Cerebral palsy (CP) is one of the highest prevalences of physical disability affecting children globally. People with CP usually have a heterogenic motor disorder resulting from brain issues. Their clinical manifestations vary, ranging from mild to severe physical impairment, with or without cognitive impairment. Therefore, in the past, they faced many inconveniences and challenges when engaging in sports activities, despite exercises that may have helped in developing their healthy lifestyles. Due to the development of ambulatory devices and related medical innovations, an integrated and comprehensive approach with a range of specialties is to be tailored to each patient on a case-by-case basis. Hence, medical guidelines recommend exercise and the appropriate amount of physical activity to reduce the rate of future bone and muscle diseases in people with CP and eventually decrease their morbidity and mortality. In this section, we will introduce the cerebral palsy sport classification, types of sports training suitable for people with CP, and special Olympics and Paralympics for CP.
Cerebral Palsy Sport Classification
The CP8 Classification System
CPRISRA stands for Cerebral Palsy International Sports and Recreation Association. It is the leading international sports organisation to provide an international platform for people with cerebral palsy (CP) and related neurological conditions to engage in recreational sports and activities.
And this association developed a cerebral palsy sport classification which can be used in Paralympic Games.
This classification system includes eight classes, which are CP1, CP2, CP3, CP4, CP5, CP6, CP7, and CP8. Below are the details of the class and their definitions.
| Class | Definition |
|---|---|
| CP1 | Use wheelchairs; affected by or relating to the paralysis of all four limbs. |
| CP2 | Similar to CP1 but with better upper body control. |
| CP3 | Use wheelchairs in daily lives, able to move their bodies with the assisted devices. Have problems when moving the head and trunk. |
| CP4 | Similar to CP3 but has fewer problems when moving the head and trunk. |
| CP5 | Better control of the upper body. No issue on general movement with assisted device. Have balance issue when quick movement. |
| CP6 | Ambulatory and able to walk without the use of an assistive device. Their bodies are constantly in motion. |
| CP7 | Able to walk but may appear to have a limp as half their body is affected by cerebral palsy. |
| CP8 | Least physically affected by their cerebral palsy, their disability generally manifested as spasticity in at least one limb. |
The Gross Motor Function Classification System-Expanded & Revised (GMFCS-E &R)
This is a classification system for therapists and clinicians to assess the motor function of children with cerebral palsy. This classification system is only used for infants to 18-year-old children.
Level I: Walks without Limitations
For example, children walk at home, at school, outdoors and in the community. They can climb stairs without the use of a railing. Children perform gross motor skills such as running and jumping, but their speed, balance, and coordination are limited.
Level II: Walks with Limitations
For example, children walk in most settings and climb stairs while holding onto a railing. They may experience difficulty walking long distances and balancing uneven terrain, inclines, crowded areas, or confined spaces.
Children may walk with physical assistance, a handheld mobility device or use wheeled mobility over long distances. Children have only minimal ability to perform gross motor skills such as running and jumping.
Level III: Walks Using a Hand-Held Mobility Device
Children walk using a hand-held mobility device in most indoor settings. They may climb stairs while holding onto a railing with supervision or assistance. Children use wheelchairs for mobility when travelling long distances and may self-propel for shorter distances.
Level IV: Self-Mobility with Limitations; May Use Powered Mobility
Children use methods of mobility that require physical assistance or powered mobility in most settings. They may walk short distances at home with physical assistance or use powered mobility or a body support walker when positioned. At school, outdoors, and in the community, children are transported in a manual wheelchair or use powered mobility.
Level V: Transport in a Manual Wheelchair
Children are transported in a manual wheelchair in all settings. Children are limited in their ability to maintain antigravity head and trunk postures and control leg and arm movements.
Types of Sports Training Suitable For People with Cerebral Palsy
Guidelines
Olaf Verschuren, PhD from the Netherland and Mark.D Peterson from the USA developed the first CP-specific Physical Activity(PA) and exercise guideline based on various medical literature, expert opinion and clinical experience. This guideline introduces the types of sports training suitable for people with CP:
| Type of Training | Details | Examples |
|---|---|---|
| Cardiorespiratory (Aerobic) Exercise -Frequency -Intensity -Time -Type | – Starting with 1–2 sessions a week and gradually progressing to 3 sessions a week – > 60% of peak heart rate, or >40% of the HRR, or between 46–90% VO2peak – A minimum time of 20 minutes per session, and for at least 8 or 16 consecutive weeks, depending on frequency (2 or 3 times a week). – Regular, purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature | – Swimming – Using an elliptical trainer – Walking – Rowing – Using an upper body ergometer (a piece of equipment that provides a cardiovascular workout that targets the upper body only). |
| Resistance Exercise – Frequency – Intensity – Time – Type | – 2–4 times a week on nonconsecutive days – 1–3 sets of 6–15 repetitions of 50–85% RM – No specific duration of training has been identified for effectiveness. Training period should last at least 12–16 consecutive weeks – Progression in mode from primarily single-joint, machine-based resistance exercises to machine plus free-weight, multi-joint (and closed-kinetic chain) resistance exercises.Single-joint resistance training may be more effective for very weak muscles or for children, adolescents or adults who tend to compensate when performing multi-joint exercises, or at the beginning of the training | – Knee Flexion and Extension. Lay down flat and have your caregiver lift your leg and bend it towards the chest. – Hip Rotations. Just like the previous exercise, lay down flat and have your caregiver bend one knee. |
| Physical Activity (Moderate to Vigorous) – Frequency – Intensity – Time – Type | – More than 5 days/week – Moderate-to-vigorous physical activity – 60 min – A variety of activities |
| Physical Activity (Sedentary) – Frequency – Intensity – Time – Type | – 7days/week – Sedentary (<1.5 METs) – <2hrs/day or break up sitting for 2 minutes every 30–60 minutes – Non-occupational, leisure-time sedentary activities such as watching television, using a computer, and/or playing video games |
Adaptive Sports
Adaptive sports are an ideal choice of sport for people with CP, as the rules of sports will be modified based on the physical classification system. For example, the rules will allow people with CP who use wheelchairs to race in specially designed racing chairs. Examples of adaptive sports that people with CP can engage in are listed below:
- Archery
- Wheelchair basketball
- Skiing
- Equestrian
- Golf
- Hand cycling
- Sailing
- Scuba
- Sled hockey
- Snowboarding
- Wheelchair rugby
- Tennis
- Waterskiing
- Wheelchair racing
- Yoga
Special Olympics and Paralympics for CP
Special Olympics welcomes all athletes with intellectual disabiites such as cognitive delay or developmental disability whereas paralympics welcomes athletes from six main disabilty categories which are cerebral palsy, amputee, intellectual disability, visual impairmmemt, spinal injuries, and others.
To be simplified, people with cerebral palsy can participate in both Special Olympics and Paralympics, only that the criteria for entering paralympics is more stricter, which requires the participants to go through certain qualification process. Below is the famous athletes with Cerebral Palsy:
- Dato’ Mohammad Ridzuan bin Mohamad Puzi
He is one of the well-known athletes who had won pride and golden medals for Malaysian in Paralympics 2016. He had been diagnosed with cerebral palsy at a very early age. Despite that, his running and jumping talents were discovered, and he worked very hard. Eventually, he broke the 100 metres world record at the 2018 Asian Para Games.
- Chew Wei Lun
A Malaysian boccia player who won a silver medal at the Tokyo Paralympics in 2019. For many years, he was not defeated by his cerebral palsy, and instead, he urged people with disabilities to be brave and keep on trying on new things.
- Justin Gallegos
He is the first professional athlete with cerebral palsy to sign a contract with Nike. In 2016, he won a gold medal in the 400 metres at the Paralympics. One of his famous quote is “The only limit we have is our mind.”
Conclusion
Currently, we can see the growth in the new innovations for exercise training for people with CP. Therefore, people with CP can be optimistic about their future being able to engage in more and more sports activities while there are a lot of opportunities being provided. However, even with the most advanced technologies and most professional programs, the current challenge will mostly be the psychological barriers. Many people with CP feel inferior or face other psychological challenges when participating in sports activities and try to compare their progress to others. And this situation will cause unnecessary competition, and their therapists and sports coaches could do more in this process in order to let them enjoy the fun of sport first instead of pursuing improvements. Make them know that they should never underestimate themselves and that they can try anything if they want.
References:
1. Krigger KW. Cerebral palsy: an overview. Am. Fam. Physician. 2006; 73:91–100.
2. Novak I. Evidence-based diagnosis, health care, and rehabilitation for children with cerebral palsy. J. Child Neurol. 2014; 29:1141–56.
3. Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev. Med. Child Neurol. 1997; 39:214–23.
4. Peterson MD, Zhang P, Haapala HJ, et al. Greater adipose tissue distribution and diminished spinal musculoskeletal density in adults with cerebral palsy. Arch. Phys. Med. Rehabil. 2015; 96:1828–33.
5. Verschuren O, Peterson MD, Balemans AC, Hurvitz EA. Exercise and physical activity recommendations for people with cerebral palsy. Dev. Med. Child Neurol. 2016; 58:798–808.
6. Carlon SL, Taylor NF, Dodd KJ, Shields N. Differences in habitual physical activity levels of young people with cerebral palsy and their typically developing peers: a systematic review. Disabil. Rehabil. 2013; 35:647–55.
7. Waltersson L, Rodby-Bousquet E. Physical activity in adolescents and young adults with cerebral palsy. Biomed. Res. Int. 2017; 2017:8080473–6.
8. Nsenga AL, Shephard RJ, Ahmaidi S. Aerobic training in children with cerebral palsy. Int. J. Sports Med. 2013; 34:533–7.
9. Maltais DB, Pierrynowski MR, Galea VA, et al. Physical activity level is associated with the O2 cost of walking in cerebral palsy. Med. Sci. Sports Exerc. 2005; 37:347–53.
10. Hoofwijk M, Unnithan V, Bar-Or O. Maximal treadmill performance of children with cerebral palsy. Pediatr. Exerc. Sci. 1995; 7:305–13.
11. Jung JW, Woo JH, Ko J, Kim H. Cardiorespiratory endurance in children with and without cerebral palsy as measured by an ergometer: a case series study. J. Phys. Ther. Sci. 2015 May; 27:1571–5.
12. Dallmeijer AJ, Rameckers EA, Houdijk H, et al. Isometric muscle strength and mobility capacity in children with cerebral palsy. Disabil. Rehabil. 2017; 39:135–42.
13. Park EY, Kim WH. Meta-analysis of the effect of strengthening interventions in individuals with cerebral palsy. Res. Dev. Disabil. 2014; 35:239–49.
14. van Vulpen LF, de Groot S, Rameckers E, et al. Improved walking capacity and muscle strength after functional power training in young children with cerebral palsy. Neurorehabil. Neural Repair. 2017; 31:827–41.
15. Dodd KJ, Taylor NF, Graham HK. A randomized clinical trial of strength training in young people with cerebral palsy. Dev. Med. Child Neurol. 2003; 45:652–7.
16. Liao HF, Liu YC, Liu WY, Lin YT. Effectiveness of loaded sit-to-stand resistance exercise for children with mild spastic diplegia: a randomized clinical trial. Arch Phys Med. 19230216. Rehabil. 2007; 88:25–31.
17. Lee JH, Sung IY, Yoo JY. Therapeutic effects of strengthening exercise on gait function of cerebral palsy. Disabil. Rehabil. 2008; 30:1439–44.
18. Aye T, Thein S, Hlaing T. Effects of strength training program on hip extensors and knee extensors strength of lower limb in children with spastic diplegic cerebral palsy. J. Phys. Ther. Sci. 2016; 28:671–6.
19. Peungsuwan P, Parasin P, Siritaratiwat W, et al. Effects of combined exercise training on functional performance in children with cerebral palsy: a randomized- controlled study. Pediatr. Phys. Ther. 2017; 29:39–46.
20. Ryan JM, Theis N, Kilbride C, et al. Strength training for adolescents with cerebral palsy (STAR): study protocol of a randomised controlled trial to determine the feasibility, acceptability and efficacy of resistance training for adolescents with cerebral palsy. BMJ Open. 2016; 6:e012839.
21. Colquitt G, Kiely K, Caciula M, et al. Community-based upper extremity power training for youth with cerebral palsy: a pilot study. Phys. Occup. Ther. Pediatr. 2019; 40:1–16.
22. Brandao MB, Mancini MC, Ferre CL, et al. Does dosage matter? A pilot study of hand-arm bimanual intensive training (HABIT) dose and dosing schedule in children with unilateral cerebral palsy. Phys. Occup. Ther. Pediatr. 2018; 38:227–42.
23. Nuara A, Avanzini P, Rizzolatti G, Fabbri-Destro M. Efficacy of a home-based platform for child-to-child interaction on hand motor function in unilateral cerebral palsy. Dev. Med. Child Neurol. 2019; 61:1314–22.
24. Chen YL, Chen HL, Shieh JY, Wang TN. Preliminary efficacy of a friendly constraint-induced therapy (friendly-CIT) program on motor and psychosocial outcomes in children with cerebral palsy. Phys. Occup. Ther. Pediatr. 2019; 39:139–50.
25. Hoare BJ, Wallen MA, Thorley MN, et al. Constraint-induced movement therapy in children with unilateral cerebral palsy. Cochrane Database Syst. Rev. 2019; 4:CD004149.
26. Novak I. Commentary on development of a pediatric goal-centered upper limb spasticity home exercise therapy program. Phys. Occup. Ther. Pediatr. 2019; 39:136–8.
27. Lee HJ, Moon HI, Kim JS, Yi TI. Is there a dose-dependent effect of modified constraint-induced movement therapy in patients with Hemiplegia. Neuro Rehabilitation. 2019; 45:57–66.
28. Hung YC, Ferre CL, Gordon AM. Improvements in kinematic performance after home-based bimanual intensive training for children with unilateral cerebral palsy. Phys. Occup. Ther. Pediatr. 2018; 38:370–81.
29. Shin SO, Kim NS. Upper extremity resistance exercise with elastic bands for respiratory function in children with cerebral palsy. J. Phys. Ther. Sci. 2017; 29:2077–80.
30. Cavalcante Neto JL, Steenbergen B, Wilson P, et al. Is Wii-based motor training better than task-specific matched training for children with developmental coordination disorder? A randomized controlled trial. Disabil. Rehabil. 2019; 42:1–10.
31. Kassee C, Hunt C, Holmes MWR, Lloyd M. Home-based Nintendo Wii training to improve upper-limb function in children ages 7 to 12 with spastic hemiplegic cerebral palsy. J. Pediatr. Rehabil. Med. 2017; 10:145–54.
32. Maltais DB, Wiart L, Fowler E, et al. Health-related physical fitness for children with cerebral palsy. J. Child Neurol. 2014; 29:1091–100.
33. Engsberg JR, Ross SA, Collins DR. Increasing ankle strength to improve gait and function in children with cerebral palsy: a pilot study. Pediatr. Phys. Ther. 2006; 18:266–75.
34. Scholtes VA, Becher JG, Comuth A, et al. 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; 52:e107–13.
35. van Vulpen LF, de Groot S, Rameckers EA, et al. Improved parent-reported mobility and achievement of individual goals on activity and participation level after functional power-training in young children with cerebral palsy: a double-baseline controlled trial. Eur J Phys Rehabil Med. 2018; 54:730–7.