R E S E A R C H R E P O R T

Effects of Combined Exercise

Training on Functional
Performance in Children With
Cerebral Palsy: A Randomized-
Controlled Study
Punnee Peungsuwan, PhD; Pattamavadee Parasin, MSc; Wantana Siritaratiwat, PhD; Jilada Prasertnu, BSc;
Junichiro Yamauchi, PhD
Research Center in Back, Neck, Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University, Thailand
(Drs Peungsuwan, Siritaratiwat, and Yamauchi); School of Physical Therapy, Faculty of Associated Medical Sciences,
Khon Kaen University, Thailand (Drs Peungsuwan and Siritaratiwat); Physical Therapy Department, Faculty of Allied
Health Sciences, University of Phayao, Thailand (Ms Parasin); Srisangwan Khon Kaen Special School, Thailand
(Ms Prasertnu); Graduate School of Human Health Sciences, Tokyo Metropolitan University, Japan (Dr Yamauchi); and
Future Institute for Sport Sciences, Tokyo, Japan (Dr Yamauchi).

Purpose: The purpose of this study was to investigate the effects of combined exercise training on functional
performance in participants with cerebral palsy. Methods: Fifteen participants with spastic cerebral palsy were
randomly allocated into either exercise or control groups. Participants in the exercise group participated in
a combined strength and endurance training program for 70 minutes per day, 3 days per week, for 8 weeks,
whereas those in the control group did not participate in an exercise program. Study participants in both
groups continued with their regular physical therapy during the study. Results: After the 8-week training, a 6-
minute walk, 30-second sit-to-stand, 10-m walk, and Functional Reach Tests, participants in the exercise group
had significant improvement over their baseline values and were significantly higher than those in the control
group. Conclusions: Combined exercise training improved walking ability, functional lower limb strength, and
balance in participants with cerebral palsy. (Pediatr Phys Ther 2017;29:39–46) Key words: combined strength
and endurance training, exercise training intervention, flexibility, leg strength, walking ability

INTRODUCTION nonprogressive disturbances in the developing fetal or in-

Participants with cerebral palsy (CP) have a group
of disorders affecting the development of movement and
posture, causing activity limitation, that are attributed to
0898-5669/110/2901-0039
Pediatric Physical Therapy
Copyright C 2017 Wolters Kluwer Health, Inc. and Academy of
fant brain.1 Regardless of the type of CP, participants with
CP have lowered physical fitness levels because their mo-
tor impairments restrict their participation in daily phys-
ical activities.2,3 This inactivity in participants with CP
further causes a loss of neuromuscular function in phys-
ical performance, which includes decreases in muscular
strength.4 These losses of neuromuscular functions in par-

Pediatric Physical Therapy of the American Physical Therapy

Association
Correspondence: Punnee Peungsuwan, PhD, School of Physical Therapy,
Faculty of Associated Medical Sciences, Khon Kaen University, 123 Mit-
traphap Highway, Muang District, Khon Kaen Province 40002, Thailand
(ppunne@kku.ac.th).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000338
ticipants with CP can be prevented and improved through
exercise training. Strength training can increase muscular
strength in association with improvements of functional
activities,5-9 whereas endurance training improves aerobic
fitness in participants with CP.10,11 Both strength and en-
durance exercise training become increasingly demanding
in participants with CP. The adaptive responses in skeletal
muscle to endurance training are different and sometimes
opposite from those of strength training. For example,

Pediatric Physical Therapy Exercise Training for Children With Cerebral Palsy 39
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Unauthorized reproduction of this article is prohibited.
strength training may cause muscle fiber hypertrophy and
a decrease in both capillary density and mitochondrial vol-
ume density, whereas endurance training may cause an in-
crease in capillary density, mitochondrial volume density,
and oxidative enzyme activity. Concurrent endurance and
strength training may result in an antagonism of the train-
ing response.12 This antagonism of concurrent strength
and endurance training may rely on training design vari-
ables and the interaction of these variables, including the
training status of the trainees and the training modes.13-15
Accordingly, appropriate training programs play a role in
developing specific motor abilities. Exercise training pro-
grams should be closely related to the functional activi-
ties of daily living such as a knee-hip extension exercise
(squat).16 Because many of our daily living activities re-
quire muscle strength and aerobic endurance, a functional
exercise program with combined strength and endurance
training should be a better way to improve physical func-
tion for participants with CP. The literature supports in-
cluding both strength and endurance training exercises for
participants and with cerebral palsy.17 Therefore, a concur-
rent lower-body strength and endurance training may be
an effective way to enhance both lower-body strength in
neuromuscular learning and cardiorespiratory functions,
consequently improving motor function and health-related
quality of life (HRQOL) scores. It is important to under-
stand how exercise training combined with strength and
endurance exercises in participants with CP affects muscle
functions that relate to daily activity; however, no studies
have shown the effects of a functionally related combined
strength and endurance exercise program on functional
performance in participants with CP. The aim of this study
was to investigate the effect of a functionally related com-
bined strength and endurance exercise program on walk-
ing ability, lower limb strength, balance, and flexibility in
participants with CP. We hypothesized that a combined
strength and endurance exercise program would have a
positive effect on muscle functions that are related to daily
activities for participants with CP.
METHODS
Study Design
A randomized controlled trial was conducted at a spe-
cial education school for participants with disabilities. The
local ethics committee for human research approved the
study. Participants with CP were randomly allocated into
an exercise group (EX) or a control group (CON) by com-
puter. They were stratified according to sex, age, and the
Gross Motor Function Classification System (GMFCS) lev-
els (I to III). The 2 examiners were masked to the groups
when performing assessments and data analysis. Assess-
ments were performed at baseline and after the 8-week
training program.
Participants
Thirty participants and, who could walk with either
hemiplegic or diplegic CP, with GMFCS levels from I to
40 Peungsuwan et al
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III, were enrolled in and screened for this study. Eighteen
participants with CP aged 7 to 16 years met the inclusion
criteria. The inclusion criteria were the ability to perform
the exercise training program and outcome tests and to
understand verbal instructions. The exclusion criteria in-
cluded receiving botulinum toxin injections or surgical
procedures for spasticity treatment within the 3 months
prior to the intervention, including serious medical condi-
tions in which a physician suggested that exercise was
contraindicated; performing other exercise programs
within the previous 4 months; and having muscle con-
tractures that limited movements of the lower limbs. Par-
ticipants were screened for these criteria using passive
movements and pretesting of each test criterion. Three par-
ticipants were excluded from the study. One participant re-
fused to enter the program because he had to go home after
school, and 2 participants could not perform the exercises
because they were unwilling or unable. Fifteen participants
with hemiplegic or diplegic CP completed the study, which
included CON (n = 7) and EX (n = 8) groups. Most of the
participants resided at the boarding school. Demographics
and classification of participants, baseline age (CON, 13 ±
4.16; EX, 13.5 ± 3.3 years), height (CON, 1.39 ± 0.15;
EX, 1.38 ± 0.16 m), and body mass (CON, 36.29 ± 12.99;
EX, 37.63 ± 11.07 kg), which were not significantly dif-
ferent between groups (P > .05), are shown in Table 1.
There were 2 participants with hemiplegia in each group,
and 5 and 6 participants with diplegia in the CON and EX
groups, respectively. There were 2, 4, and 1 participants
at GMFCS levels I, II, and III, respectively, included in the
CON group, and 2, 4, and 2 participants in the EX group,
respectively. Most of the participants had spastic diplegia
and were classified as GMFCS-E&R level II and III. Three
participants were without aids in each group and 4 and 5
participants with aids in the CON and EX groups, respec-
tively. Figure 1 is a flow chart of participants through the
trial and data analysis. One participant was lost to follow-
up at the final testing of outcomes. Data were analyzed us-
ing the principle of intention to treat. Missing data were re-
placed using the last observation carried forward method.18
Details of the testing procedure and parental consent forms
were explained to the parents or guardians prior to the on-
set of the study, and informed consent was obtained from
all participants and their parents or guardians.
Procedures
The EX group received a functional exercise program
that included a combined strength and endurance train-
ing program for 8 weeks, whereas the CON group did not
receive this exercise program. EX participants trained af-
ter school classes. The exercise training program consisted
of functional strength and endurance training, which was
designed by pediatric physical therapists as a group cir-
cuit. A functionally based exercise program was performed
using simple equipment including leg stationary bicycles
and elliptical machines (Figure 2). Prior to exercise, the
participants had warm-up and cool-down periods with
Pediatric Physical Therapy
 TABLE 1
Demographics and Classification of Participants

Participant # Gender Age, y Height, m BM, kg Diagnosis GMFCS Walking Aid

Control group
1 Female 14 1.48 46 Right hemiplegia I No device
2 Male 16 1.47 42 Right hemiplegia I No device
3 Female 7 1.16 20 Diplegia II No device
4 Male 7 1.21 18.5 Diplegia II Crutches
5 Male 15 1.37 46 Diplegia II Walker
6 Male 16 1.54 50 Diplegia II Walker
7 Female 16 1.53 31.5 Diplegia III Wheel walker
Mean (SD) 13 (4.16) 1.39 (0.15) 36.29 (12.99)
Experimental group
1 Female 15 1.44 37 Right hemiplegia I No device
2 Female 16 1.59 50 Left hemiplegia I No device
3 Male 8 1.13 22 Diplegia II No device
4 Male 9 1.18 25 Diplegia II Crutches
5 Male 13 1.48 30 Diplegia II Crutches
6 Male 16 1.48 49 Diplegia II Walker
7 Female 15 1.33 48 Diplegia III Wheel walker
8 Female 16 1.44 40 Diplegia III Wheel walker
Mean (SD) 13.5 (3.3) 1.38 (0.16) 37.63 (11.07)

Abbreviations: BM, body mass; GMFCS, Gross Motor Function Classification System; SD, standard deviation.

Fig. 1. Flow chart of participants. CON, control group; EX, exper-
imental group; PT, physical therapy; ITT, intention to treat.
self-muscle stretching of the hip external rotator and ab-
ductor muscles, knee extensor and flexor muscles, and calf
muscles. The total 70-minute exercise program consisted
of a 5-minute warm-up period, 60 minutes of circuit ex-
ercises, and a 5-minute cool-down period. This 3 days per
week training program was supervised by a physical thera-
pist. Music was used to motivate participants. Both the EX
and CON groups continued their physical therapy (PT)
program for 1 session per week. A physical therapist from
a special school determined the appropriate PT program
for the participants. The PT program consisted of passive
Fig. 2. Combined strength and endurance exercise program.
Station 1, leg stationary bicycling and elliptical machine walk-
ing; Station 2, sit-to-stand; Station 3, step up-down; and Station
4, fast walking or running recreation. Participants started at any
station.
leg muscle stretching, upper limb activity in groups, sit-
ting or standing ball throwing, handiwork, and a leisurely
walk or playing for 1 hour during school hours. This phys-
ical therapist was also masked to each group. After school,
the CON group had leisure time while we monitored their
varied activities. They often had physical inactivity such as
talking and playing with each other.
Functional strength training consisted of a sit-to-stand
(STS) and a step up-down (SUD) activity. Each participant

Pediatric Physical Therapy Exercise Training for Children With Cerebral Palsy 41
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performed the standard protocols of the STS.19 For STS,
each participant sat with hip flexion at 90◦ , knee flex-
ion at 105◦ , ankle dorsiflexion at 15◦ , and feet flat on the
floor. Most participants folded their arms over the chest,
but participants who used assistive devices were permitted
to use a stall bar. They were instructed to stand up at a
comfortable speed without swinging their arms or mov-
ing their feet. Repetitions were counted each time their
legs and hips were within 15◦ of the extended position.
For SUD, participants stood in front of a step 17 cm in
height for the starting position and moved up and down at
a self-paced speed. During practice, the participants were
allowed to hold the handrail if they felt unstable. Repeti-
tions were counted when their legs returned to the starting
position. In the first week of exercise training, the partic-
ipants performed STS and SUD with free load for 8 to 10
repetitions per set, 3 to 5 sets per day, with 3 minutes’
rest between sets. They were subsequently asked to wear
a weighted vest. These weights were initially added in the
second week as 30% of body weight, and afterward the
progressive resistance was adjusted from 50% to 60% to
60% to 70% of 1-repetition maximum STS every 2 weeks.
Endurance training was performed on cycling and
stepping machines in a circuit. The 3 stations for endurance
training included (1) leg stationary bicycles, (2) elliptical
machines, and (3) recreational fast walking or running.
For leg cycling, participants initially sat on the saddle with
a knee flexion of 30◦ to 35◦ and performed cycling with a
self-selected speed and load. For the elliptical machine, the
participants stood on the pedals, grabbed the handlebars,
and pedaled their feet while pushing the handlebars al-
ternately forward while stepping. For walking or running,
each participant was asked to walk as fast as possible, or
run in a race by picking up a ball from a basket and putting
the ball in another basket placed 20 m away. Each partici-
pant continuously exercised on the leg stationary bicycles
and elliptical machines for 15 minutes per session, and
recreational fast walking or running was performed for
10 minutes, with a 5-minute rest between stations. Total
exercise time was 40 minutes for the 3 exercise stations.
Each participant was encouraged to perform the program
to the end of the period. If the participants wanted to
rest, they could stop. During the endurance exercises, the
participants’ heart rates were maintained at 65% to 85%
of their maximum heart rate as determined with a heart
rate monitor (FT4, Polar, Kempele, Finland). Maximum
heart rate was defined as equal to 220 minus age of each
participant.
Outcome Measures
Physical performance was evaluated using the
6-minute walk test (6MWT), 30-second sit-to-stand test
(30sSTST), 10-m walk test (10mWT), Timed Up and Go
test (TUGT), and a Functional Reach Test (FRT). All out-
come measures have been shown to have high to very high
levels of test-retest reliability.17-21 To determine the consis-
tency of each measure, assessors evaluated the intratester
42 Peungsuwan et al
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reliability of variables. Outcomes were measured 1 week
before the start of the program and within a week after
the conclusion of the exercise program. All participants
wore shoes and could use walking assistive devices during
the tests if needed, and they were allowed to rest between
testing for 3 to 10 minutes, or as required. All participants
completed all outcomes.
6MWT is a measure used to assess functional car-
diorespiratory capacity.16 The test-retest reliability is very
high.20 A 40-m square course was replicated indoors. A
1-m wide walkway was designated with traffic cones and
ropes between the 4 inside and outside corners of the
course. Masking tape was placed at 2-m intervals along
the route. The patients were instructed to walk as far as
they could within 6 minutes. They were allowed to slow
down or stop as necessary, and when they had to stop for
rest, the duration of the rest period was recorded. The par-
ticipants were given encouragement to do the test when
examiners found that they did not try to walk continu-
ously. The distance walked was recorded after the test.
30sSTST is a measurement of functional lower limb
muscle strength and performance with a high test-retest
reliability.21 30sSTST measured the number of repetitions
for a sit-to-stand task within a 30-second period. Each
participant sat on a chair without a backrest or armrest
with feet flat on the ground, and hips and knees flexed
at 90◦ and 105◦ , respectively. The examiner instructed
the participant to repetitively move from the sitting to
standing position as many times as they could within a
30-second period without using arms for support. Two
participants who used walkers were allowed to use their
support tool when their hips were extended at the end
range. Repetitions of a sit-to-stand task were counted when
their hips extended beyond 75◦ from sitting to standing.
10mWT is a measure to assess walking speed. 10mWT
has a high test-retest reliability,21 and this test is correlated
with gross motor functions for participants with CP.22,23
The test was conducted on a 14-m walkway that included
2 m at the start and end points to allow for acceleration
and deceleration. Before the test, the examiner instructed,
“Please walk towards the end, at your usual speed.” When
the participant was given the cue “ready and go,” they
walked toward the end of the walkway. The examiner
started a timer when the participant’s first foot crossed
the plane of the 2-m line and stopped the timer when the
first foot crossed the plane of the 12-m line. During the
test, an examiner walked beside the participant and en-
couraged him/her to continue walking. The time to reach
the middle of the 10-m walk was recorded for walking
speed calculations.23,24
TUGT is a measure used to assess functional dynamic
balance that has good test-retest reliability.24,25 Partici-
pants sat in an adjustable-height chair with no backrest
or armrest. The height of the seat was adjusted such that
both knee and hip flexion were 90◦ while sitting with the
feet resting on the floor. None of participants wore shoes
or orthoses, and participants with level III were allowed
to use walking devices for the test. During the test, the
Pediatric Physical Therapy
participant stood up from an adjustable-height chair,
walked a distance of 3 m, turned around a mark, walked
back to the chair, and sat down again. Time was recorded
from the “go” until the participant sat down in the chair.
Each participant performed the test 3 times. The best time
was recorded in seconds.25
FRT is a clinical measure of balance developed by
Duncan et al26 that has excellent reliability.27 This study
followed standard protocol.26 FRT measures the distance
between the length of the arm and a maximal forward reach
in the standing position. Participants were instructed to
stand close to a wall (not wearing shoes or socks), but not
touching the wall, with the dominant side arm position
set at the zero mark of the stick, which was placed on a
measuring stick against the wall at the height of the par-
ticipants’ acromion. The participants were asked to extend
their arms to 90◦ of shoulder flexion. The assessor recorded
the starting position at the third metacarpal head on the
yardstick and instructed the participants to “reach as far
as you can forward without taking a step.” The location of
the third metacarpal was then recorded. The difference be-
tween the start and end positions was the reach distance.
The test was repeated 3 times with 5-second rest inter-
vals between each test, and the results were recorded and
averaged for data analysis.
Data Analysis
All data are presented as a mean (standard devia-
tion). The distribution of the data was examined with the
Shapiro-Wilk test for the assumption of normality. All data
for 6MWT, 30sSTST, 10mWT, TUGT, and FRT were nor-
mally distributed. The difference between pre- and posttest
for each outcome was analyzed with a paired t test. An anal-
ysis of covariance compared differences between adjusted
posttest means between the 2 groups; the pretest means
were used as covariates. The baseline differences of each
outcome were analyzed using an independent t test. The
individual training effect was further analyzed for the re-
lationships of magnitude of change between 6MWT and
other variables after the training using Pearson’s correla-
tion coefficient test. The power of the test was 0.8 and
the level of significance was set at P < .05. The reliabil-
ity of each tool was tested by 2 assessors using the test-
retest intraclass correlation coefficient and Bland-Altman
analyses.
RESULTS
Table 2 has the comparison outcomes within and be-
tween EX and CON. The intraclass correlation coefficients
of the intrareliability of 6MWT, 30sSTST, 10mWT, TUGT,
and FRT were 0.99, 0.97, 0.93, 0.99, and 0.75, respectively.
The baseline scores of outcome variables were not signif-
icantly different between the groups. After the 8-week in-
tervention, outcomes significantly improved in EX, except
TUGT, but outcomes did not change in CON compared
with the baseline scores. The adjusted postmean of EX
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and CON for each outcome was compared; the 6MWT,
30sSTST, 10mWT, and FRT in EX were significantly dif-
ferent in comparison with the CON means. TUGT was not
significantly different between groups. Changes in 6MWT
were positively correlated with 10mWT (r = 0.8, P < .001)
but not with 30sSTST or FRT.
DISCUSSION
This study supported positive effects of a combined
exercise training program on walking endurance (6MWT),
walking speed (10mWT), leg muscle strength (30sSTST),
and physical balance (FRT) for participants with CP.
The task-specific exercise program designed to imitate
functional mobility, such as sitting-to-standing with ex-
tra load, progressive step-up and step-down, walking and
running, resulted in improved physical performance tests.
Stationary cycling exercise improved respiratory and car-
diovascular capacity and elliptical machine exercise re-
duced muscle tightness and increased range of motion
of joints, which increases step length and speed and leg
muscle strength and physical balance. The importance
of muscle strength for participants with CP can be seen
in the direct relation between strength and motor func-
tion. Participants with stronger knee extensors can walk
faster.8 These results support previous research support-
ing improvement of muscle strength and physical fitness
and HRQOL scores in participants with CP after exercise
training.28,29
Our combined functional strength and endurance ex-
ercise program supported an increase in muscle strength
associated with improvements of functional activities sim-
ilar to the results of strength training alone.5,6,7-9 De-
spite the antagonism of concurrent training previously
described in healthy people,30 it may be possible to inte-
grate resistance and endurance training regimens for posi-
tive effects on physical performance.31,32 Increased muscle
strength after the exercise training had a positive influence
on activities of daily living in participants with CP. Many
participants with CP experience difficulty when moving
their bodies quickly or standing up from a chair. These
disabilities are predictive of falls and subsequent disabil-
ity. Increases in leg muscle strength support bodyweight
during those movements.
Appropriate exercise and regular participation in ac-
tivities are important goals for therapeutic interventions
in participants with CP, and feasibility and reproducibility
of the program are important factors in a clinical setting
and after the school day. This study had 70-min/session
durations and a frequencies of 3 sessions per week for
8 weeks, with a total of 3.5 hours per week of exercise.
The exercise sessions were supervised by a physical ther-
apist. Although the frequency, intensity, time, and type
of exercise for health and fitness benefits in participants
with CP are unknown, the design of an exercise train-
ing program could be based on the same principles as
those for the general population. The findings of this study
suggest that because a combined functional strength and
Exercise Training for Children With Cerebral Palsy 43
 44
Peungsuwan et al
TABLE 2
Outcomes Pre- and Postintervention

Comparison Between Groups (Adjusted

Comparison Within Group (Paired t Test) for Baseline Using ANCOVA)

Baseline Posttest Mean Difference Adjusted Mean Difference

Outcome Group Mean (SD) Mean (SD) (95% CI) Posttest (95% CI)

Walking endurance Experimental 292.11 (56.4) 349.50 (60.7) 57.4a (27.0 to 87.8) 351.07 53.37b
6MWT, m Control 295.84 (96.8) 299.50 (88.8) 3.67 (−5.5 to 12.8) 297.70 (22.3 to 84.4)
Walking speed Experimental 1.00 (0.2) 1.11 (0.2) 0.11a (0.04 to 0.18) 1.12 0.15b
10mWT, m/s Control 1.11 (0.2) 0.99 (0.2) − 0.05 (−0.2 to 0.1) 0.98 (0.06 to 0.24)
Leg muscle strength Experimental 8.38 (2.1) 11.13 (2.4) 2.75c (1.9 to 3.6) 11.05 2.54b
30sSTST, rep Control 8.14 (3.1) 8.43 (1.8) 0.29 (−1.3 to 1.9) 8.51 (1.15 to 3.93)
Balance Experimental 10.1 (3.1) 9.5 (3.9) − 0.62 (−2.5 to 1.3) 10.13 −0.87
TUGT, s Control 11.6 (3.0) 11.7 (3.4) 0.12 (−2.2 to 2.4) 10.99 (−3.7 to 2.0)
Balance Experimental 7.1 (1.88) 8.9 (2.7) 1.8a (0.54 to 3.1) 8.96 1.74d
FRT, cm Control 7.2 (1.8) 7.3 (2.0) 0.10 (−0.52 to 0.72) 7.23 (0.35 to 3.12)

Abbreviations: 6MWT, 6-minute walk test; 30sSTST, 30-second sit-to-stand test; 10mWT, 10-m walk test; ANCOVA, analysis of covariance; CI, confidence interval; FRT, Functional Reach Test; TUGT,
Timed Up and Go test; SD, standard deviation.
a P < .05 as compared with pretest value.

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b P < .05 as compared with control.
c P < .001 as compared with pretest value.
d P < .01 as compared with control.

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Pediatric Physical Therapy
endurance exercise program with supervision by a phys-
ical therapist elicits beneficial effects for physical func-
tional ability in participants with CP, this program could
be an alternative treatment in both clinical and school
settings.
Our results did not show improvement in the TUGT
because our exercise program did not include specific bal-
ance training. During the TUGT measurements, partici-
pants with CP had difficulty turning around while walking
quickly because of limited balance or agility. Participants
with CP have less ability to maintain their postural control
during physical performance.25,29 Moreover, participants
with spastic CP often have cocontractions of the distal
and proximal muscles and do not have a smooth distal-to-
proximal patterns of muscle activity.33
A limitation of the study was the lack of outcome
measures across the World Health Organization Interna-
tional Classification of Functioning, Disability and Health.
Because HRQOL is an important outcome of treatment for
participant with CP, a long-term exercise training program
is needed to maintain their fitness levels and HRQOL. Be-
cause it seems to be difficult for participants with CP to
maintain their fitness level after an exercise program, fu-
ture studies are needed to determine the clinical efficacy
of a combined functional strength and endurance exer-
cise program over the long term in participants with CP.
Another limitation was the small sample of participants
with CP. The study might be underpowered for some re-
sults, and thus a replication study with a larger sample
is necessary before the results could be considered more
than preliminary. Despite these limitations, our findings
may contribute to the advancement of the general under-
standing of a combined functional strength and endurance
exercise program for participants with CP.
CONCLUSIONS
This study provides evidence that an 8-week com-
bined functional strength and endurance exercise program
carried out as a group circuit can be an effective and fea-
sible strategy for improving motor function, such as walk-
ing performance and leg muscle strength, in participants
with CP. This study suggests that a concurrent lower body
strength and endurance training program may provide pos-
itive adaptations in cardiorespiratory and motor function
for physical activities of daily living and may lead to im-
provement of HRQOL in participants with CP.
ACKNOWLEDGMENTS
The authors would like to thank all who participated
in this study. The study was supported by the Research
Center of the Back, Neck, Other Joint Pain and Human Per-
formance, Faculty of Associated Medical Sciences, Khon
Kaen University, Thailand. Additional thanks to Srisang-
wan, Khon Kaen Special School, for the location and equip-
ment that was used in this study.
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CLINICAL BOTTOM LINE

Commentary on “Effects of Combined Exercise Training on Functional Performance in Children With
Cerebral Palsy: A Randomized-Controlled Study”

“How could I apply this information?”

Children with cerebral palsy often have lower levels of physical fitness, which can lead to activity limitations
and participation restrictions. In this study, children with Gross Motor Function Classification System (GMFCS)
levels I to III improved walking ability, functional strength, endurance, and balance following participation in
an 8-week, group circuit exercise program that included strength and aerobic training. Although subjects from
both exercise (EX) and control (CON) groups received traditional PT 1 time per week during the intervention,
improvement in outcome measures was only observed in the EX group. Supervised group circuit training programs
targeting functional activities and progressive intensity have potential to augment or replace traditional therapy.
“What should I be mindful about when applying this information?”
Generalization of results should be applied cautiously. A small sample size limited the ability to stratify by
GMFCS level. Determining response to exercise by GMFCS level would assist the clinician in determining
appropriate exercise dosing.1 Although procedures for performance and progression of exercises were provided,
it was unclear how the EX group moved between stations or how they were supervised to ensure treatment
fidelity. Reproduction of this exercise program may be challenging for clinicians to implement. Walking distance
recorded using the 6-minute walk test significantly increased in the EX group. It is difficult to determine whether
the change was due to physiologic or psychological factors.2 More detailed data reflecting heart rate response,
perceived exertion, and energy expenditure would aid in differentiating between the 2 factors. A second follow-up
assessment including outcome measures that examine changes in activity level and quality of life could address
the benefits on activity and participation in a group circuit exercise program such as the one described here.

REFERENCES
1. Kamp FA, Lennon N, Holmes L, Dallmeijer AJ, Henley J, Mille F. Energy cost of walking in children with spastic cerebral palsy: relationship
with age, body composition and mobility capacity. Gait Posture. 2014;40:209-214.
2. Verschuren O, Ketelaar M, Keefer D, et al. Identification of a core set of exercise tests for children and adolescents with cerebral palsy: a
Delphi survey of researchers and clinicians. Child Neurol. 2011;53:449-456.

James G. Moore, PT, PhD, PCS

Department of Physical Therapy, Miller School of Medicine, University of Miami
Coral Gables, Florida
Cheryl W. Gimenez, PT, DPT, PCS
Nicklaus Children’s Hospital
Miami, Florida
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000348

46 Peungsuwan et al Pediatric Physical Therapy

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