Fitness training

Fitness training can be accomplished with or without specialised fitness professionals, depending on the trainee’s knowledge and motivation. Exercise professionals, however, will tailor a fitness program to an individual’s abilities and goals. They will also will focus on the person’s motivation to persist and will supervise incremental changes to the exercise program. If working with an exercise professional it is important to ensure they are suitably qualified.

Cerebral Palsy Alliance offers a range of services where our exercise physiologists and personal trainers work with people who wish to reduce sedentary (inactive) behaviour and improve their fitness.

Find a Cerebral Palsy Alliance service

Fees will apply for trained fitness and exercise professionals, and will depend on the provider and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or provider travel.

Fitness training can vary in expense. Some fitness activities are free, require no equipment and at times no specialist prescription. These include home and community-based exercises such as walking and running, interval training like sprint relays, and body-weight resisted exercises including sit ups and squats. Other exercises such as swimming and cycling may require small fees. There is a wide range of exercise equipment available to buy, including handheld weights, boxing equipment and treadmills.

Gym memberships can be a significant outlay, with prices varying between AUD$10 to $25 per week, but provides access to specialised equipment and the opportunity to work with fitness professionals in both group and one-on-one sessions. One-on-one service may involve an additional fee, depending on the facility.

Ask health and fitness providers if you are eligible for funding to assist with fees. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

For children and adolescents aged 5 to 17 years, and for adults, a mix of moderate and vigorous activity completed every day is recommended to enhance health and fitness. Further details in the Recommendations section below.

Three areas of fitness are important for people of all ages – with, and without cerebral palsy¹:

• Aerobic fitness - the ability of the body to work for prolonged periods of time using oxygen as fuel. Aerobic activities include walking, running and swimming
• Anaerobic fitness - the ability of the body to complete more strenuous activities that are much shorter in duration, i.e. less than 15 seconds. These are the main forms of activity for children and include climbing stairs and games such as hide and seek and tag
• Muscle strength – improving muscle strength and endurance can assist with walking², pushing one’s own wheelchair, and improving the efficiency of other exercises. Maintaining muscle strength may help with sustaining ability to function in everyday life³. Muscle strengthening exercises include lifting weights and resistance training.

Sedentary behaviours are long periods spent sitting or lying such as when watching TV, sitting at a computer and reading. They are linked to poor health and lifestyle related diseases including obesity, diabetes and cardiovascular disease. People with cerebral palsy who have difficulty moving are likely to be more sedentary than others³. It is important to make opportunities to move every day in order to reduce sedentary behaviours regardless of whether a person with cerebral palsy uses a walking device (such as a walking frame or crutches), a wheelchair or can walk.

Guidelines for healthy living

People with cerebral palsy of all ages and all GMFCS levels can enhance their health and well-being by increasing their fitness levels and reducing sedentary behaviours.

Generally, people who avoid physical activity or have high levels of sedentary behaviours are at an increased risk of developing cardiovascular disease and other chronic health conditions⁴. The Australian Physical Activity Guidelines⁴ recommend that young people aged five to 17 years should do at least 60 minutes of moderate to vigorous physical activity every day and also do activities that strengthen their muscles and bones at least three days per week. For adults (18 to 64 years), the minimum requirement is two sessions of muscle strengthening activities per week plus 2½ to 5 hours of moderate to high intensity physical activity per week.

The increased levels of fitness developed through training programs will only be maintained if training continues. A regular increase in the intensity of fitness activities is also required.

Take a team approach

There are many kinds of fitness training and the types used will depend on the person’s age, family situation, health and mobility. There are a multitude of exercise and activity options for all individuals with cerebral palsy regardless of level of severity and physical disability. The important thing is finding the right approach for the individual. The best way to do this is to consult with an exercise physiologist or other suitably qualified health professional.

Individuals are advised to notify appropriate medical or allied health staff if there is any concern regarding participation in exercise⁵ or any changes in mobility status, pain or function associated with exercise. Individuals are also advised to notify other health professionals involved in their care that they are undertaking an exercise program.

Screening for cardiovascular risk by an exercise or medical professional, or through an exercise facility such as a gym is recommended for anyone undertaking a new exercise program or for people with special medical or physical needs. Extra care in planning and monitoring fitness programs will be required for these people

Exercise professionals will provide a thorough assessment of the person’s abilities, limitations and goals, to ensure training is properly targeted and safe.

The second type of assessment is used to work out whether fitness training has been effective. The exercise professional, together with the person with cerebral palsy and their family, will determine the most suitable measure to use. Fitness tests include⁶:

• Six-minute walk test (or 6-minute push test) - measures the distance an individual is able to walk over six minutes on a hard, flat surface
• Modified shuttle run test - measures performance on a 15 level scale of increasing speeds over a 10 metre course. There is a version for manual wheelchair users also – 10-metre shuttle ride test
• Dynamometry – measures strength of individual muscle groups

The medical and allied health literature was searched to find studies evaluating the outcomes of fitness training programs for children, adolescents and adults with cerebral palsy.

The search aimed to find the best available research evidence to answer the question: Does fitness training improve the aerobic fitness, and anaerobic and strength capacities of people with cerebral palsy?

Research focussed on strength training as a standalone intervention was not included.

The best available evidence about fitness training is one good quality systematic review¹ of five randomised controlled trials (RCTs) and three more recent good quality RCTs^7-9, all of which were with children, adolescents or young adults with cerebral palsy. No high level research evaluating the outcomes of fitness training with older adults with cerebral palsy was located. We also located a review which made recommendations about exercise and physical activity for people with cerebral palsy based on a combination of research findings, clinical experience and expert opinion³.

Overall, moderate quality evidence from high level studies suggests fitness training is effective for increasing aerobic capacity for children, adolescents and young adults with cerebral palsy. The evidence is not conclusive for the effects of fitness training on anaerobic capacity and strength. No serious risks or burdens were identified in these studies. People with cerebral palsy whose goal is to increase aerobic fitness should liaise with exercise professionals to implement an appropriate fitness training program. There may or may not be additional benefits for anaerobic fitness and strength.

Fitness training can increase the aerobic capacity of children, adolescents and young adults

The systematic review¹ and two RCTs^{7, 9} reported that fitness training increased aerobic capacity. These studies used different but direct measures of aerobic capacity. The RCT that did not support this finding used an indirect measure of aerobic capacity (average walking strides per day)⁸. Overall, greater gains are made with longer training programs and for people with cerebral palsy who are more mobile and participate in higher dosages of training³.

Results are inconclusive for increasing anaerobic capacity through fitness training

Two RCTs^8,9 measured anaerobic capacity but reported conflicting results. In one study the intervention group improved by 11 per cent⁹. These participants had an aerobic exercise program for four months before switching to an anaerobic program for four months. The second study⁸ did not find an improvement in anaerobic capacity. The intervention in this study, however, was half the length of time (four months in total), and intensity was reduced for the second two months.

Results are inconclusive for increasing muscle strength through fitness training

The systematic review¹ and three RCTs^7-9 measured strength in children, adolescents and young adults following an exercise program. The systematic review and one RCT⁷ reported programs to be effective for increasing strength. Two remaining RCTs^7,8 did not find an increase in strength which may have been due to a low training frequency (e.g. one session per week).

Long term fitness training is required

Each of the recent RCTs for children evaluated group based fitness training. The RCT that showed improvements in strength for the intervention group⁹ had an intervention period that was twice as long (eight months) as the remaining studies, suggesting that more than four months is required for improvements to occur in this population.

As in the wider population, fitness training must be ongoing to sustain results

No study that examined long term follow up found that gains achieved were maintained. This suggests that, as in studies of the general population, increases in fitness levels obtained by exercise programs will only be maintained if the exercise programs continue. Once the desired level of fitness is achieved, a lower intensity program may be sufficient to sustain the effects³.

More research needed

The research regarding fitness training has included mostly children and adolescents with cerebral palsy who are at GMFCS Levels I and II and only a small proportion at GMFCS Level III. Further research is required to identify if similar outcomes can be achieved by people at GMFCS Levels III to V.

The decision to undertake fitness training involves understanding the evidence, cost, time and resources required, and the needs and preferences of the person with cerebral palsy and the family. Reducing sedentary behaviour is also important and is recommended as a goal for all people with cerebral palsy.