90 22 160
d e f

6RM (% bodyweight)
*

HHD – total (N/kg)

80 140 *
MobQues-28

20
#
70 120
18
60 100
16 80
50 Training
60 Control
40 14
0 6 12 18 0 6 12 18 0 6 12 18
Time (wks)

Figure 2: Estimated marginal means and standard errors of (a) Gross Motor Function Measure, 66 items (GMFM-66), (b) Sit-to-Stand, (c) Lateral Step-Up,
(d) Dutch mobility questionnaire (MobQues-28), (e) hand-held dynamometer (HHD)– total, and (f) six-repetition maximum (6RM) scores at measurement points
0 (baseline), 6, 12, and 18 weeks for the intervention and the control groups. aStatistically significant baseline difference. bStatistically significant difference in
change between intervention and control groups, corrected for baseline differences (p<0.05).

controlled trials that apply appropriate guidelines. We feel
that our study adds to this discussion and the current evi-
dence20 that PRE strength training is effective in increasing
leg muscle strength in this group of patients.
There was a detraining effect, resulting in loss of muscle
strength at 6 weeks after the training ended, which was
expected, and has also been observed in healthy children.21
Surprisingly, this effect was not observed in the few compara-
ble (mostly uncontrolled) studies in children with CP3,9,12 with
a follow-up assessment. Based on the findings of our random-
ized controlled trial, we recommend that strength training
should be included in a regular exercise routine to maintain
increased strength levels.22
Unexpectedly, the 8 to 14% strength improvements were
not accompanied by mobility improvements, according to the
GMFM-66, the functional strength tests, and the mobility
questionnaire. Two out of three comparable randomized con-
trolled trials showed that their strength training resulted in
small, but significant, functional improvements on the
GMFM-66 in favour of the training group.8–10 So, despite the
current popularity of strength training, the evidence from
current randomized controlled trials is inconclusive on the
effectiveness of strength training to improve mobility in
children with CP.
Possible explanations for the lack of mobility improvement
in our study might be that the 8 to 14% improvements were
too small to improve mobility, or that the number of individ-
ual muscles gaining strength was too limited. Therefore,
future studies should focus on optimizing the training pro-
gramme to reach maximum strength gains in children with
CP. Besides this, we need to gain a better understanding of
the longitudinal relation between muscle strength and mobil-
ity. Daily activities require only a certain amount (e.g. lowest
threshold) of muscle strength. Increases above these lowest
threshold values may be accompanied by increases in mobil-
ity,23 but there might also be a point (e.g. highest threshold) at
which further strength increases provide no additional advan-
tage in mobility improvements.24 In that case, strength train-
ing would not be the appropriate choice of treatment when
the aim is to improve mobility. Here, other components, such
as balance and coordination, might influence mobility
improvement to a greater degree than muscle strength alone.
This should also be a subject for future research. In addition,
the lack of effectiveness on mobility improvement found in
this study might also be explained by the lack of variation in
task contexts and individually tailored exercises. It is said that
functional improvement is unlikely to occur unless the task to
be learned is practised under various different contexts.25 Even
though our training contained functional exercises that resem-
bled daily mobility activities (e.g. rising from a chair), the
actual context of these exercises (i.e. chair height) remained
unchanged throughout the training period. The lack of effec-
tiveness on mobility improvement might also be explained by
the non-individual specificity of the exercises. Selection of
individually tailored mobility exercises with a more goal-ori-
ented approach might improve the effectiveness of strength
training on mobility outcomes.26
There was no change in spasticity (in either group) during,
directly after, or 6 weeks after the training, confirming the
results of similar studies.3 This supports the current belief that
strength training for patients with spasticity is not contra-indi-
cated. Children were informed that they could experience a

e112 Developmental Medicine & Child Neurology 2010, 52: e107–e113

mild to moderate degree of muscle soreness the day after the
training. Muscle soreness was occasionally reported. This
muscle soreness, rated as mild or moderate, was transient and
never interfered with their training or daily life. Therefore,
this cannot be interpreted as a contra-indication. Moreover, it
might confirm that training intensity was sufficient to generate
muscle overload.
This study has some limitations. First, the groups differed
slightly statistically, although non-significantly, in personal
characteristics, but none of these were found to be confound-
ers. Secondly, the intervention group performed better at
baseline on all outcome measures, reaching statistical signifi-
cance in the number of STS repetitions, isometric ankle plan-
tarflexion, and total muscle and six-repetition maximum
strength. Therefore, outcome measures were controlled for
baseline differences. Another limitation was the unknown fre-
quency and content of the usual physiotherapy of the control
group. However, the therapists of the control group did not
know the PRE training principles.
In conclusion, 12 weeks of functional PRE strength training
is effective in increasing isometric muscle strength of the knee
extensors and hip abductor by 11 to 12%, and increasing six-
repetition maximum leg-press strength by 14%. However, this
does not result in an increase in mobility. Consequently, func-
tional PRE strength training is indicated for a child with CP
when the aim is to improve leg muscle strength. It could also
be included in a more extensive treatment regime, addressing
several elements of fitness including muscle strength, or used
as a target treatment specifically anticipating temporary mus-
cle weakness, such as before or after botulinum-toxin-A or
surgical treatment.
ACKNOWLEDGEMENTS
This study was supported financially by a grant from the Johanna
Kinder-Fonds (2005 ⁄ 0123-357), the Adriaanstichting, and the Phelps
Stichting (2006016).We are indebted to all the children and their par-
ents for their participation. We are also grateful for the contributions
of members of the Popeye study group: Linda Smallenbroek, Maartje
Hensen (Mytyl and Tyltylschool and Rehabilitation Center Amster-
dam), Eugene Rameckers, Yvonne Jansen-Potten, and Lucianne
Speth (Rehabilitation Foundation Limburg, location Franciscusoord,
Valkenburg), Els Tempelaars, Nienke Bergsma, and Han Houdijk
(Rehabilitation Center Heliomare, Wijk aan Zee). Thanks are due to
Enraf Nonius and Noppe Orthopedie for their support in providing
training equipment.

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