# The strategy of muscle strength training in children with spastic cerebral palsy

> CP is a neurological disorder that affects muscle tone, development of movement and posture and it’s caused by damage to the parts of the brain that control movement, balance and posture.

## Background: Evidence-Based Physical Therapy
Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. In October 2023, Savonia University of Applied Sciences hosted a Blended Intensive Program (BIP) focused on EBP. Over 40 physiotherapy students and 7 teachers from Savonia University of Applied Sciences (Finland), Universidade da Coruña (Spain), and Charles University (Prague) collaborated on various themes, including children with disabilities.

## Understanding Cerebral Palsy (CP)
Cerebral palsy (CP) is one of the most common developmental disabilities, with a prevalence of approximately 0.2–0.3%. It is a neurological disorder caused by damage to the brain during the fetal period, childbirth, or early childhood, affecting muscle tone, movement, and posture.

Spastic CP is the most common form (70–90%), encompassing:
*   Spastic monoplegia
*   Spastic hemiplegia
*   Spastic diplegia
*   Spastic triplegia
*   Spastic tetraplegia

Less common forms include athetosis and ataxia. Because CP results from injury to motor regions of the developing brain, muscle weakness is a primary impairment.

## Muscle Strength Training in CP Rehabilitation
Historically, strength training was discouraged due to fears that physical effort would aggravate spasticity. However, studies have shown that strength training does not negatively affect spasticity and instead improves muscle strength and functional activity levels. Under the Evidence Alert Traffic Light System, strength training is classified as "GO," meaning high-quality evidence supports its effectiveness.

## Guidelines and Training Strategies
*   **ACSM Guidelines:** Recommend supervision by a qualified team, tailoring therapy to CP progression, focusing on single-joint movements on one side at a time, and prioritizing movement practice over weight progression.
*   **Verschuren et al. (2016):** For GMFCS levels I-III, recommended a gradual approach, 2–3 times per week on non-consecutive days, utilizing 1RM (one-repetition maximum) prescriptions.
*   **Practical Implementation:** Due to the difficulty of measuring true 1RM in CP patients, a gradual increase in resistance within a designated repetition-maximum range is preferred. A familiarization period of 2–4 weeks using simple, low-dosage activities (10–15 reps, 1–2 sets) is recommended for beginners. Intermediate to advanced patients may progress to 6–12 reps for 2–4 sets using 60–80% of 1RM, incorporating complex, multi-joint activities.

## Research Findings
*   **Merino-Andrés et al.:** A 4–12 week program (2–5 days/week) focusing on lower limbs and trunk showed improvements in maximum work resistance, gait speed, standing balance, and gross motor function. Benefits were short-term, suggesting a need for longer-duration therapy.
*   **Van Vulpen et al. (2017):** A 14-week functional high-velocity resistance training (power-training) program for children aged 4–10 (GMFCS I-II) resulted in significant increases in muscle strength and walking capacity.
*   **Kara et al. (2019):** A 12-week program combining lower limb strength, balance, and plyometric exercises for children aged 7–16 (GMFCS I) improved gait function, gross motor capacity, dynamic balance, and muscle strength.

## Limitations and Future Directions
Current research faces several limitations:
*   Lack of long-term follow-up analysis.
*   Insufficient focus on upper limb training.
*   Lack of investigation into patients with higher GMFCS levels (IV and V).
*   Inconsistency in measurement methods; there is a need for standardized tools like the Functional Strength Measurement (FSM).

## Authors
*   **Dvorská Kateřina**, physical therapy student, FTVS Univerzita Karlova, Czech Republic
*   **Hiltunen Roosa**, physical therapy student, Savonia University of Applied Sciences, Finland
*   **Mäkinen Aurora**, physical therapy student, Savonia University of Applied Sciences, Finland
*   **Dr. Padín Sofía**, master degree student, Universidade da Coruña, Spain
*   **Regentová Kristýna**, physical therapy student, FTVS Univerzita Karlova, Czech Republic
*   **Silvennoinen Oona**, physical therapy student, Savonia University of Applied Sciences, Finland
*   **Marja Äijö**, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Finland
*   **Mari Tuppurainen**, physiotherapy lecturer, Savonia University of Applied Sciences, Finland
*   **Dagmar Pavlu**, Physiotherapist, Assoc. Prof. Charles University, Czech Republic
*   **Ivana Vláčilová**, Professor, Charles University, Czech Republic
*   **Jamile Vivas Costa**, PhD, MSc, PT, Lecturer, Universidade da Coruña, Spain
*   **Montserrat Fernández Pereira**, MSc, PT, Lecturer, Universidade da Coruña, Spain
*   **Verónica Robles García**, PhD, MSc, PT, OT, Lecturer, Universidade da Coruña, Spain

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