Patient profile

• 14 year old male
• Spastic diplegic Cerebral Palsy
• GMFCS Level II
• History of tendon lengthening
• Forearm crutches for community distances
• Has not been attending PT regularly
• Cognitively intact and motivated

Patient goals

• Participate in physical education class
• Play basketball without requiring rest breaks

Example of GMFCS Levels:

PICO

What are the effects of functional strength training versus typical physical therapy on walking ability in a pediatric population (<22 years of age) with spastic cerebral palsy?

Search Strategy 

100 articles identified

in: PubMed, CINAHL, OVID- Medline

16 duplicates removed

84 records screened

74 not relevant

10 full text screened

4 full text excluded

6 included

Inclusion Criteria

• Pediatric Population (<22 years old) with a diagnosis of spastic cerebral palsy who are also ambulatory

• Interventions that include strength or resistance training of lower extremities

• Assessment of at least one of the following: 6 minute walk test, TUG, 20 meter walk test, GMFM D/E

Exclusion Criteria

• Patient’s who had undergone botox injections within the past 3 months
• Surgery in the past 6 months
• Non-ambulatory patients
• Adult population
• Upper extremity training
• Inability to follow direction or cognitive/behavioral diagnosis

Results 

Limitations

• Small sample sizes, underpowered
• Cross-contamination of intervention
• Undefined control interventions; “typical PT”
• Lack of randomized controlled trials
• Lack of blinding
• Recruitment of convenience

Clinical Bottom Line

There is conflicting and limited, low quality, evidence that suggests that strength training does not improve walking ability in pediatric populations with spastic cerebral palsy with diagnoses that fall into GMFCS Levels I, II, & III.

• 2 studies were randomized controlled trials, both looking specifically at strength training, and lacking defined controls. Neither of these studies found significant improvement in any measures of walking ability, such as the TUG or GMFM D/E.

• 3 studies, all lower level evidence; case studies or quasi-experimental studies, found evidence that strength training improved measures of walking ability, but did not have control groups and included other intervention strategies within their therapeutic sessions, such as dynamic balance or gait training.

• The final study found that strength training and treadmill training both led to clinically detectable improved walking ability.

Application to Case

Strength training should be included in a standard physical therapy plan of care if it aligns with patient-specific goals or to specifically increase strength. Interventions that focus on gait training and walking endurance may be more beneficialwhen implemented as primary interventions to improve walking ability

Strength training does not appear to cause any negative effects to patients with spastic CP, although range of motion and spasticity should be monitored if strength training regimens are implemented.

References

Auld ML, Johnston LM. “Strong and steady”: a community-based strength and balance exercise group for children with cerebral palsy. Disabil Rehabil. 2014;36(24):2065-71.

Aviram R, Harries N, Namourah I, Amro A, Bar-haim S. Effects of a group circuit progressive resistance training program compared with a treadmill training program for adolescents with cerebral palsy. Dev Neurorehabil. 2016:1-8.

Aye T, Thein S, Hlaing T. Effects of strength training program on hip extensors and knee extensors strength of lower limb in children with spastic diplegic cerebral palsy. J Phys Ther Sci. 2016;28(2):671-6.

Dos Santos AN, da Costa CS, Golineleo MT, Rocha NA. Functional strength training in child with cerebral palsy GMFCS IV: case report. Dev Neurorehabil. 2013 Oct;16(5):308-14. doi: 10.3109/17518423.2012.731085. Epub 2013 Apr 25. PubMed PMID: 23617884.

Scholtes VA, Becher JG, Janssen-Potten YJ, Dekkers H, Smallenbroek L, Dallmeijer AJ. Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: a randomized controlled trial. Res Dev Disabil. 2012 Jan-Feb;33(1):181-8. doi: 10.1016/j.ridd.2011.08.026. Epub 2011 Oct 11. PubMed PMID: 22093663.

Taylor NF, Dodd KJ, Baker RJ, Willoughby K, Thomason P, Graham HK. Progressive resistance training and mobility-related function in young people with cerebral palsy: a randomized controlled trial. Dev Med Child Neurol. 2013 Sep;55(9):806-12. doi: 10.1111/dmcn.12190. Epub 2013 Jun 22