The Effects of Strengthening Exercises in Patients with Neurological Dysfunction

PT 224March 10, 2010

Daniel Maclean, Josh Mitchell,Jennifer Jones, Alyssia Peyton., Oliver Bracero

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Learning Objectives Discriminate between the traditional and

contemporary views of strength training effects on patients with neurological dysfunction

Describe the progressive overload principle Discuss the effects strength training has on

spasticity in Stroke, Multiple Sclerosis and Cerebral Palsy

List at least 3 task-specific, functional exercises appropriate for strength training: 1. A patient post stroke 2. A patient with multiple sclerosis 3. A patient with cerebral palsy

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Traditional View of Strength training

Berta Bobath Reflex/hierarchical theory

Strength training increases spasticity. Movement is controlled by chained reflexes Reflexes are controlled by a rigid CNS

hierarchy Motor dyscontrol is caused by CNS lesions Treatment is directed at re-establishing

CNS hierarchy Re-establishing CNS hierarchy will produce

normal movement which will automatically transfer to functional ability

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

This view is not what the research supports!

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Contemporary View

Complex Systems Theory Strength/Resistance exercise DOES NOT

increase spasticity in patients Movement is controlled by the interaction of the

performer, task, and environment Motor dyscontrol is caused by factors within and

outside the CNS Treatment is directed at recovery of functional

capacity with task-oriented training

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

The Progressive Overload Principle

Progressive overload is the gradual increase of stress placed upon the body during exercise training by manipulating the variables of frequency, intensity and duration. Affects: strength, gait, balance/cone of stability, ADLs,

cognitive and emotional well-being

Strength training is commonly considered to be progressive resistive exercise and can be accomplished by using task-specific, functional movements

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Stroke

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Progressive resistive strength training reduces impairment and improves physical performance in stroke patients. Susan L. Morris, Karen J. Dodd, Meg E.

Morris Marte Bale, Liv Inger Strand Yea-Ru Yang, Ray-Yau Wang, Kuei-Han

Lin, Rai-Chi Chan UB Flansbjer, M Miller, D Downham, J

Lexell Cramp MC, Greenwood RJ, GillM,

Lehmann A, Rothwell JC, Scott OM. Jorgensen JR, Thue Bech-Pederson D,

Zeeman P, Sorensen J, Andersen LL, Schonberger M.

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Task-Oriented strength training improves lower extremity muscle strength and carries over into improvement in functional activities

Yea-Ru Yang, Ray-Yau Wang, Kuei-Han Lin, Rai-Chi Chan

Susan L. Morris, Karen J. Dodd, Meg E. Morris

Cramp MC, Greenwood RJ, GillM, Lehmann A, Rothwell JC, Scott OM.

Paks S, Patten C.

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Benefits of strength training can be seen in stroke patients even one year post stroke and beyond

Yea-Ru Yang, Ray-Yau Wang, Kuei-Han Lin, Rai-Chi Chan

Edward Phillips, MD; Joel Stein, MD; Walter R. Frontera, MD, PhD; Roger A. Fielding, PhD

UB Flansbjer, M Miller, D Downham, J Lexell

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

What strength training intensity is appropriate for increasing function???

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

IT DOES NOT MATTER!!!

High and low intensity training show significant improvements in function

Higher intensity shows more improvement

Lower intensity can still increase lower limb strength, walking velocity, balance and everyday function

Cramp MC, Greenwood RJ, GillM, Lehmann A, Rothwell JC, Scott OM.

Jorgensen JR, Thue Bech-Pederson D, Zeeman P, Sorensen J, Andersen LL, Schonberger M.

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

PT practice implications for stroke patients

Treat with progressive resistive strength exercises

Use exercises that are task-specific and functional

Where do I start?

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Sample program for stroke patients Exercises:

1. Standing/sitting and reaching for objects located beyond arm’s length Promotes loading of the lower limb and activation of the lower

limb muscles 2. Sit to stand from various chair heights 3. Stepping forward or backward onto blocks of various

heights 4. stepping sideways onto blocks of various heights

2-4 are for strengthening of the lower limb muscles 5. Heel raise and lower while standing

Strengthening of the plantarflexor muscles Duration and Frequency:

30 minutes 3 times per week for 4 weeks

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Multiple Sclerosis

Chronic, progressive illness that effects the CNS

Autoimmune disease, systemic

2-3 times more women than men

Affects 2.5 million people worldwide

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

MS Symptoms

Visual Systems Blurred vision, double vision, nystagmus, blindness

Motor Paresis, paralysis, muslce wasting

Sensory Numbness, tingling, loss of sensation, facial pain

Coordination Impaired balance, ataxia, dysmetria

Bowel and Bladder, impotence, anorgasmy

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

BWSTT is effective at increasing gait speed and improving mobility, and it transfers to a more functional gait in Stroke and MS patients.

Katherine J Sullivan, David A. Brown, Tara Klassen, Sara Mulroy, Tingting Ge, Stanley P Azen, Carolee J Winstein

Barbara Giesser, Janell Beres-Jones, Amy Budovitch, Elise Herlihy, Susan Harkema

Jorgensen JR, Thue Bech-Pederseb D, Zeeman P, Sorensen J, Andersen LL, Schonberger M.

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Strength training in MS patients does not increase spasticity

Robert W. Motl, Erin M. Snook, Marcus L. Hinkle LJ White, SC McCoy, V Castenello, G. Guitierrez,

JE Stevens, GA Walter, K Vandenborne Ada L, Dorsch S, Canning CG Pak S, Patten C. Patten C, Dozono J, Schmidt S, Jue M, Lum P

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Resistance training in MS patients improves ADLs such as transfers and navigating the environment. It also increases their overall endurance by decreasing fatigue.

LS deBolt, JC McCubbin U Dalgas, E Stenager, T Ingemann-

Hansen Dalgas U, Stenager E, Jakobsen J,

Petersen T, Hansen HJ, Knudsen C, Overgaard K, Ingemann-Hansen T

De Souza-Teixiera F, Costilla S, Avan C, Garcia-Lopez D, Gonzalez-Gallego J, de Paz JA

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

PT implications for the MS patient

EXCESSIVE TRAINING INTENSITY CAN CAUSE EXACERBATION FATIGUE IS FINE – EXHAUSTION IS DANGEROUS

Treat the whole body with focus on the lower extremities

Treat in the A.M. - MS patients tend to fatigue later in the day

Include a HEP that focuses on FUNCTION Keep it simple by using body weight and minimal

equipment

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Sample program for MS patients Exercises:

1. Squats 2. Sit to stand 3. Step ups 4. Wall push-ups 5. Theraband UE

exercises Duration and

Frequency: 8-12 repetitions, 2-3 sets,

3 times per week depending on progression of disease and patient tolerance

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Cerebral Palsy Etiology

CNS injury during development fetal growth, birth, within first 2 months

Serious infection or head injury

Unknown

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Cerebral Palsy Common Impairments

Paresis Plegia (Mono-, Hemi-, Quadra-) Spasticity

Notable Functional Deficits Abnormal gait Limited UE use Mental Retardation

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Progressive resistive training increases strength in children and adolescents with cerebral palsy. UE (not measured)

Shoulder, Elbow, Forearm Unnithan et al. 2007

Trunk (not measured) Unnithan et al. 2007

LE Hip, Knee, Ankle

Dodd et al. 2003* Unnithan et al. 2007 Nyström Eek et al. 2008 Salem Y et al. 2009 Scholtes et al. 2010

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Strength training does not increase spasticity in cerebral palsy patients.

DOES NOT increase spasticity

Fowler et al. 2001 Dodd et al. 2003 Lee et al. 2003 Nyström Eek et al. 2008 Scholtes VA et al. 2010

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Strength Training increases functional ability and decreases impairment in cerebral palsy children and adolescents. Gross Motor Function Measure (GMFM) 88 items; 0-3 scale

(A) lying and rolling (B) sitting (C) crawling and kneeling (D) standing (E) walking, running, and jumping

Unnithan et al. 2007 Nyström Eek et al. 2008 Salem Y, Godwin ED 2010

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Strength Training increases functional ability and decreases impairment in cerebral palsy children and adolescents.

Gait Increased Speed (significant) Increased Stride length (significant) Increased SLS (trend) Decreased DLS (trend)

Lee et al. 2003 Nyström Eek et al. 2008 Salem Y, Godwin ED 2010

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

PT Implication for Cerebral Palsy

Efficacy

Strength Training is appropriate for Cerebral Palsy Patients of all ages

Increases Strength DOES NOT Increase Spasticity Increase Function / Decrease Impairments

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

PT Implication for Cerebral Palsy Sample Exercises (varies by patient)

Body Weight (10 reps w/o fatigue) Sit-to-Stand Squats

Manual Resistance (PT dependent) Ankle Plantar Flexion Knee Extension Hip Extension

Weight Resistance (0.5 kg – 3 kg; 10 reps w/o fatigue) Bicep curls Triceps Extensions Side-arm lifts Leg-press Loaded sit-to-stand (weight vest)

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

PT Implication for Cerebral Palsy

MAKE

Rx’s

FUN ! ! !The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Take Home Message: Exercises prescribed for patients with

neurological dysfunction should be TASK-SPECIFIC and FUNCTIONAL Progressive Resistive Strength Training

reduces impairment and increases strength and function in patients with neurological dysfunction

Strength training patients with neurological dysfunction will NOT increase spasticity

Patients who have suffered a stroke can benefit from strength training in the acute phase and in the sub-acute phase (beyond one year)

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

The Type of Load Matters

Speculation form research results Mass load: practice accelerating/decelerating

mass load might facilitate generating more appropriately timed agonist/antagonist muscle activation

Elastic load: might foster stability Viscous load: might preferentially facilitate agonist

muscle recruitment with minimal co-contraction(Stoeckmann et al, PTJ,89:7, July 2009)

Review of Learning Objectives Discriminate between the traditional and

contemporary views of strength training effects on patients with neurological dysfunction

Describe the progressive overload principle Discuss the effects strength training has on

spasticity in Stroke, Multiple Sclerosis and Cerebral Palsy

List at least 3 task-specific, functional exercises appropriate for strength training: 1. A patient post stroke 2. A patient with multiple sclerosis 3. A patient with cerebral palsy

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

QUESTIONS??

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Intensive Mobility TrainingUniversity of South Carolina

http://www.youtube.com/watch?v=fK7fscHbJ1w

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

References1. Cramp MC, Greenwood RJ, Gill M, Lehmann A, Rothwell JC, Scott OM.

Low intensity strength training for ambulatory stroke patients.Disabil Rehabil. 2006 Jul 15-30;28(13-14):883-9.

2. Pak S, Patten C. Strengthening to promote functional recovery poststroke: an evidence-based review.John Muir Rehabilitation Center, Walnut Creek, CA, USA.

3. Jørgensen JR, Thue Bech-Pedersen D, Zeeman P, Sørensen J, Andersen LL, Schönberger M.Effect of Intensive Outpatient Physical Training on Gait Performance and Cardiovascular Health in People With Hemiparesis After Stroke.Phys Ther. 2010 Mar 4.

4. Lee MJ, Kilbreath SL, Singh MF, Zeman B, Davis GM.Effect of progressive resistance training on muscle performance after chronic stroke.Med Sci Sports Exerc. 2010 Jan;42(1):23-34.Faculty of Health Sciences, The University of Sydney, Sydney, Australia.

5. Dalgas U, Stenager E, Jakobsen J, Petersen T, Hansen HJ, Knudsen C, Overgaard K, Ingemann-Hansen T.Resistance training improves muscle strength and functional capacity in multiple sclerosis.Department of Sport Science, University of Aarhus, Dalgas Ave. 4, 8000 Aarhus C, Denmark. Neurology. 2009 Nov 3;73(18):1478-84.

6. de Souza-Teixeira F, Costilla S, Ayán C, García-López D, González-Gallego J, de Paz JA.Effects of resistance training in multiple sclerosis.Biomedical Science Institute, Facultad de Ciencias de la Actividad Física y del Deporte, University of León, León, Spain. Int J Sports Med. 2009 Apr;30(4):245-50. Epub 2009 Feb 6.nile

7. Scholtes VA, Becher JG, Comuth A, Dekkers H, VAN Dijk L, Dallmeijer AJ.Effectiveness of functional progressive resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: a randomized controlled trial.Dev Med Child Neurol. 2010 Jan 28.

References8. Ada L., Dorsch S., Canning C.G.,

Strengthening interventions increase strength and improve activity after a stroke: a systematic reviewAustralian Journal of Physiotherapy 52: 241-248

9. Patten C, Dozono J, Schmidt S, Jue M, Lum P.Combined functional task practice and dynamic high intensity resistance training promotes recovery of upper-extremity motor function in post-stroke hemiparesis: a case study. Rehabilitation Research & Development Center/153 VA Palo Alto Health Care System, CA, USAJ Neurol Phys Ther. 2006 Sep;30(3):99-115.

10. Dalgas U, Stenager E, Jakobsen J, Petersen T, Hansen HJ, Knudsen C, Overgaard K, Ingemann-Hansen T.Resistance training improves muscle strength and functional capacity in multiple sclerosis.Neurology. 2009 Nov 3;73(18):1478-84.

11. Scholtes VA, Becher JG, Comuth A, Dekkers H, VAN Dijk L, Dallmeijer AJEffectiveness of functional progressive resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: a randomized controlled trial. Department of Rehabilitation Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.Dev Med Child Neurol. 2010 Jan 28.

12. Salem Y, Godwin EM.Effects of task-oriented training on mobility function in children with cerebral palsy. Division of Physical Therapy, Long Island University, Brooklyn, NY, USA.

NeuroRehabilitation. 2009;24(4):307

13. Fowler, Eileen G, Ho, Teresa W, Nwigwe, Azuka I, Dorey, Fredrick JThe Effect of Quadriceps Femoris Muscle Strengthening Exercises on Spasticity in Children With Cerebral PalsyPhys Ther 2001 81: 1215-1223

14. Meta Nyström Eek, Roy Tranberg, Roland Zügner, Kristina Alkema, Eva Beckung Muscle strength training to improve gait function in children with cerebral palsy Developmental Medicine & Child Neurology 2008, 50: 759–764

References15. Susan L Morris, Karen J Dodd, Meg E Morris

Outcomes of progressive resistance strength training following stroke: a systematic review Clinical Rehabilitation 2004; 18; 27-39

16. Marte Bale, Liv Inger Strand Does functional strength training of the leg in subacute stroke improve physical performance? A pilot randomized clinical trial

Clinical Rehabilitation 2008; 22; 911-921

17. Yea-Ru Yang, Ray-Yau Wang, Kuei-Han Lin, Mou-Yu Chu, Rai-Chi Chan Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with

stroke Clinical Rehabilitation 2006; 20; 960-970

18. Sullivan, Katherine J; Brown, David A; Klassen, Tara; Mulroy, Sara; Tingting Ge; Azen, Stanley P; Winstein, Caroline J Effects of Task-Specific Locomotor and Strength Training in Adults Who Were Ambulatory After Stroke: Results of the STEPS

Randomized Clinical Trial Physical Therapy, Dec 2007; 87 (12); 1580-1602

19. Michelle M. Ouellette, MSPT; Nathan K. LeBrasseur, PhD; Jonathan F. Bean, MD; Edward Phillips, MD; Joel Stein, MD; Walter R. Frontera, MD, PhD; Roger A. Fielding, PhD High-Intensity Resistance Training Improves Muscle Strength, Self-Reported Function, and Disability in Long-Term Stroke

Survivors Stroke: Journal of the American Heart Association 2004; 35; 1404-1409

20. LJ White, SC McCoy, V Castellano, G. Guitierrez, JE Sterns, GH Walter, K Vandenborne Resistance Training improves strength and functional capacity in persons with Multiple Sclerosis Multiple Sclerosis 2004; 10: 668-674 21. B. Giesser, J. Beres-Jones, A, Budovitch, El Herlihy Locomotor training using body weight support on a treadmill improves mobility in persons with Multiple Sclerosis: A Pilot Study Multiple Sclerosis 2007; 13: 224-231

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

22. L.S. deBolt, J.A. McCubbin The effects of home based Resistance Exercise on Balance, Power, and Mobility in adults with Multiple Sclerosis Archives of Physical Medicine and Rehabilitation 2004 Feb; 85(2); 290-297

23. Viswanath b. Unnithan, George Katsimanis, Christina Evangelinou, Christoulas Kosmas, Ifigenia Kandrali, and Eleftherios Kellis Effect of Strength and Aerobic Training in Children with Cerebral Palsy MEDICINE & SCIENCE IN SPORTS & EXERCISE, 2007 Vol. 39, No. 11, pp. 1902-1909

24. Karen J Dodd PhD, Nicholas F Taylor PhD, HKerr Graham MD FRCS (Ed) FRACS, A randomized clinical trial of strength training in young people with cerebral palsy Developmental Medicine & Child Neurology 2003, 45: 652–657

25. Lee, Jung Hwan, Sung, In Young and Yoo, Jong Yoon 'Therapeutic effects of strengthening exercise on gait function of cerebral palsy', Disability & Rehabilitation (2008),30:19,1439 — 1444

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

Additional References1. Kocabas H, Levendoglu F, Ozerbil OM, Yuruten B.

Complex Regional Pain Syndrome in Stroke Patients Int J Rehabil Res. 2007 Mar 30(1): 33-8

2. Flansbjer UB, Miller M, Downham D, Lexell J Progressive resistance training after stroke: effects on muscle strength, muscle tone, gait performance and perceived participation

J Rehabil Med. 2008 Jan;40(1):42-8

3. Sharp SA, Brouwer BJIsokinetic strength training of the hemiparetic knee: effects on function and spasticity.Archives of Physical Medicine & Rehabilitation 2001 78(11):1231-6

4. Fowler, Eileen G, Ho, Teresa W, Nwigwe, Azuka I, Dorey, Fredrick JThe Effect of Quadriceps Femoris Muscle Strengthening Exercises on Spasticity in Children With Cerebral Palsy Phys Ther 2001 81: 1215-1223

5. Teixera-Salmela Luci F, Olney, Sandra J, Nadeau, Sylvie, Brouwer, BenMuscle Strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivorsArchives of Physical Medicine & Rehabilitation: 80(10): 1211-8

6. Teixeira-Salmela LF, Nadeau S, Mcbride I, Olney S Effects of Muscle Strengthening and Physical Conditioning Training on Temporal, Kinematic and Kinetic Variables During Gait in Chronic Stroke SurvivorsJ Rehab Med 2001 33:53-60

7. Cramp, M.C.,Greenwood, R.J., Gill, M.,Rothwell, J.C., Scott, O.M. Low Intensity Strength Training for Ambulatory Stroke Patients Disability and Rehabilitation 2006 28(13-14): 883-889

8. Morris S.L., Dodd K.J., Morris M.E. Outcomes of progressive resistance strength training following stroke: a systematic reviewClinical Rehabilitation 18: 27-39

The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)