Journal Club Presentation

@ Physiotherapy Dept., NIEPMD

Mr. Joshua Thangaraj Gnanasekar PT ,PG (Paed.) Final year student., VMCPT - Salem
First March 2023

The Effects of Functional Progressive Strength and

Power Training in Children With Unilateral Cerebral Palsy

A Study done by:

Ozgun Kaya Kara, PT, PhD; Ayse Livanelioglu, PT, PhD; Bilge Nur Yardımcı,
PT, MSc; Abdullah Ruhi Soylu, MD
A Study done at:
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences (Drs Kaya Kara and Livanelioglu, and Ms
Yardımcı) and Department of Biophysics, Faculty of Medical Sciences (Dr Soylu), Hacettepe University, Ankara, Turkey.

 Purpose:

The purpose of this study was to investigate the effects of

a novel functional strength and power-training program
on gait and gross motor function in participants with
unilateral cerebral palsy.



 Inclusion Criteria:

The inclusion criteria were between 7 and 16 years of age;

classi ed as level I using the Gross Motor Func- tion
Classi cation System (GMFCS); and able to follow and accept
verbal instructions.


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 Exclusion Criteria:

The exclusion criteria were ortho- pedic surgery or botulinum toxin

injection in the past 6 months, participants whose parents refused
permission for them to par- ticipate, and participants with epilepsy, or
those who had any other disease that interfered with physical activity
so that they could not continue a regular training program.



 Procedure of classification:

The participants were strati ed according to 3 variables:

1. Gender
2. Manual Ability classi cation System (MACS) (Level 1-3)
3. Age: (7-11 years as the youngest & 12-16 years the oldest)



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 Procedure of classification:

The participants were strati ed according to 3 variables:

1. Gender
2. Manual Ability classi cation System (MACS) (Level 1-3)
3. Age: (7-11 years as the youngest & 12-16 years the oldest)



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 Total Participants: 30

15 - Control Group
15 - Experimental Group

 Methods:

Study design: Randomised control Trial

Ethical Committee approved and consent form was signed and received.
Motor function and Manual ability was classi ed using MACS
Height and weight was also measured.
BMI was also calculated.



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 Primary outcomes: (walking and gross motor capacity)

SHORT TERM MUSCLE POWER: Assessed using, MUSCLE

POWER SPRINT TEST (Reliable in participants with CP)
Participant has to complete 6, 15 meter runs at their maximum pace
durint this test. Mean power output was calculated in watts for each
participant



 Primary outcomes:

GROSS MOTOR FUNCTION MEASURMENT: GMFM is

reliable and valid to assess changes in gross motor function in
participants with CP ages 5 months to 16 years.
GMF was assessed using dimensions (Standing, Walking ,
running & jumping)



 Primary outcomes:

GROSS MOTOR FUNCTION MEASURMENT: 1 minute walk

test (1MWT) was used to assess walking ability in participants with
CP.
Each participant walked as fast as possible without running, around
a 20 m oval track for a duration of 1 minute.
(This walk distance was used as the outcome variable)



 Secondary outcomes (Balance & Muscle strength)

TIMED UP AND GO: Functional mobility and dynamic balance were assessed
using the Timed Up and Go test (TUG) which is reliable and valid for participants
with CP.
Participants began the test while seated in an adjustable -height chair without an
armrest or backrest, their knees and hips were exed at 90 degree and their feet on
the oor.
The child was asked to stand up and walk 3 m as fast as possible without running
and then turn around walk back and sit down.
This test was repeated 3 times, and shorter times showed better functional ability.
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 Secondary outcomes (Balance & Muscle strength)

LEG PRESS: The 1 Repetition Maximum (1RM) of a leg press (combined

hip extension, Knee extension and plantar exion) was used to measure
lower extremity strength. The 1RM can evaluate the muscle strength in
pwople with CP with a high level of association and responsiveness.
The leg press was adjusted according to the child’s height. To evaluate the
isotonic muscle strength of the lower limbs, the maximum weight (in kg)
that can be lifted only once through the full range with good form using the
leg press was assessed.

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 Secondary outcomes (Balance & Muscle strength)

HAND HELD DYNAMOMETER : Isometric muscle contraction (Quadriceps

femoris, Hamstrings, tibialis anterior, gastrosoleus) of participants with CP was
assessed using an equipment called powertrack II Commander (JTECH Medical,
Utah, USA).
The PT instructed the child to press as hard as possible against the device for 1
second.
Three trials were recorded for each muscle group in the affected and unaffected legs.
The score was obtained by averaging the second and third trials (Kg/N)
This method is reliable and valid for measuring Lower extremity strength in
participants with CP

 Intervention for active comparison group:

locomotor training, improving symmetry of weight-bearing, stretching & did

not include Progressive resistance strengthening exercises.
3 times per week
60 mins per session
For 12 weeks
Totalling 36 sessions.



 Intervention for experimental group:

The experimental protocol consisted of functional strength- ening using the leg
press (for eccentric, concentric, and iso- metric contraction of quadriceps
femoris, hamstrings, tibialis anterior, and gastrosoleus), plyometric exercises
(including jumping), and balance training
3 times per week
90 mins per session
For 12 weeks
Totalling 36 sessions.



RESULTS
 Primary Outcomes:

There were no stastically signi cant differences between the experimental

and comparision groups for the baseline scores.

Only the Experimental group had signi cant improvements in the GMFM -
E (walking, running & Jumping) score, muscle power, and 1MWT scores
after 12 weeks.



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 Secondary outcomes:

At baseline there were no statistically signi cant differences between the

experimental and comparison groups.
After 12 weeks, the experimental group had signi cantly decreased TUG values,
Icreased 1RM values for the affected and unaffected legs, and increased muscle
strength in the quadriceps femoris, hamstrings, dorsi exor and plantar exor
muscles on both legs.
However there were no changes in the comparision group.



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 Adverse Events:

There were no adverse events assosiated with the training

protocol. None of the participants reported discomfort or
muscle soreness and all participated in the ADSL during study.



 Discussion:

In a study by, Vulpen et al : they investigated the effects of a functional power training program, including
high velocity resistance exercises, in children (aged 4-10 years, 3 times a week for 60 minutes for 14 weeks)
and they reported an increase of 83% in the muscle power sprint test.
The larger increase might be because of the inclusion of more younger participants with CP who may have
more muscle and neural plasticity.
In a study by Gillet et al: they examined the ef cacy of a combined functional anaerobic and strength-
training programme in young adults with CP (aged 15-30 years)
3 times a week for 12 weeks.
They reported an increase of 8.3% in the muscle power sprint test.
This difference may be because of the inclusion of older participants with CP.
Our Results: our results further support previous ndings that high velocity exercises provide greater
functional improvements than other strength - training programmes.



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 Limitations:

The Signi cant limitation of this study was the duration (90 minutes) of therapy in
the experimental group was longer than that of the comparison group (60 minutes).
Another limitation of this study was, it focussed only on minimal functional
impairments (GMFCS level I).
An active comparision group that did not use strengthening was used in this study.
For future studies, a comparison group inscluding muscle strengthening without
power training would more clearly demonstrate the differences.



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 Conclusion:

The progressive functional strength training with plyometric

exercises and balance training, increased muscle strength and power
in the lower extremities, balance and gross motor function adding to
the evidence that supports the use of muscle strengthening in
participants with Spastic CP.



THANK YOU