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. At week 43 in 2023, we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of Applied Science about EBP. This BIP program opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields week 43 in 2023 we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of applied science.

More than 40 physiotherapy students and 7 teachers from three universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, and Charles University Prague, actively participated this week and shared experiential group dynamics and social activities. Students worked together and wrote articles devoted to the following themes: Evidence Based in McKenzie, back pain, spinal cord injuries, aquatic therapy, ergonomics at work, Nordic walking, sport injuries, sport and young adults: Prevention of sport injuries and children with disabilities. In the following you can consult the works presented by the students on each topic.

Introduction

Cerebral palsy (CP) remains one of the most common developmental disabilities with motor disfunction , where the prevalence of CP is approximately 0.2–0.3 %.

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. The symptoms are affected not only by the extent and location of the brain damage, but also by the time when the damage occurred. The brain damage that causes the injury occurs during the fetal period, during childbirth or at the latest in early childhood. CP injuries are classified by muscle tightness and the most common forms of CP injury (70–90 %) are spastic CP injuries, which include spastic monoplegia, – hemiplegia, – diplegia, – triplegia and – tetraplegia. Less common forms of CP injury are athetosis and ataxia. As CP results from an injury to motor regions of the developing brain, muscle weakness is a primary impairment, so there is strong evidence that children with CP are significantly weaker than typically developing children.

The thought of muscle strength training in rehabilitation of CP was not always very supported in conventional clinical practice mostly due to the fear that the physical effort during strength training will aggravate spasticity. , However, studies have shown that strength training does not change or have adverse effects on spasticity. On the contrary, it has positive effects on muscle strength, contributing to improved functional and activity levels without effects on spasticity. , In fact strength training received the green light while using the Evidence Alert Traffic Light System in assessing the quality of the evidence , meaning: “GO: High-quality evidence exists supporting the effectiveness of this intervention – therefore use this approach.”

Searching for the best strategy in muscle strength training

Cerebral palsy (CP) poses unique challenges, but recent studies and guidelines offer insights into effective approaches for individuals seeking to enhance their muscle strength, walking capacity, and overall well-being.

The American College of Sports Medicine (ACSM) provides guidelines that can help with creating the therapy plan. They accentuate supervision by a qualified team and tailoring therapy to CP progression. Focusing on single joint movements on only one side at the time is advised, respecting active range of motion, and prioritizing the practicing of the movement instead of progressing the weight. Regarding the repetition of the exercises a repetition-maximum range (RM) is usually prescribed. To determine one-repetition maximum (1RM), it’s suggested to use a 1RM max calculator based on the patient’s 10-repetition maximum.

In 2016, Verschuren and colleagues united exercise recommendations for people with CP with GMFCS level I-III, advocating for a gradual strength training approach. The recommended training frequency was 2-3 times per week on non-consecutive days, which is consistent with the NSCA guidelines. The study also drawled from the ACSM guidelines and focused on the usage of the 1RM prescription.

Due to the inherent challenges and safety concerns associated with determining a true one-repetition maximum (1RM) in individuals with cerebral palsy, the most practical, secure, and efficient approach is to gradually increase resistance within a designated repetition-maximum range. The research emphasizes the significance of a familiarization period, starting with simple activities and low dosage. Weaker individuals and beginners start with 10-15 reps for 1-2 sets, 2 times per week, for at least 2-4 weeks. At this time they recommend simple, single-joint activities (for example knee extension). Progressing over time, while intermediate to advanced patients complete 6-12 reps for 2-4 sets using 60-80 % of 1 RM. In this phase they recommend adding complex, multi-joint activities (like step-ups and sit-to-stand exercises) to the training. Patience and a systematic progression are key to achieving lasting and meaningful improvements.

Merino-Andrés at al. explored the effects of progressive muscle strength training in young individuals with spastic CP. The participants were aged between 3-22 years with GMFCS level I-III. The study acquired positive impacts after a 4–12-week program conducted 2-5 days a week for 20-60 minutes per session with 3-20 repetitions, 1-3 series and 60-80 % of 1RM with progression to 5-10 % increasement per week. The program focused mainly on the lower limbs and trunk. The results had shown that in terms of muscle strength training in lower limbs, maximum work resistance, gait speed, standing balance and gross motor function improved. The only deficiency was that these positive effects with this duration of therapy were only short-term, which led us to the conclusion that longer time of therapy is needed in order to preserve and collect the benefits of the training over the long term.

Van Vulpen and team (2017) focused on functional high-velocity resistance training (power-training) in young children with spastic CP meaning children aged 4-10 years with GMFCS level I and II. Their 14-week program included 60-minute training sessions 3 times per week and they contained dynamic exercises like running and stair climbing, resulting in significant increases in both muscle strength and walking capacity. Each exercise was performed during 25 seconds on maximal effort, with resting period of 30-50 second, and 6-8 reps of each exercise. Dynamic, functional exercises tailored to individual abilities emerged as a powerful strategy and the study indicates that power training increases walking capacity and muscle strength.

Kara et al. (2019) conducted a randomized controlled trial involving 30 participants with CP. The study included children between of age 7-16 years, classified as level I on the GMFCS system. The 12-week, which was conducted 3 times per week for 40 minutes per session. The lower limb training was performed with the intensity of 60-80 % of the 1RM, using 3 sets (1 set with the affected leg, 1 set with the unaffected leg and the last set with the affected leg) and with progression of increasing 10 % of the 1RM every 2 weeks. The program combined lower limb strength training with and balance training and plyometric exercises. This fact led to improvements in gait function, gross motor capacity, dynamic balance, and muscle strength, highlights the benefits of integrating various exercise forms to address multiple facets of motor function.

Results

Tailored exercise programs, following ACSM guidelines, exhibit positive impacts on muscle strength and mobility in cerebral palsy. A 4-12 week program, conducted 2-5 days a week for 20-60 minutes per session, revealed improvements in muscle strength, gait speed, and standing balance. Another 14-week study in young children, with sessions 3 times per week, demonstrated significant increases in strength and walking capacity. A 12-week trial, conducted 3 times per week for 40 minutes, showcased comprehensive enhancements in gait function, motor capacity, balance, and muscle strength.

These findings underscore the importance of personalized exercises, considering frequency, intensity, and duration, for lasting benefits in cerebral palsy. Summarizing the outcomes of the studies, we would like to emphasize the need for a familiarization period, introducing individuals to simple activities and low-dose exercises to ease them into the training routine. Additionally, to point out the disadvantages of the short-term nature of therapy benefits, stressing the necessity for longer therapy durations to safeguard and accrue positive outcomes over an extended period. This underscores the importance of gradual and sustained interventions for lasting improvements.

Conclusion

During the research into the most effective strategies for muscle strength training, we encountered several limitations. Firstly, we observed a common absence of analysis follow-up or long-term effect analysis. Secondly, few of them focuses on the advantages of upper limb training. This limitation restricts our understanding of the comprehensive benefits of strength training across all muscle groups.

Thirdly, our findings highlighted a significant lack of investigation into patients falling within the highest ranks of the Gross Motor Function Classification System (specifically IV and V). This group has been understudied, making it difficult to extrapolate findings to this particular population. Lastly, the results of the studies are not comparable, because they don’t measure the muscle strength using measuring devices such as dynamometer or test measuring muscle strength. We would like to see more studies using more specific outcome measures and tests directly aimed at muscle strength, for example the Functional Strength Measurement (FSM) that was recently introduced.

In conclusion, despite the promising results in terms of enhanced benefits associated with strength training, it is evident that further research in this field is imperative. This research gap must be addressed to ultimately improve the functional mobility of children and adolescents.

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 SavoniaUuniversity 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, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Finland
Mari Tuppurainen, physiotherapy lecture, Savonia University of Applied Sciences, Kuopio, Finland
Dagmar Pavlu, Physiotherapist, Assoc. Prof. Charles University, Czech Republic
Ivana Vláčilová, Professor, Charles University, Czech Republic
Jamile Vivas Costa, PhD, MSc, PT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at Psychosocial intervention and functional rehabilitation group, Universidade da Coruña, Spain
Montserrat Fernández Pereira, MSc, PT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Physiotherapist at Spinal Cord Injury Unit, A Coruña Hospital (CHUAC), Spain
Verónica Robles García, PhD, MSc, PT, OT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at the Neuroscience and motor control group, Universidade da Coruña and Biomedical Institute of A Coruña, Spain

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