Strength training of the arm

To be safe and effective, strength training of the arm needs to be introduced and monitored by an experienced professional. Anyone undertaking a new exercise program, especially people with special medical or physical needs associated with their cerebral palsy, should consult with an exercise or health professional.

It is important to remember that extra care in planning and monitoring a strength training program may be required for some people. Cerebral Palsy Alliance offers a service where our exercise physiologists, occupational therapists and physiotherapists can help a person with cerebral palsy and their family decide if this intervention is a good choice for them.

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Fees will apply for occupational therapy, physiotherapy or exercise physiology assessment and monitoring, 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.

Equipment for strength training for the arm can vary in expense. Some strength training activities are reasonably inexpensive, such as hand held weights. Access to specialised equipment and the opportunity to work with professionals in a gym involves a more substantial outlay, with prices varying between AUD$10 to $25 per week.

Ask the provider 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 a person to increase their arm strength, they will need to train two to four times a week for a minimum of eight weeks. They will also need rest days in between.

Each training session should last for a minimum of 20 to 30 minutes¹. During the sessions, they should complete one to three sets of six to 15 repetitions of each exercise.

Muscle weakness is a well-known challenge associated with cerebral palsy. It is common for muscle weakness to co-exist with spasticity and involuntary muscle movements (dyskinesia).

• Progressive resistance training - people with cerebral palsy who are undertaking strength training learn a technique called progressive resistance training¹. This technique involves using exercises that are made progressively more difficult through an increase in the amount of weight or the resistance. The exercises can be completed in a gym or other exercise environment and often uses pieces of equipment such as handheld dumbbells, arm weights and gym machines.
• Functional strength training - one commonly used form of progressive resistance training is called functional strength training⁵. It involves doing everyday functional activities while the amount of resistance increases. Examples of this method include repetitively throwing and catching weighted balls, or moving around in a self-propelling wheelchair to help increase arm strength.

Organisations that are recognised for their expertise in this field^3,4 have set out guidelines for safe and effective^3,4,6 progressive strength training programs. These guidelines include recommendations for how much resistance, or what load, the strengthening exercises should provide; how many times an exercise should be repeated in a session; and how many times each week strengthening sessions should be carried out. These organisations also recommend that progressive resistance training is most appropriate for children over seven-years-old, as well as adolescents and adults.

Before a person begins training, it is really important for an experienced professional to carry out a thorough assessment to identify their goals for therapy and ensure exercises are suitable for their ability level. Often the specialist will measure the maximum amount the person can lift or their hand can squeeze (called one repetition max). They will then focus the person’s strength training on increasing the repetition max.

The second type of assessment is to measure whether the person’s strength training program is meeting their needs and goals. The professional, together with the person with cerebral palsy and their family will decide on the most suitable assessments to use. Common assessments to measure the outcome of arm strength training programs include:

• Goal Attainment Scaling (GAS goals) – measures the extent to which the person’s goals are being achieved
• Measures of muscle strength – this will be done using a device that measures force and power, such as a hand held dynamometry. A range of other methods are also available to measure the amount of weight a person can lift.

We searched the medical and allied health literature to find research evaluating the outcomes of using arm strengthening to help children and adults with cerebral palsy.

The search aimed to find the best available research as to whether strengthening, as part of a training program, or embedded in functional activities could improve a person’s arm strength or their ability to complete daily activities.

For children and adolescents with cerebral palsy. We found one critical review of all levels of evidence which summarised the existing literature on strengthening for children and adolescents⁷. Rameckers’ review⁷ of studies evaluating arm strength training in children and adolescents included six small studies ranging from case studies to randomised controlled trials with between one and 30 participants. The intensity of training in the studies was lower than recommended levels. The quality of evidence is considered very low because the studies were mostly low level and used different methods of strength training, and at different intensities.

For adults with cerebral palsy. Two small studies evaluating arm strength training for adults with cerebral palsy were found. As these studies were both small and low level (Level 3⁸ and Level 4⁹) and there was inconsistency in the participants in the studies and outcome measures used, these studies are considered to provide very low quality evidence on the benefits of strength training. People participating in these studies had a range of types and severity of cerebral palsy, including a number with severe physical disability and mild to moderate intellectual disability. The arm strength training program appeared to be at recommended levels of intensity.

Overall, the evidence suggests that strength training may help increase arm strength for children, adolescents and adults with cerebral palsy. It is not clear, however, whether it helps people with cerebral palsy to use their arms more effectively in everyday activities. People with cerebral palsy and their families who are interested in arm strengthening are advised to partner with an appropriate professional to discuss their goals, and identify the appropriate muscle groups they need to exercise. The gains made during strength training are likely to be lost once the program ends, so individuals, families and professionals will need to consider strategies for maintaining their strength afterwards.

Strength training increases arm strength for children and adolescents

Each of the studies included in Rameckers’ review⁷ concluded that the arm strength of participants increased. Few of the studies evaluated whether the benefits of strengthening persisted once children stopped their training. In the studies that did, the results were inconclusive as to whether results achieved through training were retained afterwards.

Effect on functional outcomes for children and adolescents is unclear

Evidence for the effects of arm strengthening on the ability of children and adolescents to use their arms for daily activities was unclear⁷. Few studies focused on strengthening muscles of the shoulder and those required for grip strength. Further research is needed to identify if including such muscles in a strength training program may change a child’s ability to use their arms in daily activities.

None of the studies achieved the intensities of strength training recommended by the expert organisations^3,4. Strength training at higher intensities (that is, higher loads or weight) may achieve better outcomes.

Most studies included children with spastic hemiparesis so it is difficult to say if the results would be relevant to other groups of children and adolescents with cerebral palsy.

Strength training increases arm strength for adults with cerebral palsy

In the studies of adults, arm strength of participants increased immediately after the intervention but was not sustained when assessed 10 weeks after training ended⁷.

Strength training may increase hand and arm function, but it is not clear if the ability of adults to use their arm for daily activities improves

One of the studies⁸ provided very low quality evidence suggesting that while participants improved on tests of hand function, there was no change in their ability to complete everyday activities such as dressing and feeding.