Universal Fitness Innovation & Transformation
Max is an 8-year-old boy who was has been using a wheelchair for most of his life. Max loves super heroes and hockey and he needs assistance to take part in most activities. Max has been going to physical therapy sessions twice a week for the past year. His mom has noticed that since beginning therapy, Max is better at feeding himself (he is more coordinated using his utensils and picking up food, like grilled cheese sandwiches- his favourite!) as well as throwing a ball and playing with his sister. However, Max doesn’t like going to the medical centre for physical therapy and they are looking for a way for him to continue building strength and increasing flexibility in a more fun and community focused setting.
Sarah is 12 and she wants to be in the Olympics, or the Paralympics. It doesn’t matter to her, she loves competition and can’t wait to stand on the podium at a track and field event. Sarah’s cerebral palsy affects the right side of her body- including both her right arm and leg. She does not use a mobility device, although her gait looks a little off balance as she has a slight limp when walking. Sarah wants to pursue competitive athletics and is looking for a training program that will help her excel as an elite level athlete (once she finishes middle school!).
Cerebral Palsy (CP) is a motor disorder that occurs due to damage to the developing brain either during pregnancy, birth or after birth. The damage (lesions) in the brain generally does not progress, yet the impact is lifelong. The symptoms vary from person to person, depending on the area of the brain that is damaged and so it is important to consider each person on an individual basis, while acknowledging that there are often commonalities. For example, CP can impact body movement, muscle control, muscle coordination, muscle tone, reflexes, posture and balance.
How does CP effect someone’s movements?
These are different types of cerebral palsy:
These types of CP can occur in various combinations (spastic CP and dyskinetic CP often occur together) and can also affect various parts of the body.
Due to speech difficulties, many people often assume that someone with CP also has an intellectual disability- Do not make this assumption! If you are having trouble understanding the individual: Be patient. Try again. Ask someone for help (e.g., a parent or support worker). Don’t pretend to understand if you don’t. It’s ok if you’re not sure what they said, you’ll get to know their speech and become better at understanding as you work together!
Exercise is important for everyone! For people with CP, the benefits of regular exercise include:
When someone with CP comes in for their consultation you may (or may not!) notice the following:
What are you going to do?
Use the consultation as an opportunity to get to know the participant. Gather relevant medical information and fitness/ physical activity experience and spend some time focusing on goal setting and learning about participant preferences. In addition to discussing the exercises themselves, ask the participant about how they will get to the fitness centre, and the level of support they need to access the locker room, and prepare for exercise.
You want to support the participant to be as independent as possible. Depending on the individual, this may change over time as they become more familiar with the setting and feel more confident and capable. Some participants may choose to include task-specific training as part of their goal setting (e.g., movements to help with picking up dropped items from the floor or moving around small spaces) or maybe they want to work towards increased community participation (e.g., for youth this might being able to take part in a PE class or keep up with their friends in the school yard).
Exercise (especially a new program!) can be exhausting for anyone. People who have more severe spasticity, weak muscles and impaired motor control will require more energy for movement and activities. This leads to increased heart rates and blood pressure which can decrease aerobic and anaerobic capacity as the body’s rate of oxygen uptake is reduced. This means they’ll get tired quickly- especially at the beginning!
Exercise (both strength training and aerobic activity) is important (see all of the reasons listed above!), however, low fitness levels are common among people with CP and impaired fine motor skills can result in difficulty performing skilled movements.
There are lots of reasons why someone might think that strength training is not suitable for people with CP. They may have muscle imbalances, poor functional strength and reduced range of motion due to spasticity or contractures. Strength training alone is not enough to improve mobility (ACSM), however, combining regular aerobic exercise with strength training is important to avoid the downward spiral that is associated with physical inactivity.
Recommendation: Exercise in the water!
This framework is used primarily to describe meaningful functioning in daily life for people with CP. The system is in alignment with the International Classification of Functioning, Disability and Health (WHO, ICF), however the focus is on the participant’s typical ability (performance) rather than their best possible performance (capability). The GMFCS is most often used by rehabilitation professionals (e.g., physiotherapists or occupational therapists) and they may use these classifications to tell you about an individual’s abilities.
The GMFCS can be useful as a starting point, however, it is important to consider environmental and personal factors (check out the ICF for more details about this classification system) to help you get to know the participant. Some examples of personal factors include readiness (stage of change), motivation, behaviour, likes and dislikes, past experiences, gross and fine motor functioning, goals etc. Environmental factors can include but are not limited to accessibility of the physical environment, transport, use of mobility equipment, social support etc.
Coordination, speed and balance reduced
Often uses wheeled mobility in the community
Every person is like every other person, like some other person, and like no other person.
It’s really important that people who are new to exercise learn how to monitor and describe how they are feeling or their response to exercise. One helpful way to do this is to introduce the Rate of Perceived Exertion (RPE) scale. The smiley face RPE Scale or the OMNI scale (see below for examples of both) may be more suitable for participants with various disabilities than the age-predicted maximal heart rate (220 – age) (Stanish & Aucoin, 2007).
In the beginning, it is also recommended that participants measure their heart rate (using wearable technology such as a heart rate monitor may make this easier!). This information will help the trainer and participant to work together to learn about how the participant perceives their exertion during exercise and may help to inform programming strategies. For example, a trainer may encourage the participant to work towards a specific level of RPE, which can be complemented with information from the HR monitor to measure exercise intensity. Monitoring HR may also be useful in the event that participants are exercising at a level beyond the recommended intensity, which may happen if the participant is very engaged in the activity or trying to make a positive impression on the trainer.
Smiley Face Relative Perceived Exertion Scale
Individuals with CP will most likely be taking regular medications. Similar to the variability you will find across individuals, you will find that different people are taking different medications to manage secondary impairments and limitations (e.g., antispasmodics to help manage spasticity). It is recommended that you talk about this during the consultation to see if there are any side effects that you should be aware of. You may also want to check in with them each time they come in to work out to see if there are any changes or any new information that you should know. It is also important to ensure the individual has the go ahead from their health care provider prior to beginning a new exercise program. You can read about specific medications in (ACSM)
The tips and strategies found within the inclusive TIMES section will help you to create an environment that will support your participant’s participation in physical activity as independently as possible. It is important that you involve the participant whenever possible, along the way to ensure the program that you design will meet their needs physically, as well as emotionally and socially. Introducing a few simple strategies such as offering visual images of the participant’s program will help them to be more independent in completing their fitness programme. Ultimately, they will gain confidence and belief in their abilities (increasing self-efficacy) and experience self-determination (sense of control over their own destiny). This is key to establishing healthy habits that will be adopted for the long term.
Copyright © 2020 by UNESCO Chair , Institute of Technology Tralee
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UFIT c/o, UNESCO Chair, Institute of Technology Tralee, Tralee, Co Kerry. Ireland
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