Research in Developmental Disabilities 34 (2013) 4343–4354

Contents lists available at ScienceDirect

Research in Developmental Disabilities

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
Yeshayahu Hutzler a,b,*, Beatriz Lamela Rodrı́guez c,d, Nuria Mendoza Laiz d,e,
Isabel Dı́ez d, Sharon Barak f
a
Zinman College of Physical Education and Sport Science, Israel
b
Israel Sport Center for the Disabled, Israel
c
Rey Carlos University of Madrid, Spain
d
CRE IMSerso, Ministry of Health, Social Affairs and Equality, Spain
e
University of Toledo, Spain
f
The Edmond and Lily Safra Children’s Hospital, The Chaim Sheba Medical Center, Israel

A R T I C L E I N F O A B S T R A C T

Article history: The purpose of the current study was to establish measurement reliability in adults with
Received 27 May 2013 Cerebral Palsy (CP), and to examine the feasibility and outcomes of an upper extremity
Received in revised form 5 September 2013 strength training program (three times per week for 90 min each time). A control group
Accepted 9 September 2013
design mixed with a prospective time series design for the intervention group was
Available online 18 October 2013
completed, including a pre-test, a post-test after a 12-week intervention period, and a
follow-up in the intervention group after an additional 10-week period. Seventeen adults
Keywords:
with CP with severe motor impairment took part in the study (10 in the intervention and
Assessment
Fitness seven in the control group). The test battery was comprised of wrist and hand
Physical activity dynamometry; dominant hand upper-extremity function measures (Jebsen Hand
Upper extremity Function Test = JHFT, Minnesota Manual Dexterity Test = MMDT, and the Nine Hole Peg
Rehabilitation Test = NHPT); and activity of daily living with the Barthel Index.
The results indicated that in both the control and the intervention groups, the
strength tests exhibited good-to-excellent reliability during pre-test and post-test. The
group comparison revealed that while in the pre-test no between-group differences
existed, in the post-test the strength training group demonstrated significantly higher
values in five out of eight strength measures, as well as in the MMDT. Discontinuing the
program for eight weeks reversed the effects almost to baseline. In conclusion, the
outcomes demonstrated the reliability of the assessments utilized in this study, as well
as the feasibility of the strength training program, in adults with severe motor
impairment due to CP.
ß 2013 Elsevier Ltd. All rights reserved.

1. Introduction

Cerebral Palsy (CP) describes a group of permanent disorders of the development of movement and posture causing
activity limitations, which are attributed to non-progressive disturbances that occur in the brain development of the fetus or

* Corresponding author at: Zinman College of Physical Education and Sport Sciences, Wingate Institute, 42902 Netanya, Israel. Tel.: +972 36484946;
fax: +972 37511649.
E-mail address: [email protected] (Y. Hutzler).

0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2013.09.015
4344 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354

infant. The motor impairment of CP is often accompanied by epilepsy; sensory abnormalities; and cognitive, perceptual,
communication, and behavior disorders (see Krugger, 2006; Odding, Roebroeck, & Stam, 2006; Rosenbaum, Paneth, Leviton,
Goldstein, & Bax, 2007). In an epidemiological survey of CP across Europe, an occurrence of 2.12–2.45 per 1000 live births
was reported (Surveillance of Cerebral Palsy in Europe, 2002). The frequency of CP increases to 40–100 per 1000 preterm
births (Odding et al., 2006). Every year there are approximately 10,000 newborns diagnosed with CP in the European Union
(Surveillance of Cerebral Palsy in Europe, 2002). The prevalence of CP has not decreased, and some authors argue that in the
past forty years it has even increased (Odding et al., 2006). It is estimated that 65–90% of children with CP survive to
adulthood (Zaffuto-Sforza, 2005). The mean lifetime cost of treatment and lost income for a person with CP has been
estimated in the United States as US$ 921,000 (CDC, 2004).
The limitation of activity in CP typically leads to muscle weakness and atrophy (Bottos, Feliciangeli, & Sciuto, 2004), which
increases in adulthood (Allen, Dodd, Taylor, McBurney, & Larkin, 2004). Most adults with CP, regardless of the degree of
disability, have common limitations in performing activities of daily living (ADL; see Verschuren et al., 2011). The degree of
functional performance in CP is typically classified across five categories by means of the Gross Motor Function Classification
System (GMFCS; see Bax et al., 2005; Palisano, Rosenbaum, Bartlett, & Livingston, 2007), based on independence in
locomotion and ranging from walks without limitations (Level I), through walks with limitations (Level II), walks using a hand-
held mobility device (Level III), self-mobility with limitations – may use powered mobility (Level IV), up to transported in a manual
wheelchair (Level V).
In a systematic review that extracted and summarized 10 clinical trials using strength training as their major intervention
(Dodd, Taylor, & Damiano, 2002), it was reported that the majority exhibited a significant impact on strength with effect sizes
ranging between 0.5 and 5.0. However, non-significant poor effects were seen in motor function, mostly walking. In a more
recent systematic review performed with randomized clinical trials only (Scianni, Butler, Ada, & Teixeira-Salmela, 2009), the
beneficial effect on strength was seen to diminish. However, most of this research has focused on children and adolescents
with fair to moderate levels of functional limitation (i.e., GMFCS levels I–III; see Verschuren, Ketelaar, Takken, Helders, &
Gorter, 2008). Moreover, there is very little evidence regarding the outcomes of strength training in adults with CP,
particularly in those with severe functional limitations (GMFCS levels IV and V).
Experts in rehabilitation and health promotion of persons with CP have addressed the significant role of being physically
active and of physical training in functional ability and quality of life. For example Thorpe (2009) acknowledged that as more
and more persons with CP lead meaningful lives into advanced age, it is imperative that the scientific community provide
definitive information to help guide decisions related to the type and extent of fitness-related activities that might benefit
these individuals. In addition, Zaffuto-Sforza (2005) reported that although there is an increasing awareness of the rights of
people with disabilities, there is more work to be done particularly as relates to the cost and availability of adaptive
equipment and exercise. Nevertheless, very few reports regarding the physical activity and functional ability of adults with
CP have been published. In a study of 51 adults with CP, Gaskin and Morris (2008) reported very low physical activity
participation rates, and a medium correlation between physical activity and functional ability (r = .45). In a more recent
study (Maltais, Dumas, Boucher, & Richards, 2010), it was found that in individuals who were able to walk, inactivity was
associated with an increase in the severity of additional health problems or complications. However, in non-walkers
inactivity was most clearly associated with perceived range-of-motion limitations.
In an intervention study of Andersson, Grooten, Hellsten, Kaping, and Mattsson (2003), ten adults with spastic diplegia
who participated in strength training twice a week over 10 weeks, were compared to seven individuals with a similar
disability who did not participate in training and served as controls. The authors reported significant improvements in the
experimental groups in most outcome measures: (a) isometric strength of the hip extensors (p < .01) and hip abductors
(p < .01), (b) isokinetic concentric work at 308 of the knee extensors (p < .05), (c) Gross Motor Function Measure (GMFM)
dimensions D and E (p < .005), (d) walking velocity (p < .005), and (e) timed Up and Go (p < .01), while no change in these
measures was observed in the controls. In addition, the authors noted that no adverse spasticity effects were encountered in
the participants.
Very limited information has been reported so far about the impact of a training program on the strength and motor
function of the hand and wrist in rehabilitation clients with CP, all of them children or youth. O’Connell and Barnhart (1995)
studied the effect of an eight-week upper body concentric resistance training program on wheelchair propulsion in three
children with CP and three with Spina Bifida, aged 4–16 years. These authors reported significant increases in strength (six-
repetition maximal load in upper extremity muscle groups that are relevant for wheelchair propulsion) as well as distance
covered in 12 min, suggesting that a specific muscle strengthening program could assist in wheelchair propulsion. A recent
study performed on nine children with CP with a mean age of 9.1 years (SD = 1.8 years) reported improvement in the velocity
of a reaching task at a comfortable speed as a result of a 10-week three times per week home based strength training program
(Kim et al., 2012). Furthermore, the same reaching task as well as hand function in the Jebsen Taylor Hand Function Test
(JHFT) improved significantly as a result of a Comprehensive Hand Repetitive Intensive Strength Training (CHRIST) program
lasting 10 weeks, with three sessions of 60 min per week, in 10 children with CP with a mean age of 8.6 years (SD = 1.9 years;
Lee et al., 2013). This program included body weight supported treadmill training for the upper limbs (body in quadruped
position).
So far no strength training outcomes on wrist and hand function have been reported in adults with CP. Therefore, the aim
of the current study was to establish measurement efficacy in adults with CP who are unable to walk, and to examine the
feasibility and efficacy of a strength training program designed to improve their strength and upper-extremity functionality.
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The specific research questions were: (a) Are the strength measurement devices reliable?; (b) Is a specifically designed
strength training program in a group setting effective in increasing strength and function of the hand and wrist musculature,
and in performance in daily life activities, of adults with CP?; (c) Will the effects of the strength training program, if achieved,
be maintained after the program is discontinued?; and (d) What is the relationship between the strength and motor function
variables?

2. Method

A control group design mixed with a prospective time series design for the experimental group was completed, including
a pre-test, a post-test after a 12-week intervention period, and a follow-up in the experimental group after an additional 10-
week period.

2.1. Participants

Participants were rehabilitation clients in a Spanish state referral center for persons with severe disability, who were
institutionalized for periods of 12–18 months with the aim of improving their functional level. A prospective cohort group
design (Euser, Zoccali, Jager, & Dekker, 2009) was performed. One group participated in a strength training program offered
to the residents, and the other did not participate.
The total sample consisted of 17 adults with CP. In the strength training program (intervention group) 10 participants (six
males and four females) with a mean age of 46.80  11.35 years took part. Their functional classification varied across GMFCS
levels II (n = 2), III (n = 5) and IV (n = 3). The control group was comprised of seven participants (four males and three females) with
a mean age of 39.85  14.43 years and GMFCS levels III (n = 3) and IV (n = 4). All participants were Caucasian.
All participants underwent an individualized rehabilitation program, which included two physical therapy sessions
(30 min each session) per week, in which stretching and tone management techniques were utilized to inhibit spasticity of
the upper and lower extremities. In addition, two occupational therapy sessions were completed weekly (one hour each
session) in which manipulative dexterity, as well as task-oriented reach, grip, and handling of different objects were
performed.
Inclusion criteria for the strength intervention and the comparison groups were: (a) scores of less than 45 out of 100
points in the Barthel Index (BI); (b) CP with involvement of all four limbs to a moderate extent; (c) functional ambulation in a
wheelchair; and (d) a degree of muscle tone and range of motion that allows the performance of manual movements with
objects such as weights and bands. Hand-dominance was determined by the hand used for all activities of daily living and for
managing the joystick for electric-chair driving. Four participants had left-hand dominance and six participants had right-
hand dominance in the intervention group, while in the control group three were left-handed and four right-handed. The
difference across groups was non significant (x2 = 1.92; p > .05)

2.2. Instruments

2.2.1. Severity of gross motor function

The GMFCS (Palisano et al., 1997) was used to establish the participant’s severity of gross motor function. The GMFCS has
been widely employed internationally to group individuals with CP into one of five levels, based on functional mobility or
activity limitation (Holsbeeke, Ketelaar, Schoemaker, & Gorter, 2009). Level I represents the highest level of gross motor
function, whereas level V represents the lowest level. Within the CP population, the GMFCS has good reliability and validity
(Palisano et al., 1997).

2.2.2. Strength tests

Participants were tested on eight strength tests: pinch key strength, three-jaw chuck pinch (tripod strength), tip-to-tip
strength (fingertips strength), and five dynamometry power grasps. The first three tests were conducted with the
Pinchmeter-P100 (NexGen Ergonomics Inc. Quebec, Canada). This device enables pinch strength to be accurately quantified
in 0.1 increments (kg or lbs) from 0 to 22 kg or 0 to 50 lbs. The latter five power grasps were conducted with the Grip
Dynamometer G100 (NexGen Ergonomics Inc., Quebec, Canada). This device can accurately measure five positions of grip
strength (the grip positions differ in terms of the distance of the handle from the guide) in 0.1 increments (kgs or lbs), from 0
to 90 kg or 0 to 200 lbs. All sensors were connected to the Biometrics E-Link Ltd. (Newport, UK) computerized evaluation
system, which was found to be valid and reliable for measuring grip and hand strength (e.g., Allen & Barnett, 2011; Goodson,
McGregor, Douglas, & Taylor, 2007). In all the aforementioned hand strength tests, the measurements were repeated three
times with the dominant hand and the mean of the three tests was registered (American Society of Hand Therapists, 1992).
Following is a detailed description of the various hand strength tests.

2.2.2.1. Pinch key strength. According to the protocol of the American Society of Hand Therapists, the participants sat with
their shoulder adducted and neutrally rotated, elbow flexed at 908 and the forearm and wrist in neutral position (Fess &
Moran, 1981). In addition, the participants were asked to make a fist and to put the pinch gauge between the flexed proximal
interphalangeal joint of the index finger and thumb (Mathiowetz et al., 1985).
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2.2.2.2. Three-jaw chuck pinch (tripod strength). The participants were asked to have their palm facing down and to place
their index and middle fingers in the posterior component of the measurement device and their thumb on the pinch gauge.
The pinky and ring fingers were in a flexed position. Following assumption of the appropriate position, the participants were
asked to exert force between the pads of the index and middle fingers and the pad of the thumb, through the centers of the
opposing pads (Imrhan & Rahman, 1995).

2.2.2.3. Tip-to-tip strength (fingertip strength). In this test, the participants were instructed to pinch the gauge between the
thumb (in the anterior compartment of the device) and index finger (in the posterior compartment of the device), while the
middle, ring and pinky fingers were in a flexed position. The forearm was in a pronation, supination or neutral position, while
the wrist was in a neutral position.

2.2.2.4. Dynamometer test. Dynamometry positions (power grasps) 1 through 5 corresponded to a 3, 4, 6, 7, and 8 cm
distance between the thumb and the opposing four fingers, respectively. In all five power grasps, the palm faced inward,
toward the body. The total palmar hand surface grasped the dynamometer’s handle that ran parallel to the knuckles. The
dynamometer faced away from the participant, such that the participant could not see or read the gauge (Mathiowetz et al.,
1985). Strength was measured in each of the five different spans of the dynamometer.

2.2.3. Hand function tests

The participants’ dominant hand functional level was assessed via the JHFT, the Minnesota Manual Dexterity Test
(MMDT) and the Nine Hole Peg Test (NHPT).

2.2.3.1. JHFT. The JHFT (Jebsen, Taylor, Trieschmann, Trotter, & Howard, 1969) was developed to provide a standardized and
objective evaluation of a broad range of uni-manual hand functions required for activities of daily living (ADL). The test
consists of seven subtests, namely: writing a short sentence (24 letters, 3rd grade reading difficulty), turning over 7.6 by
12.7 cm cards, picking up small common objects (e.g., paper clips, pennies, bottle caps) and placing them in a container,
simulated feeding, stacking checkers, picking up large light objects (empty cans), and picking up large heavy objects
(weighted cans of 0.454 kg). The scoring method is the time (rounded to the nearest second) necessary to complete each
subtest. The scores for all seven items can be summed for a total score. For the purpose of this study we analyzed each item
separately. According to Jebsen et al., in a sample of 300 healthy individuals of different age groups (20–29 years, 30–39
years, 40–49 years, 50–59 years, and 60–94 years), each item took under 10 s to perform, with the exception of writing.
Although the JHFT was not developed for participants with CP, it was indicated for those with neurological or
musculoskeletal conditions (Cook, McCluskey, & Bowman, 2006), and has been used in practice for those with CP (e.g.,
Kinnucan, Ven Heest, & Tomhave, 2010; Van Heest, James, & Gerwin Carlson, 2012; Vaz, Cotta Mancini, Fonesca, Vieira, & de
Melo Pertence, 2006)

2.2.3.2. MMDT. The MMDT is a test of manual dexterity (Trombly & Radomski, 2007). The testing kit consists of a plastic
collapsible board with 60 holes (3.9 cm in diameter and 0.5 cm deep) and 60 cylindrical blocks (3.7 cm in diameter and
1.9 cm high). The complete MMDT Manual (Model 32023) incorporates five subtests: the Turning Test, the Placing Test, the
Displacing Test, the One-hand Turning and Placing Test, and the Two-hand Turning and Placing Test (Surrey et al., 2003). In
this study we used the abridged version (Model 32023), which includes the Turning and Placing tests only. Since the
participants were unable to stand as requested in the manual, the tests were performed while sitting upright in the
individual’s wheelchair. Each test was started with a 15-second practice trial for each subtest, and then repeated three times.
The time of each test was recorded (rounded to the nearest second) and the average score of the three trials for each subtest
was compiled (Lafayette Instrument Company, 1991).

2.2.3.3. NHPT. The NHPT is a quick test of finger dexterity (Mathiowetz et al., 1985). The test is composed of nine
wooden pegs and a square board with nine holes, spaced 3.2 cm apart. The pegboard is centered in front of the
subject and the participant is asked to take the pegs from a container, one by one, and place them into the holes on the
board, as quickly as possible. Following this, the participants were asked to remove the pegs from the holes, one by one,
and put them back into the container. The participant is entitled to hold the edge of the board with the hand not being
evaluated in order to provide stability (Mathiowetz et al., 1985; Sommerfeld, Eek, Svensson, Holmqvist, & von Arbin,
2004). The scoring method is based on the time it takes to complete the test, recorded in seconds (Mathiowetz et al.,
1985).

2.2.4. Activities of daily living

The BI was used to establish the participant’s ability to independently ambulate and conduct ADL. More specifically, the BI
assesses the following activities (items): feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair
transfer, ambulation and stair climbing. Each of the aforementioned items is rated based on the amount of assistance
required to complete it (i.e., the individual can perform activities independently, with some assistance, or is dependent)
(Mahoney & Barthel, 1965). The BI yields a total score out of 100. Higher scores denote a greater degree of functional
independence (McDowell & Newell, 1996).
 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354 4347

All measurements were conducted three times: at baseline (pretest), immediately post intervention (post-test) and
during follow-up (10 weeks after post-test). The observations and the administration of the tests were performed by two
blinded evaluators. All the test trials were individually performed at the same time of the day in a controlled laboratory
environment.

2.3. Intervention

The intervention period lasted three months. The first four weeks focused on familiarizing the participants with the
equipment, methods and exercises, since the majority of the participants were not experienced in fitness training. The
subsequent eight weeks comprised the main training period, where three training sessions each (totaling 24 sessions) lasted
a net time of 90 min within a two and a-half hour total time. Each session included four parts: (a) 10 min of warm-up and
flexibility training of the upper extremity and trunk joints; (b) main specific training of the major muscle groups (i.e., biceps
brachii, triceps brachii, pectoralis major and deltoid) during a 40–50 min duration; (c) a stretching period of the major
muscle groups for 10 min; and (d) after about an hour’s rest, a second training period of the major muscle groups was
performed lasting 30 min.
The specific training was performed by experienced adapted physical activity coaches according to the recommendations
of Rimmer (2012), posted on the National Center of Physical Activity and Disability (NCPAD) website. The training comprised
of three sets of 8–10 repetitions, each with graded resistance. The resistance was accomplished using a variety of exercise
equipment, including dumbbells, ‘‘digiflex’’ hand exercisers, elastic ‘‘thera’’ bands, springs, weighted bars, balls of different
sizes, weights and contours, and sticky paste. Each type of equipment had varied resistance levels, which were clearly
identified by different colors. The exercises were not time-based, and were adapted to the needs and capacity of each
individual, based on his or her disability degree and trainability. The comparison group continued its regular rehabilitation
activity.

2.4. Statistical analysis

2.4.1. Test–retest reliability of strength tests

Participants were tested on eight strength tests (pinch key test, three point’s pressure test, fingertip-strength, and five
dynamometry testing positions). Each test was repeated three times. Strength assessments’ test–retest reliability was
determined by using the intraclass correlation coefficient (ICC). With trial and rater as random factors in the repeated-
measures analysis of variance (ANOVA), ICC2,3 were calculated for test–retest reliability by using the mean of three measures
(Shrout & Fleiss, 1979). The value of the ICC was interpreted as follows: poor (<0.5), moderate (0.5–0.75), good (0.75–0.9)
and excellent (>0.9) (Swets, 1988). In addition, between-trial differences were determined via repeated-measures one-way
ANOVA and protected dependent t-tests with a significance level of 0.017 (0.05/3 = 0.017). Prior to the repeated measures
ANOVA test, data which did not correspond with the homogeneity of variance assumption were transformed. The results
indicated that in both the control and the intervention groups, the eight strength tests had good-to-excellent reliability
during pre-test and post-test (an additional description of the test–retest reliability results appears in the Results section).
Therefore, additional analyses were conducted with the mean of each of the eight strength tests.

2.4.2. Strength training effect

Assessment of the effect of the strength training for individuals with CP was established via a two-step process. In the first
step, pre-test and post-test mean differences between the control and intervention groups were compared using an
independent samples t-test. Level of significance was set at 0.05 and adjusted to <0.006 (0.05/8 = 0.006) for strength tests,
<0.025 (0.05/2 = 0.025) for the MMDT test, BI and NHPT, and to <0.007 (0.05/7 = 0.007) for the JHFT, using the Bonferroni
procedure. In the second stage, for the intervention group, repeated measures ANOVA with protected dependent t-tests was
computed to compare the participant’s strength and function at three different times: pre-test, post-test and follow-up.
Significance level was set at <0.017 (0.05/3 = 0.017). For the control group, mean differences between pre-test and post-test
were assessed using paired t-tests.

2.4.3. Associations
Pearson’s correlation coefficient (r) was used to evaluate the relationship between the various activity level tests (MMDT-
placing and turning, JHFT-1-7, the NHPT and the BI) and the eight impairment level tests (strength tests) during pre-test.
Variables that did not meet the equal variance assumption were assessed via Spearman correlation coefficients. Statistical
analyses were conducted using IBM SPSS 15 software (IBM Corporation, NY, USA).

3. Results

3.1. Test–retest reliability of strength tests

Strength tests of the control and the intervention groups were subjected to test–retest reliability analysis. Overall, in both
groups the ICCs revealed excellent reliability, with ICC values ranging from .957 (pinch key) to .998 (dynamometer position
4348 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354

number 5) in the control group and from .830 (fingertip strength) to .997 (dynamometer position number 4) in the
intervention group (see Table 1). Accordingly, repeated measures ANOVA did not reveal significant differences between the
three measurement times (intervention group: F2,9 = 0.25–1.47, p = .256–.834; control group: F2,6 = 1.06–3.11, p = .082–.378),
with the exception of dynamometer position number four of the intervention group (F2,9 = 5.68, p = .012); see Table 1.

3.2. Strength training effect

3.2.1. Between-group comparisons during pre- and post-tests

Control and intervention groups’ mean scores in the various assessments were compared via independent samples t test.
During the pre-test no significant between-group differences were found in any of the assessed variables (see Tables 2 and 3).
In contrast, in the post-test, the intervention group was stronger than the control group in five out of the eight strength tests
evaluated (p < 006); see Table 2. Similarly, in the post-test, the intervention group was faster than the control group in
MMDT placing and turning tests (p  025), and in six out of the seven JHFT tests (p  0.007) (see Table 2). However, no
significant between-group differences during the post-test were observed in the NHPT or the BI (see Table 3).

3.2.2. Within-group comparisons – control group

For the control group, a paired-samples t test was calculated to compare mean pre-test scores with mean post-test scores.
No significant differences from pre-test to post-test were found in any of the eight strength tests (see Table 2), whereas in
hand and ADL, significant improvements were observed in two out of the eleven evaluated assessments (MMDT-turning and
JHFT-4) (see Table 3).

3.2.3. Within-group comparisons – intervention group

A one-way repeated measures ANOVA was calculated comparing the scores of subjects at three different times: pre-test,
post-test and follow-up. A significant effect was found in the strength tests. Follow-up protected t tests revealed that in pinch
strength, fingertips strength and dynamometer position 1, strength increased significantly from pre-test to post-test.
However, the improvements were not maintained during the follow-up assessment (see Fig. 1).
The intervention group also showed significant improvements from pre-test to post-test in MMDT-placing and turning.
However, these improvements were not maintained during the follow-up (see Fig. 2). Similarly, post-test improvements in
NHPT, JHFT-2, 4, 6 and 7 were not sustained during follow-up (Fig. 3). Moreover, the intervention did not yield significant
improvements from pre-test to post-test in JHFT-1, 3 or 5.

Table 1
Control group and intervention group test–retest reliability of strength tests (descriptives, repeated measures ANOVA and ICCs).

Variables Control group Intervention group

First Second Third F ICC First Second Third F ICC

assessment assessment assessment assessment assessment assessment
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Pinch key (Kg)

Pre-test 3.70 (0.99) 3.54 (1.00) 3.62 (1.05) 0.32 0.957 5.54 (2.27) 5.59 (2.28) 5.78 (2.28) 1.06 0.990
Post-test 4.00 (1.22) 4.01(1.24) 4.08 (1.35) 0.14 0.980 6.32 (2.00) 6.39 (1.84) 6.59 (1.89) 1.77 0.988
Three points pressure (Kg)
Pre-test 3.95 (1.52) 3.64 (1.54) 3.64 (1.73) 1.16 0.972 5.91 (2.09) 5.68 (2.40) 6.08 (2.36) 2.27 0.987
Post-test 3.64 (1.36) 3.55(1.43) 3.52 (1.60) 0.43 0.991 6.43 (1.86) 6.47 (1.81) 6.65 (1.95) 0.46 0.971
Fingertips (Kg)
Pre-test 2.68 (0.94) 2.71 (1.13) 2.67 (1.05) 0.60 0.990 3.51 (0.82) 3.43 (1.04) 3.62 (0.96) 0.90 0.959
Post-test 2.52 (0.80) 2.50 (0.89) 2.47 (0.86) 0.43 0.981 5.28 (2.00) 5.03 (1.27) 4.84 (0.93) 0.46 0.830
Dynamometer position 1 (Kg)
Pre-test 13.65 (6.55) 12.61 (5.98) 13.27 (6.13) 2.22 0.991 18.03 (5.84) 17.81 (5.10) 18.59 (6.45) 0.25 0.931
Post-test 13.37 (5.97) 13.44 (6.36) 13.74 (6.44) 0.23 0.990 20.56 (6.41) 20.10 (5.29) 21.54 (5.90) 2.98 0.978
Dynamometer position 2 (Kg)
Pre-test 15.07 (5.82) 14.87 (6.19) 14.18 (5.77) 3.11 0.994 24.62 (10.50) 25.31 (11.36) 24.42 (10.10) 1.47 0.995
Post-test 14.17 (4.64) 13.71 (4.84) 13.52 (4.80) 3.23 0.995 27.31 (11.33) 26.39 (11.57) 26.83 (11.93) 2.39 0.997
Dynamometer position 3 (Kg)
Pre-test 15.50 (5.59) 14.70 (5.74) 15.11 (5.80) 1.74 0.992 25.72 (11.58) 25.81 (12.09) 25.39 (11.43) 0.18 0.993
Post-test 14.24 (4.19) 13.64 (3.72) 14.01 (4.28) 1.78 0.991 28.14 (12.27) 27.53 (11.80) 27.30 (12.34) 2.20 0.997
Dynamometer position 4 (Kg)
Pre-test 12.18 (7.48) 11.80 (7.32) 12.27 (7.04) 0.41 0.993 23.65 (11.67)a 22.80 (10.63) 21.04 (10.38) 5.68* 0.987
Post-test 10.94 (5.46) 11.08 (5.83) 10.94 (5.42) 0.11 0.995 25.63 (11.53) 24.91 (11.26) 24.75 (11.47) 2.98 0.997
Dynamometer position 5 (Kg)
Pre-test 10.50 (6.09) 10.34 (6.05) 10.14 (5.96) 1.64 0.998 19.83 (9.13) 18.77 (8.09) 18.80 (7.67) 4.14 0.986
Post-test 9.37(4.54) 9.57 (4.83) 9.60 (4.94) 0.42 0.996 20.47 (8.00) 20.66 (8.66) 20.56 (9.58) 0.089 0.996
a
First measurement is significantly different than the third measurement.
* Significant repeated measures F score.
 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354 4349

Table 2
Fingers and hand strength at pre- and post-tests: control group vs. intervention group (descriptives and t-test).

Variables Control group (n = 7) Intervention group (n = 10) Between groups

Within group comparison Within group comparison comparison
(paired t-test) (paired t-test) (independent t-test)

Pre-test Post-test Pre-test Post-test Pre-test Post-test

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Pinch key strength (kg) 3.62 (0.97) 4.03 (1.24) 5.63 (2.25) 6.43 (1.89)* 2.50 3.14*
Tripod pressure (kg) 3.74 (1.56) 3.57 (1.45) 5.89 (2.26) 6.51 (1.82) 2.30 3.68*
Fingertips strength (kg) 2.56 (1.03) 2.50 (0.83) 3.52 (0.91) 5.05 (1.26)* 1.96 4.98*
Dynamometer position 1 (kg) 13.18 (6.18) 13.51 (6.20) 18.14 (5.44) 20.73 (5.78)* 1.71 2.45
Dynamometer position 2 (kg) 14.71 (5.90) 13.80 (4.75) 24.78 (10.62) 26.84 (11.59) 2.26 3.19
Dynamometer position 3 (kg) 15.10 (5.67) 13.96 (4.04) 25.64 (11.63) 27.65 (12.11) 2.47 3.31*
Dynamometer position 4 (kg) 12.08 (7.23) 10.99 (5.55) 22.49 (10.82) 25.09 (11.40) 2.37 3.38*
Dynamometer position 5 (kg) 10.32 (6.02) 9.51 (4.75) 18.86 (8.24) 20.56 (8.73) 2.46 3.35

* Significant difference was set to 0.006 after Bonferroni adjustment (0.05/8 = 0.006).

Table 3
Hand function and activities of daily living at pre- and post-tests: control group vs. intervention group (descriptives and t-test).

Variables Control group (n = 7) Intervention group Between groups

(n = 10) comparison (independent
t-test t value)

Pre-test Post-test Pre-test Post-test Pre-test Post-test

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

MMDT-placing (s) 1447.57 (469.16) 1443.00 (462.47) 908.90 (394.34) 813.26 (343.35)* 2.567 3.232*
MMDT-turning (s) 1388.85 (418.75) 1335.14 (412.36)* 921.00 (404.78) 786.30 (360.25)* 2.313 2.916*
JHFT-1 (s) 74.73 (21.33) 72.74 (20.31) 90.28 (64.08) 66.26 (55.28) 0.713 0.339
JHFT-2 (s) 31.32 (12.49) 30.52 (11.21) 26.66 (12.49) 13.89 (7.96)* 0.756 3.589*
JHFT-3 (s) 20.89 (4.96) 20.91 (5.05) 24.39 (24.22) 9.54 (4.27) 0.444 5.011*
JHFT-4 (s) 60.01 (28.06) 58.18 (27.31)* 45.57 (32.43) 20.29 (14.27)* 0.953 3.749*
JHFT-5 (s) 15.44 (7.46) 14.77 (5.91) 10.20 (6.08) 5.75 (2.44) 1.593 3.815*
JHFT-6 (s) 12.59 (2.53) 12.53 (2.51) 10.84 (3.60) 6.51 (2.11)* 1.106 5.345*
JHFT-7 (s) 13.70 (3.78) 13.58 (3.81) 11.09 (4.28) 6.63 (1.95)* 1.295 4.953*
Barthel Index 55.71 (17.66) 55.71 (17.66) 72.00 (19.74) 74.00 (17.60) 1.745 2.105
9-pegs test (s) 98.45 (46.36) 96.176 (45.81) 70.03 (32.20) 46.85 (20.76)* 1.498 2.663

Notes: *MMDT test-significant difference was set to 0.025 after Bonferroni adjustment (0.05/2 = 0.025); *JHFT test-significant difference was set to 0.007
after Bonferroni adjustment (0.05/7 = 0.007); *Barthel Index and 9-pegs test-significant difference was set to 0.025 after Bonferroni adjustment (0.05/
2 = 0.006); JHFT, Jebsen Hand Function Test; MMDT, Minnesota Manual Dexterity Test; SD, standard deviation; *Significant differences in within and/or
between subjects analysis.

Fig. 1. Intervention group within test differences in strength during pre-test, post-test and follow-up.
Notes: aSignificantly different than pre-test; bSignificantly different than post-test; cSignificantly different than follow-up. The figure shows that the
intervention resulted in significant increases in pinch strength, fingertips strength and dynamometer position 1 strength. However, not all improvements
were maintained during the follow-up assessment.
4350 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354

Fig. 2. Intervention group within test differences in Minnesota Manual Dexterity tests during pre-test, post-test and follow-up.
Notes: aSignificantly different than pre-test; bSignificantly different than post-test; cSignificantly different than follow-up. The figure illustrates significant
improvements from pre-test to post-test in Minnesota manual Dexterity placing and turning tests.

Despite the aforementioned improvements from pre-test to post-test in numerous strength and hand function tests, no
significant improvements were observed from pre-test to post-test or from pre-test to follow-up in the BI (see Fig. 4).

3.3. Associations

Pearson and Spearman correlation coefficients between activity level measures (MMDT tests, JHFT tests, NHPT and BI)
and impairment level measures (eight strength tests) revealed numerous significant associations. For instance, the MMDT-
placing test significantly correlated with seven out of the eight strength tests, with correlation coefficients ranging from
0.503 to 0.815, meaning that a longer time to complete the MMDT-placing is associated with less strength. No significant
associations were observed between MMDT-placing and fingertips strength (r = .426). Similarly, MMDT-turning
significantly correlated with all strength tests (r ranges from 0.473 to 0.795) (see Table 4). The NHT and the BI also
significantly correlated with numerous strength tests (r in the NHPT ranges from 0.304 to 0.679 and in the BI from 0.251
to 0.456) (see Table 4). However, only a few significant associations were found between JHFT 1-7 and the strength tests (see
Table 3).

Fig. 3. Intervention group within test differences in Jebsen Hand Function Tests during pre-test, post-test and follow-up.
Notes: JHFT, Jebsen Hand Function Test; aSignificantly different than pre-test; bSignificantly different than post-test; cSignificantly different than follow-up.
The figure demonstrates significant improvements from pre-test to post-test in numerous hand function measures. However, not all improvements were
maintained during follow-up.
 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354 4351

Fig. 4. Intervention group within test differences in Barthel Index during pre-test, post-test and follow-up.
Notes: aSignificantly different than pre-test; bSignificantly different than post-test; cSignificantly different than follow-up. The figure shows that no
significant improvements were observed from pre-test to post-test or from pre-test to follow-up in the Barthel Index test.

4. Discussion

4.1. Reliability of strength measurement

Our findings demonstrated good-to-excellent test–retest reliability value, utilizing the Biometrics computerized strength
measurement system. These values are uncommon when measuring strength in persons with CP. Previous studies reported
good reliability coefficients for lower limb strength utilizing a hand-held dynamometer, mostly in children and young people
with CP (e.g., Crompton, Galea, & Phillips, 2007; Dyball, Taylor, & Dodd, 2011; Taylor, Dodd, & Graham, 2004; van der Linden,
Aitchison, Hazlewood, Hillman, & Robb, 2004; Willemse et al., 2013). Similarly, good test–retest reliability was
demonstrated for grip strength using the Jamar dynamometer (Klingels et al., 2010). No studies were encountered measuring
the reliability of other testing positions for measuring upper extremity muscular strength in persons with CP, such as the
pinch key and the tripod strength measured in the current study.

4.2. Impact of strength training

The results of our study show that a program of eight weeks, comprised of a total of 24 training sessions, with three
sessions per week, and lasting one and-a-half hours per session, leads to substantial outcomes regarding strength and hand
function, and may have important implications on the rehabilitation of adults with disability. However, no changes were
observed in ADL. Our findings demonstrated: (a) a medium-to-strong association between most strength and hand function
variables; (b) a significant increase in strength and improved motor function of the dominant hand, including fine motor
skills and hand coordination, compared to outcomes of the non-active group at post-test; and (c) that the increase in strength

Table 4
Associations between functional tests and strength at pre-test (entire group, n = 17).

Pinch key Tripod Fingertips Dynamometer Dynamometer Dynamometer Dynamometer Dynamometer

strength pressure strength position 1 position 2 position 3 position 4 position 5

MMDT-placing 0.586* 0.503* 0.426 0.640* 0.686* 0.714* 0.815* 0.809*

MMDT-turning 0.605* 0.481* 0.473* 0.617* 0.676* 0.690* 0.795* 0.789*
JHFT-1 0.148 0.176 0.431 0.080 0.169 0.240 0.278 0.280
JHFT-2 0.470 0.204 0.106 0.176 0.412 0.465 0.493* 0.521*
JHFT-3 0.442 0.178 0.133 0.181 0.337 0.327 0.350 0.317
JHFT-4 0.470 0.133 .073 0.147 0.444 0.436 0.424 0.367
JHFT-5 0.488* 0.310 0.270 0.086 0.355 0.414 0.414 0.494*
JHFT-6 0.536* 0.505* 0.113 0.370 0.507* 0.574* 0.574* 0.594*
JHFT-7 0.350 0.323 0.216 0.177 0.292 0.344 0.320 0.354
Barthel Index 0.256 0.386 0.251 0.546* 0.410 0.478* 0.532* 0.533*
9-pegs test 0.525* 0.498* 0.304 0.376 0.492* 0.553* 0.625* 0.679*

JHFT, Jebsen Hand Function Test; MMDT, Minnesota Manual Dexterity Test.
* Significant correlation at the p < 0.05 level.
4352 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354

and hand function was not maintained when the strength-training program was ended. These findings are of particular
interest in view of the detrimental effects of increased age on daily function observed in adults with disability between the
ages of 24 and 43 years over a five-year period, (Andren & Grimby, 2004), for example reduction in strength (Andren &
Grimby, 2000; Maltais et al., 2010) and a decrease in movement quality (Andren & Grimby, 2000).
Our findings may be supported by previous findings describing a strength and functional increase in 31 adults with CP and
other disabilities who were able to walk and stand, and who underwent a group-based 10-week progressive resistance strength-
training program in a community gymnasium in Australia (Taylor, Dodd, & Larkin, 2004). In-depth interviews performed with 10
participants in the latter sample who had CP revealed that enjoyment was perceived as a key factor promoting the adherence and
sustainability of this strength-training program, and that it led to perceptions of increased strength and physical functioning
(Allen et al., 2004). Non-systematic observations of our strength coaches and participants also indicated that the participants did
enjoy the training program, which was based on small group sessions of 5–8 participants.
Our findings are the first to demonstrate the capability to increase strength as well as function of the upper extremities in
adults with CP, who have very limited trainable muscle function and are wheelchair dependent in their daily life. However, it
is difficult to estimate the clinical value of the strength changes obtained in our study. The post-training strength values,
although significantly improved compared to the pre-test values, still ranged about 50% below the means expected for adult
men and women (Mathiowetz et al., 1985). However, the capability of our programs’ participants to manipulate small
objects increased significantly, as observed in the outcomes of the JHFT, MMDT, and NHPT. As significant associations were
found between pre-test strength and manipulation ability, it is reasonable to assume that the increase in strength did
contribute to the observed increase in hand manipulation ability.
Nonetheless, we did not observe an impact of the exercise program on ADL, as measured by means of the BI. Also, previous
studies in adults with disability (mostly stroke) have mostly reported no exercise effect on the BI, while reporting such
effects on strength and activity performance (see the meta analysis of Ada, Dorsch, & Canning, 2006, and more recent
evidence from Stuart et al., 2009). This may be due to the fact that the BI is mostly a screening measure, and does not have the
sensitivity needed for measuring intervention effects in persons with a disability. Therefore, the implications of our findings
for the daily life of adults with CP are to maintain strength training as a habitual activity. These findings are consistent with
previous recommendations of rehabilitation experts who concluded, based on both quantitative and qualitative studies, that
increasing habitual physical activity is possible in persons with CP, and should be continued in order to maintain the
functional effects throughout their life-span. Additional training modalities, such as the CHRIST (Kim et al., 2012; Lee et al.,
2013), should be explored in adults with CP, and should focus on contributing to the personal independence of these
individuals, such as in increasing their active movement while transferring.

4.3. Maintenance of the program effects

Our findings revealed that discontinuing the program for eight weeks reverses the effects almost to baseline. Time frames
for diminishing training effects in healthy adults range between 5 and 31 weeks, and are dependent on exercise intensity,
age, and gender (e.g., Hakkinen, Alen, Kallinen, Newton, & Kraemer, 2000; Lemmer et al., 2000). Similar detraining effects
have also been demonstrated in a strength training program in adults with CP who were able to walk and train their larger
muscle mass of the lower extremities (Taylor, Dodd, & Graham, 2004), as well as in adolescents with CP (Verschuren et al.,
2007). Only the authors of the innovative CHRIST program (Lee et al., 2013) were able to demonstrate follow-up effects in
their sample of young children with CP. However, their outcome may be attributed to the young age of the participating
children, who might still be in the ‘‘sensitive period’’ of increased brain plasticity for motor development. Therefore, in
comparison to adults, children may possess a better ability to conduct reorganization and modification of neuro-motor
circuitry (Anderson, Spencer-Smith, & Wood, 2011).

4.4. Association between strength, hand function and ADL measurements

Our findings demonstrated moderate to good associations between most strength and function variables of the upper
extremities as measured during the pre-test in the study sample. Associations between strength and function are common in
elderly or disabled persons (e.g., Buchman, Boyle, Leurgans, Evans, & Bennett, 2009) as well as in adults with CP (Dallmeijer,
Baker, Dodd, & Taylor, 2011; Taylor, Dodd, & Larkin, 2004). A strong association between hand strength and function has
been reported in persons with rheumatoid arthritis (e.g., Bodur, Yilmaz, & Keskin, 2006), and a low to moderate association
has been reported in older adults with intellectual disability (Carmeli, Imam, & Merrick, 2012).

4.5. Limitations

Although this study shows that a strengthening program may reduce the impairment level and activity limitations in
adults with CP, it did not reveal a strength training effect on participation dimensions of functioning and disability. We
believe that the BI measure may not be suitable for addressing such an effect as a result of a short-to medium-term
intervention, and that another more sensitive instrument should be explored. In addition, participants in this study were not
randomly assigned to the control and intervention groups. Therefore, a selection bias may have occurred, and therefore the
results may not be generalized to a larger population.
 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354 4353

4.6. Summary and conclusions

The outcomes of this study reveal that (a) the measurement of hand and wrist strength by means of the Biometrics E-Link
system is reliable in adults with CP, (b) an intensive (three times per week for 90 min each time) strength training program
lasting eight weeks is feasible in non-ambulatory adults with CP, (c) this program significantly increased strength and
manual motor function in intervention group participants compared to a comparison group that participated in regular
rehabilitation treatment, (d) no change was observed based on this program in ADL as measured by the BI, and (e) moderate
to strong associations were established between most strength and motor function variables. Based on these findings, it is
suggested that researchers continue to investigate the impact of strength training on the strength and motor function of non-
ambulatory adults with CP, and to examine in particular to what degree changes in manual motor function are associated
with related ADL, such as dressing, feeding, and transferring. In addition, the effect of such training programs on participation
and quality of life measures should be investigated.

References

Ada, L., Dorsch, S., & Canning, C. G. (2006). Strengthening interventions increase strength and improve activity after stroke: A systematic review. Australian Journal
of Physiotherapy, 52(4), 241–248.
Allen, D., & Barnett, F. (2011). Reliability and validity of an electronic dynamometer for measuring grip strength. International Journal of Therapy and Rehabilitation,
18(5), 258–265.
Allen, J., Dodd, K. J., Taylor, N. F., McBurney, H., & Larkin, H. (2004). Strength training can be enjoyable and beneficial for adults with cerebral palsy. Disability and
Rehabilitation, 26(19), 1121–1127.
American Society of Hand Therapists. (1992). Clinical assessment recommendations (2nd ed.). Garner, NC: American Society of Hand Therapists.
Anderson, V., Spencer-Smith, M., & Wood, A. (2011). Do children really recover better? Neurobehavioural plasticity after early brain insult. Brain, 134, 2197–2221.
Andersson, C., Grooten, W., Hellsten, M., Kaping, K., & Mattsson, E. (2003). Adults with cerebral palsy: Walking ability after progressive strength training.
Developmental Medicine & Child Neurology, 45, 220–228.
Andren, E., & Grimby, G. (2000). Dependence and perceived difficulty in activities of daily living in adults with cerebral palsy and spina bifida. Disability and
Rehabilitation, 10(22), 299–307.
Andren, E., & Grimby, G. (2004). Dependence in daily activities and life satisfaction in adult subjects with cerebral palsy or spina bifida: A follow-up study.
Disability and Rehabilitation, 26(9), 528–536.
Bax, M., Goldstein, M., Rosenbaum, P., Leviton, A., Paneth, N., Dan, B., et al. (2005). Proposed definition and classification of cerebral palsy. Developmental Medicine
& Child Neurology, 47, 571–576.
Bodur, H., Yilmaz, O., & Keskin, D. (2006). Hand disability and related variables in patients with rheumatoid arthritis. Rheumatology International, 26(6), 541–544.
Bottos, M., Feliciangeli, A., & Sciuto, L. (2004). Functional status of adults with cerebral palsy and implications for treatment of children. Developmental Medicine &
Child Neurology, 43, 516–528.
Buchman, A. S., Boyle, P. A., Leurgans, S. E., Evans, D. A., & Bennett, D. A. (2009). Pulmonary function, muscle strength, and incident mobility disability in elders.
Proceedings of the American Thoracic Society, 6(7), 581–587. http://dx.doi.org/10.1513/pats.200905-030RM
Carmeli, E., Imam, B., & Merrick, J. (2012). The relationship of pre-sarcopenia (low muscle mass) and sarcopenia (loss of muscle strength) with functional decline in
individuals with intellectual disability (ID). Archives of Gerontology and Geriatrics, 55(1), 181–185. http://dx.doi.org/10.1016/j.archger.2011.06.032 [Epub 20
July 2011]
Centers for Disease Control Prevention (CDC). (2004). Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment—
United States. MMWR Morbidity and Mortality Weekly Report, 53(3), 57–59.
Cook, C., McCluskey, A., & Bowman, J. (2006). Increasing the use of outcome measures by occupational therapists [Final Research Report]. Penrith South, NSW:
University of Western Sydney.
Crompton, J., Galea, M. P., & Phillips, B. (2007). Hand-held dynamometry for muscle strength measurement in children with cerebral palsy. Developmental
Medicine & Child Neurology, 49(2), 106–111.
Dallmeijer, A. J., Baker, R., Dodd, K. J., & Taylor, N. F. (2011). Association between isometric muscle strength and gait joint kinetics in adolescents and young adults
with cerebral palsy. Gait & Posture, 33(3), 326–332. http://dx.doi.org/10.1016/j.gaitpost.2010.10.092 [Epub 24 December 2010]
Dodd, K. J., Taylor, N. F., & Damiano, D. L. (2002). A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Archives of
Physical Medicine and Rehabilitation, 83(8), 1157–1164.
Dyball, K. M., Taylor, N. F., & Dodd, K. J. (2011). Retest reliability of measuring hip extensor muscle strength in different testing positions in young people with
cerebral palsy. BMC Pediatrics, 11(1), 42. http://dx.doi.org/10.1186/1471-2431-11-42
Euser, A. M., Zoccali, C., Jager, K. J., & Dekker, F. W. (2009). Cohort studies prospective versus retrospective. Nephron Clinical Practice, 113, 214–217.
Fess, E. E., & Moran, C. (1981). Clinical assessment recommendations. Indianapolis, IN: American Society of Hand Therapists.
Gaskin, C. J., & Morris, T. (2008). Physical activity, health-related quality of life, and psychosocial functioning of adults with cerebral palsy. Journal of Physical
Activity and Health, 5(1), 146–157.
Goodson, A., McGregor, A., Douglas, J., & Taylor, P. (2007). Direct, quantitative clinical assessment of hand function: Usefulness and reproducibility. Manual
Therapy, 12, 144–152.
Hakkinen, K., Alen, M., Kallinen, M., Newton, R. U., & Kraemer, W. J. (2000). Neuromuscular adaptation during prolonged strength training, detraining, and re-
strength-training in middleaged and elderly people. European Journal of Applied Physiology, 83, 51–62.
Holsbeeke, L., Ketelaar, M., Schoemaker, M. M., & Gorter, J. W. (2009). Capacity, capability, and performance: Different constructs or three of a kind? Archives of
Physical Medicine and Rehabilitation, 90, 849–855. http://dx.doi.org/10.1016/j.apmr.2008.11.015
Imrhan, S. N., & Rahman, R. (1995). The effects of pinch width on pinch strength of adult males using realistic pinch-handle coupling. International Journal of
Industrial Ergonomics, 16, 123–134.
Jebsen, R. H., Taylor, N., Trieschmann, R. B., Trotter, M. H., & Howard, L. A. (1969). An objective and standardized test of hand function. Archives of Physical Medicine
and Rehabilitation, 50, 311–319.
Kim, D. A., Lee, J. A., Huang, P. W., Lee, M. J., Kim, H. K., Park, J. J., et al. (2012). The effect of comprehensive hand repetitive intensive strength training (CHRIST)
using motion analysis in children with cerebral palsy. Annals of Rehabilitation Medicine, 36, 39–46. http://dx.doi.org/10.5535/arm.2012.36.1.39
Kinnucan, E., Van Heest, A., & Tomhave, W. (2010). Correlation of motor function and stereognosis impairment in upper limb cerebral palsy. The Journal of Hand
Surgery, 35(8), 1317–1322. http://dx.doi.org/10.1016/j.jhsa.2010.04.019
Klingels, K., De Cock, P., Molenaers, G., Desloovere, K., Huenaerts, C., Jaspers, E., et al. (2010). Upper limb motor and sensory impairments in children with
hemiplegic cerebral palsy. Can they be measured reliably? Disability and Rehabilitation, 32(5), 409–416. http://dx.doi.org/10.3109/09638280903171469
Krugger, K. W. (2006). Cerebral palsy: An overview. American Family Physician, 73(1), 91–100.
Lafayette Instrument Company. (1991). The complete Minnesota Dexterity Test examiner’s manual. Lafayette, IN: The Author.
Lee, J. A., You, J. H., Kim, D. A., Lee, M. J., Hwang, P. W., Lee, N. G., et al. (2013). Effects of functional movement strength training on strength, muscle size, kinematics,
and motor function in cerebral palsy: A 3-month follow-up. NeuroRehabilitation, 32(2), 287–295. http://dx.doi.org/10.3233/NRE-130846
4354 Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 4343–4354

Lemmer, J. T., Hurlbut, D. E., Martel, G. F., Tracy, B. L., Ivey, F. M., Metter, E. J., et al. (2000). Age and gender responses to strength training and detraining. Medicine
and Science in Sports & Exercise, 32, 1505–1512.
Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61–65.
Maltais, D. B., Dumas, F., Boucher, N., & Richards, C. L. (2010). Factors related to physical activity in adults with cerebral palsy may differ for walkers and non
walkers. American Journal of Physical Medicine & Rehabilitation, 89(7), 584–597.
Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., & Rogers, S. (1985). Grip and pinch strength: Normative data for adults. Archives of Physical Medicine
and Rehabilitation, 66(2), 69–74.
McDowell, I., & Newell, C. (1996). Measuring health: A guide to rating scales and questionnaires (2nd ed.). New York, NY: Oxford University Press.
O’Connell, D. G., & Barnhart, R. (1995). Improvement in wheelchair propulsion in pediatric wheelchair users through resistance training: A pilot study. Archives of
Physical Medicine and Rehabilitation, 76, 368–372.
Odding, E., Roebroeck, M. E., & Stam, H. J. (2006). The epidemiology of cerebral palsy: Incidence, impairments and risk factors. Disability and Rehabilitation, 28(4),
183–191.
Palisano, R., Rosenbaum, P., Bartlett, D., & Livingston, M. (2007). GMFCS – Expanded and revised. Canada: CanChild Centre for Childhood Disability Research,
McMaster University.
Palisano, R., Rosenbaum, P., Walter, S., Russell, D., Wood, E., & Galuppi, B. (1997). Development and reliability of a system to classify gross motor function in
children with cerebral palsy. Developmental Medicine & Child Neurology, 39, 214–223.
Rimmer, J. (2012). Resistance training for persons with physical disabilities Retrieved from NCPAD. http://www.ncpad.org/94/699/Resistan-
ceTrainingforPersonswithPhysicalDisabilities [Online Article].
Rosenbaum, P., Paneth, N., Leviton, A., Goldstein, M., & Bax, M. (2007). A report: The definition and classification of cerebral palsy. Developmental Medicine & Child
Neurology, 49, 8–14.
Scianni, A., Butler, J. M., Ada, L., & Teixeira-Salmela, L. F. (2009). Muscle strengthening is not effective in children and adolescents with cerebral palsy: A systematic
review. Australian Journal of Physiotherapy, 55(2), 81–87.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin, 86, 420–428.
Sommerfeld, D. K., Eek, E. U., Svensson, A. K., Holmqvist, L. W., & von Arbin, M. H. (2004). Spasticity after stroke: Its occurrence and association with motor
impairments and activity limitations. Stroke, 35(1), 134–139.
Stuart, M., Benvenuti, F., Macko, R., Taviani, A., Segenni, L., Mayer, F., et al. (2009). Community-based adaptive physical activity program for chronic stroke:
Feasibility, safety, and efficacy of the Empoli model. Neurorehabilitation and Neural Repair, 23(7), 726–734. http://dx.doi.org/10.1177/1545968309332734
[Epub 24 March 2009]
Surrey, L. R., Nelson, K., Delelio, C., Mathie-Majors, D., Omel-Edwards, N., Shumaker, J., et al. (2003). A comparison of performance outcomes between the
Minnesota Rate of Manipulation Test and the Minnesota Manual Dexterity Test. Work, 20(2), 97–102.
Surveillance of Cerebral Palsy in Europe (SCPE). (2002). Prevalence and characteristics of children with cerebral palsy in Europe. Developmental Medicine & Child
Neurology, 44, 633–640.
Swets, J. A. (1988). Measuring the accuracy of diagnostic systems. Science, 240, 1285–1293.
Taylor, N. F., Dodd, K. J., & Graham, H. K. (2004). Test–retest reliability of hand-held dynamometric strength testing in young people with cerebral palsy. Archives of
Physical Medicine and Rehabilitation, 85(1), 77–80.
Taylor, N., Dodd, K., & Larkin, H. (2004). Adults with cerebral palsy benefit from participating in a strength training programme at a community gymnasium.
Disability and Rehabilitation, 26(19), 1128–1134.
Thorpe, D. (2009). The role of fitness in health and disease: Status of adults with cerebral palsy. Developmental Medicine & Child Neurology, 51(Suppl. 4), 52–58.
http://dx.doi.org/10.1111/j.1469-8749.2009.03433.x
Trombly, C. A., & Radomski, V. (2007). Occupational therapy for physical dysfunction (7th ed.). Baltimore, MD: Lippincott Williams and Wilkins.
van der Linden, M. L., Aitchison, A. M., Hazlewood, M. E., Hillman, S. J., & Robb, J. E. (2004). Test–retest repeatability of gluteus maximus strength testing using a
fixed digital dynamometer in children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 85(12), 2058–2663.
Van Heest, A., James, M., & Gerwin Carlson, M. (2012). Final Report of the Scientific Committee on Cerebral Palsy. International Federation of Societies for Surgery of
the Hand Retrieved from http://www. ifssh.info/cerebralpalsy2012.pdf.
Vaz, D. V., Mancini, M. C., da Fonseca, S. T., Vieira, D. S., & de Melo Pertence, A. E. (2006). Muscle stiffness and strength and their relation to hand function in children
with hemiplegic cerebral palsy. Developmental Medicine & Child Neurology, 48(9), 728–733.
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.
Verschuren, O., Ketelaar, M., Gorter, J. W., Helders, P. J., Uiterwaal, C. S. P. M. , & Takken, T. (2007). Exercise training program in children and adolescents with
cerebral palsy: A randomized controlled trial. Archives of Pediatric and Adolescent Medicine, 161(11), 1075–1081.
Verschuren, O., Ketelaar, M., Takken, T., Helders, P. J., & Gorter, J. W. (2008). Exercise programs for children with cerebral palsy: A systematic review of the
literature. American Journal of Physical Medicine & Rehabilitation, 87(5), 404–417.
Willemse, L., Brehm, M. A., Scholtes, V. A., Jansen, L., Woudenberg-Vos, H., & Dallmeijer, A. J. (2013). Reliability of isometric lower-extremity muscle strength
measurements in children with cerebral palsy: Implications for measurement design. Physical Therapy, Mar 28 [Epub ahead of print].
Zaffuto-Sforza, C. D. (2005). Aging with cerebral palsy. Physical Medicine & Rehabilitation Clinics of North America, 16(1), 235–249.