Cerebral Palsy Research Network Blog

Exercise and physical activity in spastic diplegia – part 2

[This post is part of our Knowledge Translation/Education Tuesday series. Guest author Lily Collison, author of Spastic Diplegia–Bilateral Cerebral Palsy, continues the series. You can ask questions of the author on the MyCP Forum].

Thankfully, with our lockdown here in Ireland COVID case numbers are decreasing. The 5km restriction here means that both my photo and I have to stay local! The photo this week is of an old mooring buoy for ships (dating from 1908) that sits forlorn on the headland.

Last week I looked at exercise and physical activity in children and adolescents with cerebral palsy (CP) but what about in adulthood? Consistently strong evidence demonstrates that people with CP participate in less physical activity and spend more time engaged in sedentary behavior than their able-bodied peers throughout the life span [1]. Studies have shown that:

  • Adults with CP who reported preserved mobility throughout adulthood attributed it to regular physical activity, participation, and maintenance of strength, balance, and overall fitness [2].
  • Adults with CP who engaged in regular physical activity were at lower risk of decline in mobility. Deterioration in gait was strongly associated with inactivity [3].
  • “What are the best long term exercise/strength training strategies to improve activity, participation and health, minimize pain, and maximize function in each GMFCS category across the lifespan?” was the number one research topic identified in a collaboration between stakeholders, to set a patient-centered research agenda for CP (Research CP) [4].

The World Health Organization (WHO) notes that participating in regular physical activity reduces the risk of many health conditions, including coronary heart disease and stroke, diabetes, hypertension, colon cancer, breast cancer, and depression. Additionally, physical activity is a key determinant of energy expenditure and thus is fundamental to energy balance and weight control [5].

Verschuren and colleagues (2016) published a set of exercise and physical activity recommendations for people with CP under the following headings [6]:

  • Cardiorespiratory (aerobic) exercise
  • Resistance (muscle strengthening) exercise
  • Daily moderate to vigorous physical activity
  • Avoiding sedentary behavior (i.e., not being physically inactive)

The following table details their recommendations. Note that these are lifetime recommendations; it may take at least eight to 16 consecutive weeks of exercise to see the benefit. Their recommendations are similar to (and based on) the WHO’s guidelines for able-bodied people [5]. Though these recommendations are relatively recent, the concept that “exercise is medicine” is not new [7].

Verschuren and colleagues (2016)Verschuren and colleagues (2016)My notes
Type of exercise/physical activityRecommendations for people with CP 
Cardiorespiratory (aerobic) exercise➡3 times per week
➡> 60% of peak heart rate*
➡Minimum time of 20 min per session
➡Regular, purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature
This is the type of exercise that gets the heart pumping and the lungs working.
Resistance (muscle strengthening) exercise2–4 times per week on non-consecutive daysMuscle strengthening is especially important for people with spastic diplegia because muscle weakness is a feature of the condition. It is important for all muscles but particularly the antigravity muscles: the hip extensors (gluteus maximus) and the ankle plantar flexors (gastrocnemius and soleus). Other muscles to be considered include the hip abductors, the ankle dorsiflexors, the core muscles, and the upper limb muscles, if there is upper limb involvement.
Daily moderate to vigorous physical activity60 minutes ≥ 5 days per weekThis is the ordinary movement we do in our everyday lives. Physical activity counts as long as it is moderate to vigorous. It is less taxing than cardiorespiratory exercise but is more vigorous than gentle movement. Walking, going up stairs, and household chores are all included in this category.
Avoiding sedentary behavior (not being physically inactive)Sit for less than 2 hours/day or break up sitting for 2 minutes every 30–60 minutesOne can be physically active but still sedentary; they are separately measured. For example, if the person meets the recommendation for moderate to vigorous physical activity but sits for long periods watching TV or playing computer games, then they are physically active but sedentary. Prolonged sitting in one position, particularly with bad posture, is not good for any person, but it is particularly ill-advised in spastic diplegia.
*Peak heart rate can be approximated as 220 minus age. For example, at age 15, peak heart rate is 205 (220 –15). 60 percent of peak heart rate is approximately 120 beats/minute (205 x 0.6).

Note that there is no lower (or upper) age limit on the exercise and physical activity recommendations for people with CP. There is no denying these recommendations are very high. However, research has found that typically developing infants can take up to 9,000 steps in a given day and travel the equivalent of 29 football fields [8]. It is important to be aware of the recommendations and aim to meet them as much as possible. And remember, any activity is better than no activity.