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

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Presentation on theme: "The Effects of Strengthening Exercises in Patients with Neurological Dysfunction PT 224 March 10, 2010 Daniel Maclean, Josh Mitchell, Jennifer Jones, Alyssia."— Presentation transcript:

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 Trunk (not measured) Unnithan et al LE  Hip, Knee, Ankle Dodd et al. 2003* Unnithan et al Nyström Eek et al Salem Y et al Scholtes et al 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 Dodd et al Lee et al Nyström Eek et al Scholtes VA et al 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  Nyström Eek et al  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 Nyström Eek et al 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 Training University of South Carolina 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 Jul 15-30;28(13-14): 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 Mar 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 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 Nov 3;73(18): 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 Apr;30(4): 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 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: 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 Sep;30(3): 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 Nov 3;73(18): 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 Jan 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): Fowler, Eileen G, Ho, Teresa W, Nwigwe, Azuka I, Dorey, Fredrick J The Effect of Quadriceps Femoris Muscle Strengthening Exercises on Spasticity in Children With Cerebral Palsy Phys Ther : 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; 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; 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; 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); 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; 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: 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: 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); 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 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– 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 Mar 30(1): 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 Jan;40(1): Sharp SA, Brouwer BJ Isokinetic strength training of the hemiparetic knee: effects on function and spasticity. Archives of Physical Medicine & Rehabilitation (11): Fowler, Eileen G, Ho, Teresa W, Nwigwe, Azuka I, Dorey, Fredrick J The Effect of Quadriceps Femoris Muscle Strengthening Exercises on Spasticity in Children With Cerebral Palsy Phys Ther : 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): 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 : 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 (13-14): Morris S.L., Dodd K.J., Morris M.E. Outcomes of progressive resistance strength training following stroke: a systematic review Clinical Rehabilitation 18: The Effects of Strengthening Exercises in Patients with Neurological Dysfunction (2010)


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