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Strength Training Program Elicits Positive Results for Spastic Cerebral Palsy

Investigators found that strength training improved muscle strength, balance, gait speed, and gross motor function in pediatric and adolescent patients.

A recent systematic review and meta-analysis found positive functional and activity effects when incorporating strength training into treatment for children and adolescents with spastic cerebral palsy. Patients exhibited improved effect on muscle strength, balance, gait speed, and gross motor function, without increasing spasticity, when compared to standard physical therapy techniques and untreated control groups.

Investigators reviewed a total of 27 studies, including 847 patients between the ages of 3 and 22 years with spastic cerebral palsy. A total of 452 patients with spastic cerebral palsy completed strength training in different settings. Patients were put in 2 groups, unilateral spastic (n = 221) and bilateral (n = 517) cerebral palsy, with patients in all 4 levels of the Gross Motor Function Classification System: level I (n = 147), level II (n = 170), level III (n = 106), and level IV (n = 9). 

Patients underwent training in a clinical physiotherapy session in 15 trials, in a natural or home environment in 8 trials, and in a school environment in 4 trials. A total of 24 studies of the 27 were included in the meta-analyses, excluding 3 that did not have data that could be analyzed.

Six trials evaluated the muscle strength of the knee flexors with strength training, which had a small positive effect with considerable heterogeneity (I2 = 85.71%; P <.001), and 11 trials evaluated knee extensor strength improvement, also showing a minimal positive effect with no heterogeneity (I2 = 0%; P = .972). Four trials evaluated plantar flexor improvement, showing a small to moderate positive effect with substantial heterogeneity (I2 = 64.19%; P = .039), and seven trials evaluated the improvement of maximum working resistance, which had a small to moderate effect with moderate heterogeneity as well (I2 = 56.25%; P = .033). 

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Balance was among the most improved areas when incorporating strength training, showing a very strong effect with considerable heterogeneity (I2 = 77.57%; P <.001) in 8 trials. Also evaluated were gait, with a small effect and no heterogeneity (I2 = 4.64%; P = .400) in 13 trials, and spasticity, with a small to moderate effect with no heterogeneity (I2 = 0%; P = .627) in 4 trials. 

“One of the most important results of this research is that strength training does not change or have adverse effects on spasticity; with some authors providing data showing no worsening of spasticity; while other authors merely state at the outset that spasticity will not be increased by strength training,” study author Javier Merino-Andrés, PT, MSc, associate professor, faculty of physiotherapy and nursing, University of Castilla-La Mancha, Toledo, Spain, and colleagues wrote.

Gross Motor Function Measure (GMFM) scores were improved when compared to other interventions, showing a small but positive effect without heterogeneity (I2 = 0; P = .703). Nine trials evaluating strength training for improving GMFM Dimension D and 10 trials evaluating Dimension E showed a small positive effect with no heterogeneity (I2 = 20.39%; P = .262). 

“The results for the specific domains of the International Classification of Functioning, Disability, and Health show an improvement in different aspects related to structure and function, such as energy expenditure during walking, improvement in balance, joint ranges, and the lack of increase in spasticity,” Merino-Andrés et al wrote. “Within the activity domain, a favorable result has been obtained for the first time from a systematic review on strength training programs in children and adolescents with cerebral palsy, shown here by a positive effect on GMFM scores, especially in the GMFM domains on standing, and walking, running and jumping.”

The study was limited due to its risk for bias, as half of the studies displayed moderate risk and the other half displayed high risk, with the former indication resulting due to sample losses and subsequent deviations and the latter resulting from error in results evaluation and difficulties with blinding. Additional imitations were a lack of follow-up and analysis of long-term effect of strength training and the lack of research into training over upper limbs.

REFERENCE
Merino-Andrés J, García de Mateos-López A, Damiano DL, Sánchez-Sierra A. effeft of muscle strength training in children and adolescents with spastic cerebral palsy: A systematic review and meta-analysis. Clin Rehabil. Published online August 18, 2021. doi:10.1177/02692155211040199