Clinical Rehabilitation 2006; 20: 469-477

Strength training in adolescent learners with

cerebral palsy: a randomized controlled trial
Marianne Unger, Mary Faure and Annette Frieg Faculty of Health Sciences, Stellenbosch University, Department of
Physiotherapy, Tygerberg, South Africa
Received 13th June 2005; returned for revisions 19th July 2005; revised manuscript accepted 3rd October 2005.

Objective: To evaluate the impact of an eight-week strength training program

targeting multiple muscle groups using basic inexpensive free weights and
resistance devices, on gait and perceptions of body image and functional
competence.
Design: A randomized control trial.
Setting: A school for children with special needs in a disadvantaged suburb in Cape
Town.
Subjects: Thirty-one independently ambulant senior learners with spastic cerebral
palsy (19 males, 12 females; aged 13-18 years; 15 diplegics and 16 hemiplegics).
Intervention: Eight-week strength training programme in circuit format executed
during school hours, one to three times per week for 40-60 min per session.
Programmes were individually designed and included 8-12 exercises selected from
a 28-station circuit to target upper and lower limbs and trunk. Twenty-one subjects
took part in the strength training programme and were compared with 10 control
subjects.
Main outcome measures: Three-dimensional gait analysis and a questionnaire were
used to evaluate the various parameters of gait and perceptions of body image and
functional competence respectively. Results were analysed using repeated
measures ANOVA and bootstrap analysis.
Results: The experimental group differed significantly from the control group
for measure of crouch gait (sum of the ankle, knee and hip angles at midstance)
(P= 0.05) and perceptions of body image (P= 0.01). Walking velocity, cadence and
stride length as well as perceptions of functional ability did not change significantly
after training.
Conclusion: Participation in a school-based strength training programme targeting
multiple muscle groups can lead to improved degree of crouch gait and improve
perception of body image.

Address for correspondence: Marianne Unger, Faculty of

Health Sciences, Stellenbosch University, Department of
Physiotherapy, PO Box 19063, Tygerberg, 7505, South Africa.
e-mail: munger(sun.ac.za
© 2006 Edward Arnold (Publishers) Ltd 10.1 191/0269215506cr961oa

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470 M Unger et al.

Introduction Other positive benefits that might occur follow-

ing participation in strength training programmes
Cerebral palsy is a neurological condition with have rarely been investigated in adolescents with
huge variation in clinical presentation. Secondary cerebral palsy. These benefits include a sense of
complications occur and the normal changes in well-being, perceptions of changes to body
body composition and physiological functioning image and functional competence. One study in
across the lifespan can be expected to be more
adolescents with cerebral palsy reported an im-
provement in perception of physical appearance,24
severe. 1-4 Continued access to support services
and another reported that successful participation
is therefore necessary to maintain an optimal in an exercise programme led to improved partici-
level of functioning in this population. However, pation in school and other leisure activities.26 In a
poor accessibility to these services in primary more recent study subjective improvement in the
health care is not uncommon and people from performance of daily activities was reported by
disadvantaged communities often experience this adults following strength training.25
more intensely due to limited resources.5-8 Strate- The effect of an individually designed strength
gies of providing alternative appropriate and training programme for adolescents with cerebral
ongoing rehabilitation to this population need to palsy, targeting multiple muscle groups has not yet
be explored. been investigated. In the current study it was
Muscle weakness is just one of the primary hypothesized that progressive resistance exercise
physical impairments contributing to the motor also targeting the upper limb and trunk muscles
dysfunction seen in people with cerebral palsy."9'10 might result in changes in gait function, percep-
This inability to generate enough force can be tions of body image and functional competence.
addressed with progressive resistance exercise.
There is increasing evidence for the effective
and safe use of strength training in this
population. i-'9 Initial studies were limited to Methods
targeting muscles of the lower limb only and gait
was analysed to assess change in function follow-
Participants
ing strength training 11,12 However, according to A sample of convenience was selected. Only
the principle of specificity20 and due to the role subjects from one school were included for parti-
of the trunk muscles as stabilizers in normal cipation to reduce the variability regarding ap-
proach to treatment and sports programmes
gait, 21,22 it might be argued that inclusion of currently found at learning centres in South Africa.
these muscles, which are predominantly weak This school caters for children with special needs
in these children, may result in even better and is situated in a disadvantaged suburb in Cape
performance. Furthermore most of these stu- the redistribution of government
dies""1,315l6 were of single group design and may fundingDespite
Town.
for health care, a decrease in the number
have overestimated the effect of increased muscle of physiotherapy posts has resulted in therapy
strength on the functional outcomes noted. A services being primarily targeted at the younger
randomized control trial (RCT) of a six-week child, while the senior children rarely receive
strength training programme'9 did not demon- individual or group therapy.
strate significant differences between the control To be included, subjects had to be between the
and experimental group except when changes in ages of 13 and 18 years, independently ambulant
the various muscles tested were combined. On the with or without a walking aid, be in good general
other hand, trends for improved activities such as health and able to understand instructions in either
walking, running, jumping and stair climbing were English or Afrikaans. Subjects were excluded if
reported. Studies to determine the efficacy of they had a history of spasticity-altering surgery,
home-based strength training programmes in such as a baclofen pump or selective dorsal
this population, supervised by either a caregiver rhizotomy, orthopaedic or neurosurgery in the
or parent,'9 as well as community fitness previous 12 months, or botulinum toxin injec-
programmes,22-25 have also been reported. tion(s) in the previous six months. Subjects who

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 Strength training in adolescent learners 471
participated in sports at provincial or international body image (section A) and functional competence
level during the trial period were also excluded. (section B). Section A included six statements and
Thirty-seven subjects were included in the final section B five statements. The themes relating to
sample. Informed written consent was obtained body image were identified from the physical
from all the parents or legal guardians. Written appearance and attributes subscale of the Piers
assent was also obtained from all participants. This Harris Children's Self-Concept Scale.29 Themes for
study was approved by the Human Research and section B were decided on in consultation with the
Ethics Committee of the University of Stellen- school therapists and included activities required
bosch (2003/021/N) as well as the by the Depart- by the child for successful functioning in his or her
ment of Education. environment. Each statement was qualified using a
Likert-type scale in which the numeric values were
Study design (Figure 1) replaced by descriptive phrases. Subjects selected
Following pretesting subjects were systematically the most applicable phrase. Two open-ended ques-
randomized into either the experimental group tions were also included for more qualitative
(n = 24) or the control group (n = 13) with every expression.
third name drawn from a hat being allocated to the Composite scores for each section were calcu-
control group. The experimental group then parti- lated and analysed. Qualitative analysis was used
cipated in an eight-week strength training pro- to discuss responses to the open-ended questions.
gramme, after which all subjects were retested.
Intervention
Outcome measures The experimental group took part in a strength
Three-dimensional gait analysis and a self-per- training programme, one to three times a week
ception questionnaire were used to determine the for eight weeks during school hours. Programmes
effect of progressive resistance exercise on various were individually designed in consultation with
gait parameters and perceptions of self. Testing their therapist to ensure correct selection of
procedures were piloted and standardized for all exercises. 15 From a 28-station circuit targeting
measurements taken. The research assistants for upper and lower limbs and trunk, 8-12 exercises,
both outcome measures were blinded to group including a 5-min warm-up on a stationary bicycle,
allocation for both pretesting and at eight-week were selected for each subject. The initial exer-
testing. cises were recorded on a participation record and
subjects were responsible for updating and record-
Three-dimensional gait analysis ing their own programme. A research assistant
The VICON 370 data station (Oxford Metrics; was given instructions on performance criteria
ViconPeak, Oxford, UK), a six-camera video- by the researcher and assisted with the imple-
based motion-capturing system, was used to cap- mentation and supervision of the exercise pro-
ture kinematic data (joint angles of the ankle, knee grammes.
and hip) and the data were processed using Work- The circuit was completed at the subjects' own
station 3.2, BodyBuilder 3.53 and Microsoft Excel pace and the speed of execution of each exercise
as described by Vaughan et al.28 Stride length, was self-selected - movements had to be controlled
stride frequency (cadence) and velocity were also and smooth. Exercises were progressed according
recorded. The subjects were instructed to walk at a to the guidelines for progressive resistance exercise
comfortable speed, barefoot and without orthotics, training as outlined by McArdle et al.20 and initial
down an 11 -m carpeted walkway. A walking aid resistance was set to allow the subject to manage at
was allowed and three to eight trials were recorded least one set of six to ten repetitions. As soon as
to ensure that at least three trials captured a three sets of 12 repetitions were reached resistance
complete full stride length of the selected side. was increased and repetitions reduced. The process
was repeated again as soon as the subject was able
Self-perception questionnaire to complete 3 x 12 repetitions. Body weight, free
A short, self-administered questionnaires shown weights, including dumbbells, ankle and wrist cuff
in the Appendix were used to assess perceptions of weights and bar-with-disc weights, elastic and

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472 M Unger et al.

48 ADOLESCENTS fWITH SPASTIC

CEREBRAL PALSY

11 did not enter study:

9 not contactable telephonically
1 incorrectly diagnosed
1 did not consent
Informed consent

Pre testing:
Gait analysis
Isometric strength testing
Economy of movement
Self Perception questionnaire
(n=37)

Systematic randomisation
(every 3d name drawn -* control group)

Experimental group Control group

(n=24) (n=1 3)

3 subjects withdrawn:
1 subject withdrawn Zff;x 1 for sport participation
for sport participation 1 incorrect diagnosis
1 participated in PRE

Figure 1 Study design.

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 Strength training in adolescent learners 473
rubber bands provided resistance. Balls were used Table 1 Description of subjects
for support or to provide an unstable surface. Characteristics Experimental group Control group
(n=21) (n=10)
Age mean (range) 15.86 years 16.28 years
Data analysis (13.5 -18.92 years) (14.0-18.33 years)
Data were analysed using Statistica (version 6). Male: female 13: 8 6: 4
Subject characteristics pertaining to age, height, Diagnoses (MF)
weight, gender, distribution of involvement and Hemiplegics (L) 4 (3:1) 4 (3:1)
severity of crouch gait as determined by the knee Hemiplegics (R) 4 (3:1) 4 (1:3)
angle in mid-stance phase were assessed to deter- Diplegics 12 (6:6) 2 (2:0)
mine the effect of randomization. To determine Triplegics 1 (1:0) 0
Quadriplegics 0 0
differences between the control and experimental
groups from pre to post measurement, repeated (range)Height mean 157.47 cm 152.34cm
(140-180.4 cm) (141.2-169 cm)
measures ANOVA was used and in all cases Weight mean 51.1 kg 43.3kg
violations of assumptions were checked. A 5% (range) (35.4-70.5 kg) (28-71.7 kg)
significance level was used. Where there was Assistive devices
uncertainty about the validity of the standard Crutches 1 0
analysis, non-parametric resampling techniques Wheelchair 1 0
(i.e. bootstrap °) and the Kruskal-Wallis tests (occasional use)
were done. Paired t-tests were done to determine Orthotics
Supra-maleolar 1 0
any differences between the genders and between (SMO)
the diplegic and hemiplegic groups for the gait Ankle foot 0 0
variables measured. These tests could not be done (AFO)
for the control groups as they were unmatched and Knee ankle foot 0 0
(KAFO)
too small.

Perceptions of body image

Results
A description of the 31 subjects appears in Table 1.
The process of systematic randomization used in
this study was successful for age, height, and
gender and severity allocation. However the sub-
jects in the control group differed significantly
from the experimental group for weight (P = 0.02)
and distribution of involvement (diagnosis) (P=
0.03).
Gait analysis
A more upright posture, represented by the sum
of all the changes that occurred at the ankle, knee
and hip angles was noted between both groups
(Table 2). The mean for the experimental group
decreased from pre to post intervention, whereas it
increased for the control group (P = 0.05). There
was no significant change for stride length, velocity
or cadence.
The comparison of the composite scores be-
tween the control and experimental groups relating
to the perceptions of body image (Table 2) showed
a significant change (P = 0.01).
Qualitative analysis of pretesting responses to
the question 'Make a list of all the things you like
about yourself and your body', related particularly
to various parts of their bodies such as their eyes
and hair. Only three subjects commented on
personality and interpersonal behaviour or quali-
ties, while 19 subjects reported acceptance of their
bodies with comments such as 'I like my body just
the way God mayed [sic] it'. Responses to the
question of what the subjects did not like about
themselves or their bodies related mostly to
arms and legs. In the experimental group nine
subjects reported negatively about their arms
and legs, three did not like the surgical scars on
their bodies and one subject commented that she
was overweight and had 'fat thighs, stomach and
big chics [sic]'.

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474 M Unger et al.
Table 2 Means and standard deviations for measures of gait variables and perceptions of body image and functional
competence before and after the strength training programme
Pre-training Post-training
Experimental group Control group Experimental group Control group
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
3D gait analysis (free speed)
Knee angle at midstance phase (") 19.3 (10.1) 19.1 (5.5) 17.8 (9.2) 19.2 (7.8)
Ankle angle at midstance phase (°) -8.6 (6.1) - 9.6 (2.2) - 7.7 (6.0) - 11.0(5.2)
Hip angle at midstance phase (1 20.1 (8.9) 14.6 (7.7) 18.4 (7.9) 15.8 (5.5)
Sum of ankle, knee and hip angles at 49.7 (16.9) 43.4 (14.3) 44.8 (16.7) 46.0 (15.4)*
midstance (I
Knee angle at heel strike (C) 26.7 (6.6) 26.6 (6.7) 25.4 (8.2) 25.2 (8.0)
Velocity (mm/s) 1075.6 (235.4) 1128 (132.0) 1119.3 (232.5) 1171.4 (141.9)
Stride length (mm) 1111.9 (207.3) 1112.8 (149.2) 1129.4 (201.5) 1143.9 (128.7)
Cadence (steps/min) 114.6 (15.1) 119.2 (11.6) 116.9 (15.8) 123.1 (11.7)
Self-perception
Body image (composite score /30) 23.9 (4.1) 23.2 (4.6) 25.9 (3.4) 22.3 (4.7)*
Functional competence 19.9 (3.4) 19.0 (3.2) 21.3 (3.3) 20.5 (3.3)
(composite score /25)

*Repeated measures ANOVA indicated that the change for the experimental group differed significantly from control group
with P.>0.05.

The responses of the experimental group at Discussion

the postintervention testing demonstrated less
emphasis on body parts, with only four comments
relating to arms and legs. The focus of the
responses was shifted towards topics that had a
potentially antisocial connotation, such as 'drink-
ing and smoking and using drugs', 'pimples on my
face', 'nail biting' and 'fighting' as characteristics
that subjects did not like about themselves.
Although the control group also expressed relative
acceptance of their bodies, the four subjects who
stated that they did not like certain body parts at
pretesting also reported the same response at the
second testing.
Perceptions of functional competence
The change in perceptions of functional compe-
tence between the control and experimental groups
was not significant (P = 0.9). Bootstrap analysis
on the individual scores, however, showed signifi-
cant change in the experimental group for the two
statements relating to walking ability between
classrooms and managing stairs without support.
There were no significant gender differences, nor
were differences noted between the hemiplegic and
diplegic experimental groups for any of the above
variables measured.
The results of this study indicate that progressive
resisted strength training resulted in an improve-
ment in crouch gait and impacted significantly on
the subjects' perceptions of their body image.
However, despite the inclusion of exercises target-
ing the trunk, the sample in the current study did
not show an improvement in stride length, cadence
or velocity.
Degree of crouch
The definition of crouch gait focuses primarily
on the knee joint, but is also determined by plantar
flexion and hip extension force generation."' 19,31
Although the circuit did not include specific
exercises for musculature around the ankle and
foot, closed-chain exercises executed in standing
and sitting would have recruited the ankle and foot
stabilizers. The inclusion of more specific exercises
for plantar flexion might have demonstrated im-
proved upward and forward motion which may
have also resulted in increased stride length.
Factors such as fixed foot and ankle deformities
and weakness of the plantar flexors may have
minimized the effect of a more upright posture and

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more stringent inclusion criteria might have
strengthened the results of this study.
Although the results from this study as well as
those from Damiano et al.1l suggest that the
magnitude of crouch decreased following strength
training, these findings were based on the measure-
ment of a single parameter of gait. Neither study
confirmed this finding with a second parameter.
Studies that have investigated energy expenditure
while walking'1322'24 reported no significant change
despite the improvement in biomechanical upright
alignment. To decrease energy expenditure while
walking, vertical sacrum and heel oscillation must
decrease31'32 and therefore a decrease in crouch
throughout the gait cycle would have to be
observed. Increased stride length and or velocity
have also been reported,' 1,13,1 however the clinical
relevance or significance thereof still needs to be
determined.
Stride length, velocity and cadence
The subjects in the current study showed no
significant change in any of these variables follow-
ing strength training, despite the inclusion of
exercises targeting the trunk and hip stabilizers.
Although not within the scope of this article
isometric dynamometry as well as scrutiny of
the subjects' participation records indicated that
strengthening of the trunk as well as hip abductors
occurred. Further investigation into the role of
the core stabilizers and lower limb function
is needed.
Clinical messages
* Strength training in adolescents using basic
and inexpensive equipment resulted in more
upright posture and improved perceptions
of body image.
* Inclusion of exercises targeting trunk mus-
culature did not result in greater effect sizes
and further research investigating the rela-
tionship between the trunk and functional
ability is recommended.
* Progressive resistance exercises using basic
and inexpensive equipment appears to be
feasible for implementation in poorer socio-
economic environments.
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Strength training in adolescent learners 475
Perceptions of body image
Awareness of change in self and functional
ability, although not a compelling measure of
patient-centred outcome, does provide some mea-
sure of clinical relevance. Although the question-
naire used in this study has not yet been validated,
subjects reported significant improvement in
perceptions of body image. These findings are
supported by a study investigating the effects of
participation in a community fitness programme24
which also reported significant change in per-
ception on the Self-Perception Profile for the
Adolescent for the category pertaining to body
image. In the current study, subjects were respon-
sible for recording their own exercises and this
self-documented progress may have empowered
them to take control of the programme and
possibly contributed to the more positive self-
perception. This was also reflected in comments
from the school therapists which included 'besides
improving physically, he's become more socially
confident, is less reserved and keen to participate
in school activities now' and 'he now comes to
physiotherapy for weight training, which is a
definite improvement from not coming at all
before'.
Enjoyment is another key factor in promot-
ing compliance with an exercise programme.25-27
This, as well as improved perception of self might
also have contributed to the subjects' desire to
continue with this programme. Although some
studies have shown that the improvement in
selected muscle strength can be maintained for
some time after cessation of training,'3'19'33 an
affirming experience may also encourage voluntary
participation in strength training programmes later
in life.
Perceptions of functional competence
No significant change in the perception of
functional ability was found in this study. Darrah
et al. reported similar findings on the Self-Percep-
tion Profile for the Adolescent.24 The open-ended
questions relating to functional ability were re-
stricted to sport participation and leading ques-
tions were avoided to minimize response bias. One
subject who used a wheelchair for mobility over
longer distances stated that he did not use his
wheelchair for the school's annual 'surf-walk'.
Another subject reported that stair climbing was
476 M Unger et al.
'easier' and that 'I feel my legs are getting much References
stronger'. Another male subject was very proud of
himself after beating a schoolmate at arm wrestling I Olney SJ, Wright MJ. Cerebral palsy. In Campbell
for the first time. These comments seem to suggest
that there was some awareness of change in
functional ability.
Implementation in disadvantaged communities
Most of the exercises as well as the equipment
selected for the current study are suitable for
independent use. Implementation of a strength
training programme at schools and community
health centres as well as in home-based pro-
grammes, using basic resistive devices such as
dumbbells, velcro-attached ankle and wrist cuff-
weights and elastic bands, is economically feasible
as this equipment is inexpensive. However, it
should also be noted that for optimal results
correct selection of exercises, correct execution
and appropriate progression as well as optimal
effort by the individual are essential. It is therefore
recommended that design and implementation of
such programmes should be done by a professional
with an understanding of the problems associated
with spastic cerebral palsy. Interested individuals
can be trained to become skilled in the principles
for implementation of progressive resisted exercise
and can take over supervision of these pro-
grammes.
Conclusions
The findings of this small study support the
evidence for effective use of strength training in
the adolescent with cerebral palsy. Although the
findings had smaller effect sizes regarding im-
proved degree of crouch gait, the results suggest
that participation in strength training programmes
has psychological benefits as well. Although the
continued success and feasibility of the use of basic
equipment in home-based strength training pro-
grammes needs to be followed up, strength training
appears to be a suitable and economically viable
management strategy to provide ongoing rehabili-
tation to this population. Studies investigating the
effects of long-term participation in strength or
weight training in the cerebral palsy population are
also recommended.
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