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Appendix A: Strength Exercises
for People with Cerebral Palsy (Bundonis,
2007)
SPINAL EXTENSORS
Weakness: Spinal
extensors, especially thoracic extensors,
are generally weak. This weakness presents
as difficulty moving against gravity
and maintaining optimal posture and
alignment. There is often an overuse
of flexors, such as pectorals, that
limit activation of the antagonist extensors.
Exercise: To work
the spinal extensors, active prone extension
is key. The child will lie prone and
then will lift his or her upper body
and legs off the surface (flying like
Superman), and hold for up to 30 seconds.
This exercise can be progressed by extending
the arms overhead or leaning over the
edge of the table and extending beyond
the height of the table. Thoracic extensors
(middle and lower trapezius and rhomboids)
can also be exercised seated for children
who cannot tolerate prone by elevating
arms above head and extending back.
Fun ways to exercise:
• Doing prone activities on a
scooter, sling swing, or platform swing
to push off a wall, reach, and knock
down objects;
• Wheelbarrow walking; or
• Swimming with support under
the belly in a pool.
ABDOMINALS
Weakness: Abdominal
weakness presents with shallow breathing,
a flared rib cage, and difficulty maintaining
optimal posture and alignment with movement.
Children often have a poor connection
between their upper and lower body,
and have difficulty flexing against
gravity.
Exercise: Abdominals
are composed of the rectus and transverse
abdominis, and the internal and external
obliques. Core exercises that engage
all the abdominal muscles are key. Sit-ups
are the most-often-thought-about abdominal
exercise. To engage the rectus abdominis,
the child needs to lift his or her head
and shoulder off the surface; the obliques
can be added with rotational movements.
Challenging a child's trunk control
can be done with numerous exercises
besides the typical sit-up or curl-up.
Rotation exercises in sitting, in which
the child rotates his or her trunk while
holding a ball or bar with both hands,
can be done. Progress by adding weight
through a medicine ball or cuff weight
attached to the bar, or by adding varying
angles of flexion and extension with
rotation. In supine, lifting and lowering
the legs off the surface works the lower
abdominals.
Fun ways to exercise:
• Playing catch with a medicine
ball, and moving the location of where
to throw and the level from which the
ball is thrown;
• Hanging from a swinging bar
and lifting legs to knock over objects;
or
• Rolling or crawling up and down
inclines.
HIP EXTENSORS
Weakness: Hip extensors
are usually weak in all positions in
children with neuromotor dysfunction.
Gluteals are elongated during infancy
through physiological flexion and do
not become effectively activated for
functional use and strengthening.
Exercise: Many children
have a difficult time activating their
hip extensors through a full range of
motion. Often, the exercise begins with
active assistance and looking for improving
muscle contraction. Bridges, in which
the child is hooklying and pushes through
his or her feet to lift his or her buttocks
off the surface, are a simple exercise
to engage the hip extensors. This exercise
can be progressed to being performed
single legged. Hip extension can also
be performed in quadruped or prone,
lying with the hip extended through
the available range of motion. Partial
squats are great for overall lower-extremity
strengthening. A squat motion while
the back is leaning against the wall
(wall slides) is easier to perform than
a squat. Or, a child can perform a stand-to-sit
movement but rise just prior to sitting.
Backward walking is also a wonderful
functional strengthening exercise, and
it can be progressed by adding resistance
with elastic tubing around the trunk
or on inclines.
Gait training on a treadmill can also
offer strength training for children
with weakness against gravity. The treadmill's
movement facilitates hip extension and
can offer movement through greater ranges
of motion.
Fun ways to exercise:
• Backward kicking to knock over
objects;
• Climbing activities on stairs
and obstacles;
• Kicking and splashing water
in prone in a pool or tub; or
• Backward walking through an
obstacle course.
HIP FLEXORS/QUADRICEPS
Weakness: The quadriceps
are two joint muscles that extend the
knee and also flex the hip. The quadriceps
are generally very weak against gravity
and in weight-bearing. Many children
have hamstring spasticity that limits
their available range of motion for
quadriceps training. The quadriceps
are often very weak in terminal knee
extension. Hip flexors (iliopsoas and
quadriceps) are generally shortened
and work with other flexors, and they
are often not considered weak muscles.
But they are very weak when isolated;
and this can greatly affect their function,
including during step length and stair
climbing.
Exercise: Movements
to work the quadriceps in weight-bearing
(closed-chain exercises) can include
step-ups, partial squats, sit to stand,
and leg presses. Open-chain exercises
include seated knee extensions (long-arc
quads), supine straight-leg raises,
or end-range knee extensions with a
small ball or roll under knee (short
arc quad).
Fun ways to exercise:
• Kicking a ball or balloon while
sitting;
• Seated pushing a scooter or
rolling chair backward;
• Using a bicycling or stepping
machine; or
• Pumping legs on a swing.
DORSIFLEXORS
Weakness: Dorsiflexors
are often elongated and weak due to
increased plantarflexor activity. Usually,
the anterior tibilias is inactive or
too weak to counteract plantarflexor
tone, which limits heel contact during
gait.
Exercise: Dorsiflexion
can be worked in sitting or supine easily
with resistance added manually or with
elastic tubing. A subtle way to work
dorsiflexion is weight shifting with
feet flat in all directions and progressing
to performing on a balance board. Heel
walking is also a challenging way to
work dorsiflexion.
Fun ways to exercise:
• Tapping the foot to play music
on a mat piano or shaking bells;
• Drawing in shaving cream with
the feet; or
• Hitting switches with the feet.
PLANTARFLEXORS
Weakness: Plantarflexors
are usually shortened but weak when
attempts are made to use them through
their full range. It is often surprising
to see that children who do not get
heel contact during gait cannot plantarflex
actively. Strengthening plantarflexors
during gait can help with push-off,
balance, and control during gait and
stance.
Exercise: Plantarflexors
should be worked through their entire
available range of motion. In standing,
this can be done with heel raises. This
can be progressed to heel raises with
the heel off a step or holding weights.
Plantarflexion can also be performed
in sitting and supine with manual resistance
to elastic tubing to progress.
Fun ways to exercise:
• Similar activities to dorsiflexion
but focusing on the opposite direction.
HIP ABDUCTORS AND ADDUCTORS
Weakness: Proximal
hip control and weakness are often seen
in children with cerebral palsy. The
hip adductors are often spastic and
tight, limiting the active control the
abductors can attain. Strengthening
the hip abductors can improve stability
and gait patterns.
Exercise: To work
the hip abductors, sidelying hip-abduction
exercises are simple and can be begun
with active assistance. Also, in hooklying,
a child can abduct and adduct his or
her legs (butterfly motion). To progress
this motion, resistance can be added
manually or by having a child squeeze
a ball or balloon to more work adduction.
In weight-bearing, hip abduction and
adduction can be worked with sidestepping
exercises or lateral step-ups.
Fun ways to exercise:
• Karate kicks at a bolster;
• Relay races while holding a
balloon or small ball between the legs;
or
• Sidestepping on a balance beam.
SCAPULAR STABILIZERS
Weakness: In many
children with neuromotor dysfunction
the scapular stabilizers are generally
weak and present with significant scapular
winging during arm movements. The scapular
stabilizers are weak because of tightness
and overactivity in the pectorals and
the latissimus dorsi. This weakness
limits weight-bearing on extended arms
and efficient upper-extremity tasks.
Exercises: The best
exercises to work scapular stabilization
are in weight-bearing on upper extremities.
When the child is exercising, it is
important to encourage or look for improvements
in how the scapula moves smoothly along
the thoracic wall. Often, the scapula
will follow arm movements with a poor
stable connection to the trunk.
Wheelbarrow walking, in which the
therapist holds the child's feet and
the child walks on their arms, is a
great exercise. This can be made less
challenging by decreasing the arm level
and holding the child higher on the
legs or trunk as needed. The child also
can perform scapular-protraction exercises
in supine with his or her arms straight
or while punching the straight arm up
toward the ceiling. Resistance can be
added by holding weights, a medicine
ball, or a wand with a cuff weight.
Fun ways to exercise:
• Rolling over a bolster on extended
arms to pick up objects;
• Having a big ball war: Two children,
or a child and a therapist, on either
side of a ball pushes into the ball
to see who can move the other past a
line (similar to tug of war);
• Pushing with arms on a scooter
or swinging in prone; or
• Playing and reaching activities
in a side-sit position, in which the
child is weight-bearing on one arm and
weight shifting over that arm at the
same time (Bundonis, 2007).
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