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= Exercise and Cerebral Palsy = Exercise is important for people with cerebral palsy (CP) to maintain health and motor movement. In general, they are less physically active than the normal population, due to impairments in muscle strength, coordination and balance. It is suggested that children with cerebral palsy to have one hour of physical activity (moderate to high intensity), five days per week. They could attain a range of benefits through exercises, typically include aerobic exercise, resistance training, as well as cardiorespiratory endurance training. Exercising improves their cardiorespiratory fitness, flexibility, muscular strength and endurance.

On the other hand, people with cerebral palsy encounter several barriers when doing exercise. They are constrained by their health conditions, ages, caregivers' capability. It should be noted that a large variety of symptoms exists among the patients, therefore, the conditions for different patients to exercise should be considered independently.

Aerobic Exercise
Aerobic exercise can improve the patients’ aerobic fitness and general motor function. This type of exercise promotes their mobility, and thus their ability to execute daily tasks. Meanwhile, the type, intensity and duration of exercise should be tailored for patients with different levels of the disorder.

Running
People with cerebral palsy can improve peak aerobic power, which refers to the muscle's ability to use oxygen to generate energy through running. They can also enhance their muscle strength and reduce the energy required for them to ambulate. This kind of aerobic exercise assists the patients to cope with motor impairments and activity restrictions associated with cerebral palsy. Whilst, people with CP have poorer movement economy, which means they need to spend more energy to achieve the same intensity of physical activity, compared with normal people. This particular condition makes running difficult for them as they have cerebral palsy fatigue very frequently. Since they are more subject to overuse injuries, they should also pay attention to proper head, trunk and joints position during the workout.

Aquatic Exercise
Aquatic exercise, which refers to the aerobic exercise in water, may overcome several problems faced by people with cerebral palsy during exercise. They are unable to perform some land-based exercises because they suffer impaired balance, serious contracture, joint problems, together with instability. Conversely, in the water environment, the buoyancy could ease the effect of poor posture control and balance on the performance of exercise. The patients improve gross motor function, including flexibility and muscle strength, through swimming Some aquatic equipments are designed for people with CP. Floating devices, such as, cerebral palsy square float, aquatic head float, aqua ring float, focus in providing support for patients' balance and weak muscle. Sprint Aquatic Water Walking Assistant targets on leg's strength.

Resistance Training
Resistance training can improve the patients’ muscle strength by working against a weight or force. The major benefits of this kind of exercise are improved neuromuscular performance (including the performance of muscles and the nerves serving them), as well as motor function. These physical improvements, including enhanced strength, flexibility and fine-motor cooperation enable them to perform better in daily activities. In one case study, strengthening the knee extensor could support patients’ standing, walking, running and jumping. In specific, resistance exercise particularly trains the weak muscle groups that oppose hypertonic muscle (excess passive tightness or stiffness) so as to balance the abnormal muscle tone through reciprocal inhibition. Therefore, it is important to identify any asymmetrical weakness, through individual muscle group’s assessment, and training of weaker muscles could generate greater effort with more effective contraction. To protect the patients from potential hurt, appropriate warm-up, stretching and cool-down should be performed in slow, dynamic muscle strengthening exercises. Stretching section before exercise could reduce muscle fatigue too.

Cardiorespiratory Endurance Training
CP is known to be related to lowered cardiorespiratory endurance, which is the ability of the lungs, heart, and blood vessels of delivering oxygen to the rest of the body. CP increases the risk of cardiovascular disease and respiratory disease, including risks of angina, upper respiratory infections, and pneumonia as it directly affects muscles that are crucial for heart and lung functioning. It is necessary for people with CP to improve their cardiorespiratory endurance to enhance own physical fitness, which directly affects the ability to carry out tasks without fatigue thus influences potential life quality. Exercise is one of the ways to improve cardiorespiratory endurance. With CP, it is normal that patients have a lower threshold of exercise intensity, nevertheless, cardiorespiratory endurance is more about the ability to sustain a moderate level of exercise. It is suggested that patients should set a goal depending on their heart rate to improve cardiorespiratory endurance. The target heart rate during an exercise should be kept between 40-85% of their maximal heart rate with a recommended duration of 10 minutes for cardiorespiratory fitness. Heart rate should be monitored well during exercise for people with CP, a heart rate of too high is risky given that they are more likely to develop heart failure, while a low heart rate is not effective in cardiorespiratory endurance training. It is important to note that they are not suggested to do trainings that stimulates a sudden and immediate increase in heart rate, the pace should be slowly built up. Some suitable exercises for them to train their cardiorespiratory endurance are Cycling and dancing.

Cycling
Assistive technologies can be used during cycling for people with CP to overcome physical barriers. For example, a Hip-extensor tricycle is a bicycle designed to strengthen the hip extensor muscles. It works by applying different amount of extra weight thus controls the pressure of cycling and is more effective and safe in terms of muscle training. It is commonly applied on children with CP to improve the gait, as walking impairment is one of the symptoms of CP, and the tricycle is said to be able to improve patients' gait thus walk movements through assisting motor control in gait.

Upper Limb Exercises
For some people with CP have problems in using their lower limbs, arm exercisers upper extremity ergometers which act same as a bike can be used instead. Upper extremity ergometers are devices similar to hip-extensor tricycle that functions in a same mechanism except they are arm exercisers. These devices can be widely used by CP patients to improve limb muscles strength thus enhancing their mobility.

Dancing
Several new research have suggested some innovative ways to help people with CP through exercising, dancing is one of them. Dancing requires good skills in balancing movements, effective strength usage, and endurance, while these are usually the weaknesses of them as their muscles function decline with age. Through dancing, these weaknesses could be trained and improved, researches also proved that dancing helps improving neurorehabilitation for CP.

Yoga
Yoga is also said to be a beneficial exercise for CP patients and is commonly introduced to children with CP. One thing about yoga is it can be modified according to each individual's needs and limitations, which is important for CP patients as they usually have different extents of physical limitations and weaknesses. It is stated that yoga improves respiration for CP patients by allowing a rhythmic and deeper breathing, it can also reduce muscle tone hence improving flexibility of patients, leading to an increase of range of motion, which plays an important role in mobility.

Barriers
People with cerebral palsy are capable to perform various types of exercise but their difficulties should be considered. Cerebral palsy affects individuals in many ways, causing different barriers that influence patients' ability to exercise.

Physical Conditions
The main symptoms of cerebral palsy are changes in coordination, strengths, and muscle tone. Other than these symptoms, some extra health issues can arise in people with CP that affect patients' ability to exercise. Epilepsy is one of these issues, people suffer from epilepsy are susceptible to unprovoked seizures repeatedly, results in occasional involuntary movements, for example, loss of consciousness. Research stated that around 40% of individuals suffering from CP experiences epilepsy. These unpredicted seizures increase the risk of any type of exercise, it becomes hard for patients to exercise without supervision. In some severe cases, patients need support in maintaining body position, and to sit or stand, it is hard for them to perform voluntary movements and exercises. Risk evaluation has to be done to ensure their safety before exercising. There are different ways of identifying beneficial and risky exercise interventions for people with CP, for example, Cardiopulmonary exercise testing (CPET) can access patients' exercise tolerance by combining different test results. Clinicians can then evaluate the risks of unsatisfying health outcomes and benefits from different exercise interventions through these procedures.

Cognitive Impairment
Around 40% of people with CP are cognitively impaired to different extents, leading to different outcomes including fatigue, attention issue, trouble in sensory information interpretation and movement control. These outcomes make exercise more difficult for them.

Age
Children with cerebral palsy have weakened muscle's strength and endurance, which are worsened by sedentary lifestyle and a lack of physical activity. By doing different kinds of exercise, they could promote muscle fitness and joint range of motion to tackle with everyday issues associated with physical disability. However, children who have uncontrolled epilepsy or severe osteoporosis should avoid physical activity. Although cerebral palsy is a non-progressive disease, meaning that it would not worsen with age, physical discomfort and stress accumulate in the patient's body, which leads to pain and premature ageing in adults. Great burdens are added on the body as people with CP spend extra energy for everyday tasks repeatedly, attributed to the fatigue and bodily weakness with the disorder.

Caregivers' Capability
Since children with cerebral palsy and patients with higher level of motor impairment rely on the assistance given by the caregivers, the extent of their involvement in exercise would highly depends on their caregivers. However, the caregivers always have time limitation, high stress, financial and emotional burdens, attributed to the special needs of the patients. Time and psychological state of the caregivers would be one of the factors determining the patients' active level.