Progressive resistance training for children with cerebral palsy: A randomized controlled trial evaluating the effects on muscle strength and morphology

Britta Hanssen, Nicky Peeters, Nathalie De Beukelaer, Astrid Vannerom, Leen Peeters, Guy Molenaers, Anja Van Campenhout, Ellen Deschepper, Christine Van den Broeck, Kaat Desloovere, Britta Hanssen, Nicky Peeters, Nathalie De Beukelaer, Astrid Vannerom, Leen Peeters, Guy Molenaers, Anja Van Campenhout, Ellen Deschepper, Christine Van den Broeck, Kaat Desloovere

Abstract

Children with spastic cerebral palsy often present with muscle weakness, resulting from neural impairments and muscular alterations. While progressive resistance training (PRT) improves muscle weakness, the effects on muscle morphology remain inconclusive. This investigation evaluated the effects of a PRT program on lower limb muscle strength, morphology and gross motor function. Forty-nine children with spastic cerebral palsy were randomized by minimization. The intervention group (nparticipants = 26, age: 8.3 ± 2.0 years, Gross Motor Function Classification System [GMFCS] level I/II/III: 17/5/4, nlegs = 41) received a 12-week PRT program, consisting of 3-4 sessions per week, with exercises performed in 3 sets of 10 repetitions, aiming at 60%-80% of the 1-repetition maximum. Training sessions were performed under supervision with the physiotherapist and at home. The control group (nparticipants = 22, age: 8.5 ± 2.1 year, GMFCS level I/II/III: 14/5/3, nlegs = 36) continued usual care including regular physiotherapy and use of orthotics. We assessed pre- and post-training knee extension, knee flexion and plantar flexion isometric strength, rectus femoris, semitendinosus and medial gastrocnemius muscle morphology, as well as functional strength, gross motor function and walking capacity. Data processing was performed blinded. Linear mixed models were applied to evaluate the difference in evolution over time between the control and intervention group (interaction-effect) and within each group (time-effect). The α-level was set at p = 0.01. Knee flexion strength and unilateral heel raises showed a significant interaction-effect (p ≤ 0.008), with improvements in the intervention group (p ≤ 0.001). Moreover, significant time-effects were seen for knee extension and plantar flexion isometric strength, rectus femoris and medial gastrocnemius MV, sit-to-stand and lateral step-up in the intervention group (p ≤ 0.004). Echo-intensity, muscle lengths and gross motor function showed limited to no changes. PRT improved strength and MV in the intervention group, whereby strength parameters significantly or close to significantly differed from the control group. Although, relative improvements in strength were larger than improvements in MV, important effects were seen on the maintenance of muscle size relative to skeletal growth. In conclusion, this study proved the effectiveness of a home-based, physiotherapy supervised, PRT program to improve isometric and functional muscle strength in children with SCP without negative effects on muscle properties or any serious adverse events. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT03863197.

Keywords: functional muscle strength; isometric muscle strength; lower extremity; muscle morphology; progressive resistance training; spastic cerebral palsy; ultrasonography.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Hanssen, Peeters, De Beukelaer, Vannerom, Peeters, Molenaers, Van Campenhout, Deschepper, Van den Broeck and Desloovere.

Figures

FIGURE 1
FIGURE 1
All children aged 5–11 years old were extracted from the clinical database of the CP reference center Leuven (n = 342) and screened based on gross motor function classification system level and type of CP. The scheduled appointments at the children’s hospital and gait laboratory were monthly checked to further screen potential participants based on the exclusion criteria (±10% eligible every month, part of the n = 342). Additionally, pediatric physiotherapists at private practices and special needs schools were consulted for potential participants resulting in 6 of the 49 participants not being followed up in Leuven. The first number, before the hyphen, represents the participants that were randomized by minimization by Minim-Py before the forced stop of the study due to the global Covid-19 pandemic, the number after the hyphen represents the participants who were manually minimized afterwards. *Included in primary analyses: control group=22 and intervention group=26 (1 randomized child did not participate in baseline assessments). Included in sensitivity analyses: • Randomized: control group=20 and intervention group=20 (1 randomized child did not participate in baseline assessments). • Finished: control group=19 and intervention group = 19. BTX, botulinum neurotoxin type A; CP, cerebral palsy.
FIGURE 2
FIGURE 2
Estimated marginal mean differences with 95% confidence interval of mixed model analyses for muscle morphology with results for within and between analyses including all participants and all affected legs. *: significant time-effect at p ≤ 0.01. Abbreviations: Δ, change; MG, medial gastrocnemius; RF, rectus femoris; ST, semitendinosus. Units: AU, arbitrary units; mL, milliliter; mm, millimeter.
FIGURE 3
FIGURE 3
Estimated marginal mean differences with 95% confidence interval of mixed model analyses for strength and functional parameters with results for within and between analyses including all participants and all affected legs for bilaterally tested parameters. #: significant time*group interaction-effect at p ≤ 0.01. *: significant time-effect at p ≤ 0.01. Abbreviations: Δ, hange; 1MWT, 1-minute walk test; BHR, bilateral heel raise; GMFM, gross motor function measure; KE, knee extension; KF, knee flexion; LSU, lateral step-up; PF, plantar flexion; SLJ, standing long jump; STS, sit-to-stand; UHR, unilateral heel raise. Units: Cm, centimeter; M, meter; Nm, Newton-meter.
FIGURE 4
FIGURE 4
Estimated marginal mean differences with 95% confidence interval of mixed model analyses for normalized muscle morphology and isometric strength parameters with results for within and between analyses including all participants and all affected legs. #: significant time*group interaction-effect at p ≤ 0.01. *: significant time-effect at p ≤ 0.01. Abbreviations: Δ, change; KE, knee extension; KF, knee flexion; MG, medial gastrocnemius; PF, plantar flexion; RF, rectus femoris; ST, semitendinosus. Units: Cm/cm, centimeter/centimeter; mL/cm, milliliter per centimeter; Nm/kg, Newton-meter per kilogram.

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