Fitness training

Last update: 12 Jan 2017

Fitness training can help children, adolescents and adults with cerebral palsy improve and maintain their health and wellbeing
Daily vigorous activity is recommended for children and adolescents
Individuals are encouraged to talk about their physical activity and exercise program with their health professionals
Experts recommend reducing sedentary (inactive) behaviour to prevent and manage lifestyle related diseases

Who is it for?

Fitness training may be suitable for children and adults with cerebral palsy who have the following characteristics:
Type of cerebral palsy : Bilateral cerebral palsy, Diplegia, Hemiplegia, Quadriplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.

Mobility : GMFCS I, GMFCS II, GMFCS III, GMFCS IV, GMFCS V

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

See full glossary

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

See full glossary

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

See full glossary

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

See full glossary

Fitness training can be accomplished with or without specialised fitness professionals, depending on the trainee’s knowledge and motivation. Exercise professionals, however, will tailor a fitness program to an individual’s abilities and goals. They will also will focus on the person’s motivation to persist and will supervise incremental changes to the exercise program. If working with an exercise professional it is important to ensure they are suitably qualified.

Cerebral Palsy Alliance offers a range of services where our exercise physiologists and personal trainers work with people who wish to reduce sedentary (inactive) behaviour and improve their fitness.

Find a Cerebral Palsy Alliance service

Fees will apply for trained fitness and exercise professionals, and will depend on the provider and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or provider travel.

Fitness training can vary in expense. Some fitness activities are free, require no equipment and at times no specialist prescription. These include home and community-based exercises such as walking and running, interval training like sprint relays, and body-weight resisted exercises including sit ups and squats. Other exercises such as swimming and cycling may require small fees. There is a wide range of exercise equipment available to buy, including handheld weights, boxing equipment and treadmills.

Gym memberships can be a significant outlay, with prices varying between AUD$10 to $25 per week, but provides access to specialised equipment and the opportunity to work with fitness professionals in both group and one-on-one sessions. One-on-one service may involve an additional fee, depending on the facility.

Ask health and fitness providers if you are eligible for funding to assist with fees. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

For children and adolescents aged 5 to 17 years, and for adults, a mix of moderate and vigorous activity completed every day is recommended to enhance health and fitness. Further details in the Recommendations section below.

More about fitness training

Fitness training is structured physical activity which uses more energy and is more intense than daily living. It aims to improve or maintain a person’s physical fitness level1.

Fitness activities include walking, swimming, hydrotherapy, cycling, dance, gymnastics, martial arts, and team sports such as soccer and basketball.

Three areas of fitness are important for people of all ages – with, and without cerebral palsy1:

  • Aerobic fitness - the ability of the body to work for prolonged periods of time using oxygen as fuel. Aerobic activities include walking, running and swimming
  • Anaerobic fitness - the ability of the body to complete more strenuous activities that are much shorter in duration, i.e. less than 15 seconds. These are the main forms of activity for children and include climbing stairs and games such as hide and seek and tag
  • Muscle strength – improving muscle strength and endurance can assist with walking2, pushing one’s own wheelchair, and improving the efficiency of other exercises. Maintaining muscle strength may help with sustaining ability to function in everyday life3. Muscle strengthening exercises include lifting weights and resistance training.
Sedentary behaviours are long periods spent sitting or lying such as when watching TV, sitting at a computer and reading. They are linked to poor health and lifestyle related diseases including obesity, diabetes and cardiovascular disease. People with cerebral palsy who have difficulty moving are likely to be more sedentary than others3. It is important to make opportunities to move every day in order to reduce sedentary behaviours regardless of whether a person with cerebral palsy uses a walking device (such as a walking frame or crutches), a wheelchair or can walk.

Guidelines for healthy living

People with cerebral palsy of all ages and all GMFCS levels can enhance their health and well-being by increasing their fitness levels and reducing sedentary behaviours.

Generally, people who avoid physical activity or have high levels of sedentary behaviours are at an increased risk of developing cardiovascular disease and other chronic health conditions4. The Australian Physical Activity Guidelines4 recommend that young people aged five to 17 years should do at least 60 minutes of moderate to vigorous physical activity every day and also do activities that strengthen their muscles and bones at least three days per week. For adults (18 to 64 years), the minimum requirement is two sessions of muscle strengthening activities per week plus 2½ to 5 hours of moderate to high intensity physical activity per week.

The increased levels of fitness developed through training programs will only be maintained if training continues. A regular increase in the intensity of fitness activities is also required.

Take a team approach

There are many kinds of fitness training and the types used will depend on the person’s age, family situation, health and mobility. There are a multitude of exercise and activity options for all individuals with cerebral palsy regardless of level of severity and physical disability. The important thing is finding the right approach for the individual. The best way to do this is to consult with an exercise physiologist or other suitably qualified health professional.

Individuals are advised to notify appropriate medical or allied health staff if there is any concern regarding participation in exercise5 or any changes in mobility status, pain or function associated with exercise. Individuals are also advised to notify other health professionals involved in their care that they are undertaking an exercise program.

Screening for cardiovascular risk by an exercise or medical professional, or through an exercise facility such as a gym is recommended for anyone undertaking a new exercise program or for people with special medical or physical needs. Extra care in planning and monitoring fitness programs will be required for these people

Assessments

There are two types of assessments which are required for people undertaking fitness training.
Exercise professionals will provide a thorough assessment of the person’s abilities, limitations and goals, to ensure training is properly targeted and safe.

The second type of assessment is used to work out whether fitness training has been effective. The exercise professional, together with the person with cerebral palsy and their family, will determine the most suitable measure to use. Fitness tests include6:

  • Six-minute walk test (or 6-minute push test) - measures the distance an individual is able to walk over six minutes on a hard, flat surface
  • Modified shuttle run test - measures performance on a 15 level scale of increasing speeds over a 10 metre course. There is a version for manual wheelchair users also – 10-metre shuttle ride test
  • Dynamometry – measures strength of individual muscle groups

Best available research evidence

The medical and allied health literature was searched to find studies evaluating the outcomes of fitness training programs for children, adolescents and adults with cerebral palsy.

The search aimed to find the best available research evidence to answer the question: Does fitness training improve the aerobic fitness, and anaerobic and strength capacities of people with cerebral palsy?

Research focussed on strength training as a standalone intervention was not included.

The best available evidence about fitness training is one good quality systematic review1 of five randomised controlled trials (RCTs) and three more recent good quality RCTs7-9, all of which were with children, adolescents or young adults with cerebral palsy. No high level research evaluating the outcomes of fitness training with older adults with cerebral palsy was located. We also located a review which made recommendations about exercise and physical activity for people with cerebral palsy based on a combination of research findings, clinical experience and expert opinion3.

Overall, moderate quality evidence from high level studies suggests fitness training is effective for increasing aerobic capacity for children, adolescents and young adults with cerebral palsy. The evidence is not conclusive for the effects of fitness training on anaerobic capacity and strength. No serious risks or burdens were identified in these studies. People with cerebral palsy whose goal is to increase aerobic fitness should liaise with exercise professionals to implement an appropriate fitness training program. There may or may not be additional benefits for anaerobic fitness and strength.

Fitness training can increase the aerobic capacity of children, adolescents and young adults

The systematic review1 and two RCTs7, 9 reported that fitness training increased aerobic capacity. These studies used different but direct measures of aerobic capacity. The RCT that did not support this finding used an indirect measure of aerobic capacity (average walking strides per day)8. Overall, greater gains are made with longer training programs and for people with cerebral palsy who are more mobile and participate in higher dosages of training3.

Results are inconclusive for increasing anaerobic capacity through fitness training

Two RCTs8,9 measured anaerobic capacity but reported conflicting results. In one study the intervention group improved by 11 per cent9. These participants had an aerobic exercise program for four months before switching to an anaerobic program for four months. The second study8 did not find an improvement in anaerobic capacity. The intervention in this study, however, was half the length of time (four months in total), and intensity was reduced for the second two months.

Results are inconclusive for increasing muscle strength through fitness training

The systematic review1 and three RCTs7-9 measured strength in children, adolescents and young adults following an exercise program. The systematic review and one RCT7 reported programs to be effective for increasing strength. Two remaining RCTs7,8 did not find an increase in strength which may have been due to a low training frequency (e.g. one session per week).

Long term fitness training is required

Each of the recent RCTs for children evaluated group based fitness training. The RCT that showed improvements in strength for the intervention group9 had an intervention period that was twice as long (eight months) as the remaining studies, suggesting that more than four months is required for improvements to occur in this population.

As in the wider population, fitness training must be ongoing to sustain results

No study that examined long term follow up found that gains achieved were maintained. This suggests that, as in studies of the general population, increases in fitness levels obtained by exercise programs will only be maintained if the exercise programs continue. Once the desired level of fitness is achieved, a lower intensity program may be sufficient to sustain the effects3.

More research needed

The research regarding fitness training has included mostly children and adolescents with cerebral palsy who are at GMFCS Levels I and II and only a small proportion at GMFCS Level III. Further research is required to identify if similar outcomes can be achieved by people at GMFCS Levels III to V.

The decision to undertake fitness training involves understanding the evidence, cost, time and resources required, and the needs and preferences of the person with cerebral palsy and the family. Reducing sedentary behaviour is also important and is recommended as a goal for all people with cerebral palsy.

Date of literature searches: October 2016

  1. Verschuren O, Ketelaar M, Takken T, Helders PJ, Gorter JW. (2008). Exercise programs for children with cerebral palsy: A systematic review of the literature. American Journal of Physical Medicine and Rehabilitation, 87, 404-17. See abstract
  2. Pouliot-Laforte A, Parent A, Ballaz L. (2014). Walking efficiency in children with cerebral palsy: Relation to muscular strength and gait parameters. Computer Methods in Biomechanics and Biomedical Engineering, 17, 104-5. See preview
  3. Verschuren, O., Peterson, M. D., Balemans, A. C., & Hurvitz, E. A. (2016). Exercise and physical activity recommendations for people with cerebral palsy. Developmental Medicine and Child Neurology, 58(8), 798-808. doi:10.1111/dmcn.13053. See abstract
  4. Australian Department of Health – Australia’s Physical Activity and Sedentary Behaviour Guidelines. Retrieved on August 7th 2014 from here
  5. American College of Sports Medicine – Health-Related Fitness for Children and Adults with Cerebral Palsy. Retrieved on august 2014 from here
  6. Verschuren, O., & Balemans, A. C. (2015). Update of the core set of exercise tests for children and adolescents with cerebral palsy. Pediatric Physical Therapy, 27(2), 187-189. doi:10.1097/PEP.0000000000000137.
  7. Slaman J, Roebroeck M, van der Slot W, et al. (2014). Can a lifestyle intervention improve physical fitness in adolescents and young adults with spastic cerebral palsy? A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 95, 1646-55. See abstract
  8. Van Wely L, Balemans AC, Becher JG, Dallmeijer AJ. (2014). Physical activity stimulation program for children with cerebral palsy did not improve physical activity: A randomised trial. Journal of Physiotherapy, 60, 40-9.
  9. Verschuren O, Ketelaar M, Gorter JW, Helders PJ, Uiterwaal CS, Takken T. (2007). Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial. Archives of Pediatric and Adolescent Medicine, 161, 1075-81. Click here to open web page and then open pdf
Find out about CP Check-Up™

Cerebral Palsy Alliance offers a service called CP Check-Up™ which provides ongoing surveillance of the health and well-being of our clients aged 0-18 years.
The information on this page was developed using the best research evidence combined with the expertise of clinicians and people with cerebral palsy and their families. It is provided to help people with cerebral palsy, their families and caregivers, clinicians and service providers make decisions about suitable interventions. This information is intended to support, but not replace, information exchanged, and decisions made, between people with cerebral palsy, their families and health professionals.