The Effects of Strengthening Exercises in Patients with Neurological Dysfunction

1. The Effects of Strengthening Exercises in Patients with Neurological Dysfunction PT 224 March 10, 2010 Daniel Maclean, Josh Mitchell, Jennifer Jones, Alyssia Peyton., Oliver Bracero The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

2. 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)

3. 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)

4. This view is not what the research supports! The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

5. 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)

6. 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)

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

8. 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)

9. 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)

10. 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)

11. What strength training intensity is appropriate for increasing function??? The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

12. 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)

13. 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)

14. 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)

15. 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)

16. 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)

17. 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)

18. 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)

19. 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)

20. 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)

21. 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)

22. 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)

23. 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)

24. 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)

25. 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)

26. 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)

27. 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)

28. 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)

29. 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)

30. PT Implication for Cerebral Palsy MAKE Rx’s FUN ! ! ! The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

31. 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)

32. 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)

33. 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)

34. QUESTIONS?? The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

35. Intensive Mobility TrainingUniversity of South Carolinahttp://www.youtube.com/watch?v=fK7fscHbJ1w The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)

36. References 1. 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.

37. References 8. Ada L., Dorsch S., Canning C.G., Strengthening interventions increase strength and improve activity after a stroke: a systematic review Australian 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, USA J 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 AJ Effectiveness 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

38. References 15. 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)

39. 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)

40. Additional References 1. 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 BJ Isokinetic 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, Ben Muscle Strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors Archives 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 Survivors J 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 review Clinical Rehabilitation 18: 27-39 The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)