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Strength training of the arm

Last update: 9 Jun 2016

Strength training of the arm can improve the ability of people with cerebral palsy to do everyday activities that use the shoulder, arm and hand
To maintain their strength, people need to continue their own training after therapy has finished
Exercise programs should be designed by an experienced health professional.

Who is it for?

Arm strength 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, Triplegia, 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

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

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

To be safe and effective, strength training of the arm needs to be introduced and monitored by an experienced professional. Anyone undertaking a new exercise program, especially people with special medical or physical needs associated with their cerebral palsy, should consult with an exercise or health professional.

It is important to remember that extra care in planning and monitoring a strength training program may be required for some people. Cerebral Palsy Alliance offers a service where our exercise physiologists, occupational therapists and physiotherapists can help a person with cerebral palsy and their family decide if this intervention is a good choice for them.

Find a Cerebral Palsy Alliance service

Fees will apply for occupational therapy, physiotherapy or exercise physiology assessment and monitoring, 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.

Equipment for strength training for the arm can vary in expense. Some strength training activities are reasonably inexpensive, such as hand held weights. Access to specialised equipment and the opportunity to work with professionals in a gym involves a more substantial outlay, with prices varying between AUD$10 to $25 per week.

Ask the provider 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 a person to increase their arm strength, they will need to train two to four times a week for a minimum of eight weeks. They will also need rest days in between.

Each training session should last for a minimum of 20 to 30 minutes1. During the sessions, they should complete one to three sets of six to 15 repetitions of each exercise.

More about strength training of the arm

For people living with cerebral palsy, muscle weakness of the shoulder, arm and hand has long been recognised as a contributor to difficulties people face completing everyday activities2 such as dressing, using cutlery, throwing and catching balls, and pushing one’s own wheelchair. Strength training is often recommended by exercise physiologists, occupational therapists and physiotherapists as a way to increase muscle strength and improve a person’s ability to complete these everyday activities.

The resistance, number of repetitions and how resistance and repetitions are progressed will be tailored to each individual according to established strength training principles3,4.

It has been found that strength gains achieved in a program of at least eight weeks will be lost approximately six weeks after training is discontinued1. Therefore, for the person’s strength gains to be maintained beyond the program, the client will need to continue their strength training through a maintenance program.

Muscle weakness is a well-known challenge associated with cerebral palsy. It is common for muscle weakness to co-exist with spasticity and involuntary muscle movements (dyskinesia).
  • Progressive resistance training - people with cerebral palsy who are undertaking strength training learn a technique called progressive resistance training1. This technique involves using exercises that are made progressively more difficult through an increase in the amount of weight or the resistance. The exercises can be completed in a gym or other exercise environment and often uses pieces of equipment such as handheld dumbbells, arm weights and gym machines.
  • Functional strength training - one commonly used form of progressive resistance training is called functional strength training5. It involves doing everyday functional activities while the amount of resistance increases. Examples of this method include repetitively throwing and catching weighted balls, or moving around in a self-propelling wheelchair to help increase arm strength.

Organisations that are recognised for their expertise in this field3,4 have set out guidelines for safe and effective3,4,6 progressive strength training programs. These guidelines include recommendations for how much resistance, or what load, the strengthening exercises should provide; how many times an exercise should be repeated in a session; and how many times each week strengthening sessions should be carried out. These organisations also recommend that progressive resistance training is most appropriate for children over seven-years-old, as well as adolescents and adults.

Assessments

There are two types of assessments a person should undertake as part of strength training:

Before a person begins training, it is really important for an experienced professional to carry out a thorough assessment to identify their goals for therapy and ensure exercises are suitable for their ability level. Often the specialist will measure the maximum amount the person can lift or their hand can squeeze (called one repetition max). They will then focus the person’s strength training on increasing the repetition max.

The second type of assessment is to measure whether the person’s strength training program is meeting their needs and goals. The professional, together with the person with cerebral palsy and their family will decide on the most suitable assessments to use. Common assessments to measure the outcome of arm strength training programs include:

  • Goal Attainment Scaling (GAS goals) – measures the extent to which the person’s goals are being achieved
  • Measures of muscle strength – this will be done using a device that measures force and power, such as a hand held dynamometry. A range of other methods are also available to measure the amount of weight a person can lift.

Best available research evidence

We searched the medical and allied health literature to find research evaluating the outcomes of using arm strengthening to help children and adults with cerebral palsy.
The search aimed to find the best available research as to whether strengthening, as part of a training program, or embedded in functional activities could improve a person’s arm strength or their ability to complete daily activities.

For children and adolescents with cerebral palsy. We found one critical review of all levels of evidence which summarised the existing literature on strengthening for children and adolescents7. Rameckers’ review7 of studies evaluating arm strength training in children and adolescents included six small studies ranging from case studies to randomised controlled trials with between one and 30 participants. The intensity of training in the studies was lower than recommended levels. The quality of evidence is considered very low because the studies were mostly low level and used different methods of strength training, and at different intensities.

For adults with cerebral palsy. Two small studies evaluating arm strength training for adults with cerebral palsy were found. As these studies were both small and low level (Level 38 and Level 49) and there was inconsistency in the participants in the studies and outcome measures used, these studies are considered to provide very low quality evidence on the benefits of strength training. People participating in these studies had a range of types and severity of cerebral palsy, including a number with severe physical disability and mild to moderate intellectual disability. The arm strength training program appeared to be at recommended levels of intensity.

Overall, the evidence suggests that strength training may help increase arm strength for children, adolescents and adults with cerebral palsy. It is not clear, however, whether it helps people with cerebral palsy to use their arms more effectively in everyday activities. People with cerebral palsy and their families who are interested in arm strengthening are advised to partner with an appropriate professional to discuss their goals, and identify the appropriate muscle groups they need to exercise. The gains made during strength training are likely to be lost once the program ends, so individuals, families and professionals will need to consider strategies for maintaining their strength afterwards.

Strength training increases arm strength for children and adolescents

Each of the studies included in Rameckers’ review7 concluded that the arm strength of participants increased. Few of the studies evaluated whether the benefits of strengthening persisted once children stopped their training. In the studies that did, the results were inconclusive as to whether results achieved through training were retained afterwards.

Effect on functional outcomes for children and adolescents is unclear

Evidence for the effects of arm strengthening on the ability of children and adolescents to use their arms for daily activities was unclear7. Few studies focused on strengthening muscles of the shoulder and those required for grip strength. Further research is needed to identify if including such muscles in a strength training program may change a child’s ability to use their arms in daily activities.

None of the studies achieved the intensities of strength training recommended by the expert organisations3,4. Strength training at higher intensities (that is, higher loads or weight) may achieve better outcomes.

Most studies included children with spastic hemiparesis so it is difficult to say if the results would be relevant to other groups of children and adolescents with cerebral palsy.

Strength training increases arm strength for adults with cerebral palsy

In the studies of adults, arm strength of participants increased immediately after the intervention but was not sustained when assessed 10 weeks after training ended7.

Strength training may increase hand and arm function, but it is not clear if the ability of adults to use their arm for daily activities improves

One of the studies8 provided very low quality evidence suggesting that while participants improved on tests of hand function, there was no change in their ability to complete everyday activities such as dressing and feeding.

Date of literature searches: October 2015

  1. American Academy of Pediatrics Council on Sports Medicine and Fitness. (2008). Strength training by children and adolescents. Pediatrics, 121(4), 835-840. doi: 10.1542/peds.2007-3790. See abstract
  2. Moreau, N. G., & Gannotti, M. E. (2015). Addressing muscle performance impairments in cerebral palsy: Implications for upper extremity resistance training. Journal of Hand Therapy, 28(2), 91-100. See abstract
  3. Faigenbaum, A. D., Kraemer, W. J., Blimkie, C. J., Jeffreys, I., Micheli, L. J., Nitka, M., & Rowland, T. W. (2009). Youth resistance training: Updated position statement paper from the national strength and conditioning association. Journal of Strength and Conditioning Research, 23(Suppl 5), S60-79. doi: 10.1519/JSC.0b013e31819df407
  4. Lloyd, R.S., et al. (2013). Position statement on youth resistance training: the 2014 International Consensus. British Journal of Sports Medicine, 48,498-505. See abstract
  5. Rameckers, E. A., Speth, L. A., Duysens, J., Vles, J. S., & Smits-Engelsman, B. C. (2009). Botulinum toxin-A in children with congenital spastic hemiplegia does not improve upper extremity motor-related function over rehabilitation alone: A randomized controlled trial. Neurorehabilitation and Neural Repair, 23(3), 218-225. doi: 10.1177/1545968308326629. See abstract
  6. Verschuren, O., Ada, L., Maltais, D. B., Gorter, J. W., Scianni, A., & Ketelaar, M. (2011). Muscle strengthening in children and adolescents with spastic cerebral palsy: Considerations for future resistance training protocols. Physical Therapy, 91(7), 1130-1139. doi: 10.2522/ptj.20100356
  7. Rameckers, E. A. A., Janssen-Potten, Y. J. M., Essers, I. M. M., & Smeets, R. J. E. M. (2015). Efficacy of upper limb strengthening in children with cerebral palsy: A critical review. Research in Developmental Disabilities, 36, 87-101. See abstract
  8. Hutzler, Y., Rodríguez, B. L., Laiz, N. M., Díez, I., & Barak, S. (2013). The effects of an exercise training program on hand and wrist strength, and function, and activities of daily living, in adults with severe cerebral palsy. Research in Developmental Disabilities, 34(12), 4343-4354. See abstract
  9. Taylor, N. F., Dodd, K. J., & Larkin, H. (2004). Adults with cerebral palsy benefit from participating in a strength training programme at a community gymnasium. Disability & Rehabilitation, 26(19), 1128-1134. See abstract
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.