Friday, 5 July 2019

Training the Cerebral Palsy (CP) Athlete by Alan Lofthouse MSc



Good Evening Everyone



I hope all is well


Newest post on the blog is the second guest post of 2019. 


By a fellow Teesside University student, Alan Lofthouse. He studied Sport Science at undergraduate level and studied Sports Therapy and Rehabilitation at MSc level. 


This post is all about the training and working with athletes who have cerebral palsy. 


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Enjoy! 

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Introduction

Cerebral palsy (CP) encompasses a heterogeneous group of early-onset, non-progressive, neuro-motor disorders, which affect the frontal lobe of the brain; this therefore affects motor control and verbal reasoning capacity (Villamor, et al., 2017). CP develops in the fetal or infant brain (Oskoui, et al., 2013). There has been much research into the physiotherapy side of rehabilitating a person with CP for a more active daily lifestyle. However, there has been a minimal, amount of research conducted into strength and conditioning for a CP from a sporting performance point of view. From the author experience CP athlete are trained from a physiotherapist prospective not from an athletic strength and conditioning outlook.

Cerebral palsy (CP) has been classified as a lesion in the brain that develops either in ultero or soon after, which disrupts normal brain development. It also effects the motor pathway, which in turn effects movement (Miller and Browne, 2007). CP affects people in many different ways. There are many classifications of CP these classifications are; Quadriplegia, which effects four limbs and Diplegia, which effects two limbs (Cerebral palsy alliance, 2015). There are sub classification of CP and these are Spastic, Dyskentic, Ataxic and a mixed type. The most common form of CP is spastic it has been diagnosed in 80% of children in Australia, (Cerebral palsy alliance, 2015).

Since the development and marketing of the Paralympics there has been a peak interest in special population athletes, (Goggin and Hutchins, 2017). For example, Wheelchair basketball is a multi-faceted sport, which requires a wide range of physical attributes; these include power, strength, agility (Jarvis, 2010). The match consists of five players a side, playing four ten minutes’ quarter. According to Molik, et al., (2010), wheelchair basketball combines repeated short intense exercise bouts that include rapid acceleration, deceleration and quick sharp postural change.  It has been suggested that the crucial part of conditioning a wheelchair basketball player (WCBP) is injury prevention (Jarvis, 2010). According to the GB wheelchair basketball association, (GBWB, 2009) WCBP are susceptible to overuse injuries in the shoulder and movement dysfunction, to counter this GBWB, (2009), have suggested that the three main areas of concern for a S&C coaches program is corrective exercise, movement quality based warm-ups and training load monitoring. Corrective exercise is the correction of muscle imbalance, postural issues and correction of any abnormal movement patterns (NSAM, 2016). Training load monitoring can help reduce injuries according to Gabbett, (2014). This essay is going to be looking at the research behind S&C for wheelchair basketball player with cerebral palsy.

Before we do, if you are working with or know someone with CP and they want to get into sport/activity. Best to contact the Cerebral Palsy Sport for England and Wales on guidance and information surrounding best practice. 

Link is here: http://www.cpsport.org/

CP Sport Logo. Image Credit: http://www.cpsport.org/news/tag/togetherwewill/ 


Literature review

Physical requirements for training a CP athlete

As stated in the introduction wheelchair basketball is a game that requires great physical ability, (Jarvis, 2010). A player will cover approximately 5km in a 40-minute timeframe (Goosey, 2010). There is a lack of research into the physical needs for playing wheelchair basketball. It has been hypothesis that strength training is vital for improvement of cerebral palsy, (Dodd, et al., 2003). A study that used strength training was found to improve the player posture in significant way and enhanced the player gait. Inversely, Blundell, et al., (2003), has suggested that when training a spastic cerebral palsy subject, it should be noted that strength training might have an adverse effect on the CP body physiological response, the study hypothesis that this could be due to the brain having to create new neural pathways to account for an increase in neuromuscular activity.

It has been publicising that CP subjects have smaller muscle mass, the majority of these muscle is predominantly type 1 fibre (Slow-twitch), which fire at a decreased rate compared to fast twitch fibres, (Dodds, et al., 2003; Balesman, et al., 2012 and Ciciliot, et al., 2013). Type 1-muscle fibres are mostly used during continuous muscular or aerobic exercises (ACSM, 2013). Therefore, is strength training accurate for training CP athletes or should a more endurance-based programme be implemented. However, Ciciliot, et al., (2013), states that the best conditioning exercise to train type 1 fibres is muscular endurance training sessions, which contradicts what Dodds, et al., (2003) suggest and supports the theory of training for endurance rather than strength training. Furthermore, it has been established that, smaller muscle mass will mean a lower oxygen extraction and a decrease in the peak oxygen uptake this could lower aerobic fitness in CP athletes and could possible affect the nutrients supply to the muscle and could further hinder the development of muscles mass in the athlete, (Ciciliot, et al., 2013).

According to Francis, et al., (2011), this could indicate why CP subjects fatigue more rapidly than non-disability athletes do. This could possibly be due to the smaller muscle mass, this is because the body will be unable to store muscle glycogen for convention into energy (ATP), and thus, the subject may possibly have less energy during because of the inability to rapidly replace their body muscles glycogen usage. In addition, Schweitzer, et al., (2017), propose that the higher the ability to convert Glycogen storage into energy has an impact in quality of life.

Athletes with CP have shown a higher hypertonicity of the muscle, which can cause neural and mechanical problems with the athlete, (Drobyshevsky, and Quinlan, 2017); this therefore, reduced the muscle length. Theoretically, this could be delayed with stretching although this method need more in-depth investigation, (Guissard and Duchateau, 2006). Although, according to Chaudry and Anderson, (2017), CP muscle may decrease tonic reflex activity or increase the threshold of the tonic stretch reflex, allowing an increase in joint range of motion (ROMs).

Theis, et al., (2013) assumption is that in a spastic muscle, the increased gain or possible the lower threshold of the stretch reflex may cause the muscle to be activated even during low levels of stretching. However, hypertonic muscle may be exaggerated due to a greater abundance of connective tissue in the muscle.  It has been recommended that using passive stretching of the posterior muscular kinetic chain to manipulate the postural control of the athlete, (Novak, et al., 2013). However, the investigation did not state which stretches were used, also, if it would be suitable for athletes with CP. Nevertheless, Wiart, et al., (2008), argues that flexibility could have an adverse effect on the body because of the neuromuscular activity. However, this study did not show a statically value and it can only be used as a guideline for coaches. It has been proven that there is conflicting evidence weather the use of stretching can increase range of motion in athletes with CP, however, it has also been stated that stretch could decrease the spasticity in muscle of a CP athlete, (Pin, et al., 2006).

Verschuren and Takken, (2010), found that testing the aerobic capacity of athletes with CP could be useful to provide an accurate measurement of aerobic capacity in the athlete; it can also be used to see if there is any change in the condition of the patient and for monitoring the rehabilitation. However, there is limited evidence about the effects of aerobic endurance training in athletes with CP. The evidence suggest that training aerobic system will increase aerobic fitness (Molik, et al., 2010). There is evidences to suggest that there is a correlation between aerobic capacity and improvement in quality of life (WHO, 1995). Nevertheless, to dispute the information above Nsenga, et al., (2013) indicates aerobic training for athletes with CP will increase the subject’s quality of life, as it will give the subjects the ability to produce and store more ATP. Therefore, more energy capacity will mean a more improved quality of life; the increased energy storage will mean it will help the training for hypertrophy, which will develop muscle. 

A meta-analysis into aerobic endurance training and the effects it has on improving the quality of life for people with CP, found that training aerobic endurance will improve fitness, although, there was no evidence for that an improve aerobic system will improve the quality of life for an athlete with CP, (Butler, et al., 2010). Although this is stated, there was a statistical heterogeneity, which could make the conclusion invalid and unreliable. Furthermore, the studies used in the meta-analysis all have different interventions, testing protocols this will mean a unreliable validity as there are different method, thus, an misinterpretation of the results.

Repetitive locomotors training has been hypnotized to improve the gait of people with cerebral palsy. The study found that after a thirty-minute session there was an improvement in the 10-meter walk test, especially with hip kinematics, (Smania, et al., 2011). Although, there was not a significant correlation for the results to be valid, the investigation can supposition that the validity of the ten meter walk test is questionable due to the fact that CP athletes all have different severity of spasticity.

Physiological testing

For able body basketball players, it has been suggested that the athlete completes a series of strength, aerobic, speed and agility physical testing. However, the GBWCA, (2009) has put together a series of physical test for WC basketball players to complete; the strength test consists of 3RM Dips, Bench press, 1RM bench press, 5RM bench pull and the bleep test. However, is the bleep test accurate to the physiological requirements for a WC basketball player? Would upper body testing be more accurate to the response for WC basketball?

Exercise corrections

It has been hypotheses that training one muscle group will force the body into a dysfunctional postural alignment and that exercising the lengthen muscle to corrective this will work as long the shorten (dysfunctional muscle) is stretched.  One possible way to this is by after a resistance training session the athlete partakes in a sport massage, where it has been suggested that sport massages will aid recovery and can possibly lengthen short muscles, (Weerapong, 2005).

GBWCA, (2009) has suggested that the corrective exercise program includes;
  • ·    Shoulder mobility (through extension)
  • ·  Thoracic mobility (exercise and rotation)
  • ·  Rotator cuff strengthening
  • · Scapula stability
  • ·  Shoulder proprioception


Interestingly, the most common suggestion on how to train a CP athlete is to design a strength training program, it has been suggested that strength training is vital for the postural improvement in CP athletes (Dodd, et al., 2003). Although, some up to date research conducted by Sa-Cauputo, et al., (2015), has identified the use of whole body vibration exercise in treatment of CP, the study found that there is a lack of evidence to suggest this works and therefore, should be furthered research. However, the review did indicate that whole body vibrating exercise increased the subjects muscle gains and helped to optimized balance and postural control. The ACSM, (2015) and the NSCA, (2015), have both produced a training sets and repetitions template, and have suggested that a CP athlete should be doing 2-4 sets, 10-12 repetitions at 60-80% weight of the client’s 1RM test, and are advised to train two to three times a week, with each periodization lasting 6-12 weeks. However, CP athletes may have issues with neuromuscular control and stability and this amount of exercise load my not be affected until control is established.

Interestingly, CP athletes have been proven to have a smaller muscle mass this could possible indicate why CP athletes may muscular fatigue more rapidly, this is due to the body ability to store muscle glycogen to re synthesis into ATP (Francis, et al., 2011). Furthermore, this could be a possible reason why training CP athletes Strength training could be impractical before the athlete’s ability to control the required movement. Furthermore, according to Balesman, et al., (2012) CP athletes have smaller muscle mass and the muscle fibre are mostly type 1 fibres. Type 1 fibres are used for continues exercise (ACSM, 2012). It has been hypotheses that the best way to train type 1 muscle fibres is through muscular endurance training (Ciciliot, et al., 2013). So, is endurance training rather than strength training best for improving physical performance for a CP athlete? 

Although most studies focus on strength training for CP subjects (Balseman, et al., 2012), there are studies that focus on the benefits of aerobic capacity (Cicilot, et al., 2013), however, it is not widely focused on and the majority of the research is focused on the ability to performed daily life activity. However, aerobic fitness if vital for daily living as the player is required to performed aerobic endurance activities every day. With wheelchair basketball, it is vital the player has explosive power in the upper body to propel the athlete quickly around the court (Jarvis, 2010).

Some exercise that can be used for un-disability basketball players cannot be used for CP wheelchair basketball player’s (British wheelchair basketball, 2010). It has been hypothesis that overhead wheelchair basketball players should not use press as an exercise to build shoulder, this is due to the increase chance of impingement syndrome in the shoulder, (Jarvis, 2010). However, if the player’s biomechanics of the shoulder griddle and the posture is not effected then there is no research to state that they should not do shoulder press exercise. Jarvis, (2010) has identified many none effective exercise, however, when dealing with a CP athlete all exercise is vital because the coach is not just training them for the sport but, they have to take into account his daily living activities and prepare them for that (SAQ, 2016).

Conclusion

To conclude all the information above, although there has been a significant amount of research conducted in to Cerebral palsy, it can be said that there is not significant evidence on what effects endurance training will have on the player. However, this mini essay has highlighted that even though strength training has been proven to improve quality of life (Sa-Caputo, et al., 2016), it still is unclear on the long-term effects of strength training. This essay has suggested that certain exercise should not be carried out in a program for WCBP with CP (Jarvis, 2010). In addition, there has been in-depth research into wheelchair basketball teams have been conducted over the years; however, like all sports there is still speculation on how to train that athlete to enhance performance (SAQ, 2016). Furthermore, it can be suggested that although there has been recent interest in Paralympics sport, there is yet to be a study that is conducted for the sole purpose of cerebral palsy athletes (Goggin, and Huntchin, 2017). The literacy review has highlighted that strength training is the overall method to use in order to improve gait, daily living wellbeing and hypothetically performance. Although, there is lack of evidence to suggest that endurance training may possibly be a more optimal training guide.

Thank you Alan for a very detailed and informative post!

If you wish to reach out to Alan his contact details are;

Email: Alan.Lofthouse@tees.ac.uk

Alan Lofthouse author of this post

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Andrew Richardson, Founder of Strength is Never a Weakness Blog








I have a BSc (Hons) in Applied Sport Science and a Merit in my MSc in Sport and Exercise Science (both from Teesside University). Building on my MSc result, I passed my PGCE at Teesside as will this academic year (graduate July 2018).


I am now employed by Teesside Students Union as President Activities for 2018/19 Academic Year. My long term goal is to become a Sport Science and/or Sport and Exercise Lecturer. I am also keen to contribute to academia via continued research in a quest for new knowledge.

My passion is for Sport Science which has led to additional interests incorporating Sports Psychology, Body Dysmorphia, AAS, Doping and Strength and Conditioning. Within these respective fields, I have a passion for Strength Training, Fitness Testing, Periodisation and Tapering. I write for numerous websites across the UK and Ireland including my own blog Strength is Never a Weakness. 









I had my own business for providing training plans for teams and athletes. I was one of the Irish National Coaches for Powerlifting, and have attained two 3rd places at the first World University Championships in Belarus in July 2016.

I would like to do a PhD to contribute new knowledge to academia whilst expanding my own areas of interest.


Feel free to email me or call me as I am always looking for the next challenge. 





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