All of those principles are based on human physiology and can be applied to disabled and nondisabled people. I don't want to explain all of those principles. However, it is important for any individual who wants to provide an intensive approach to know them before practicing. Without them, it will be impossible to design a safe and effective program.

The most important principle is progressive overload. The main purpose of an intensive program is to maximize the effect of intensive stimulation of all body systems. To induce those changes (increase strength, endurance, improve function, etc.), there has to be applied a certain level of stimulation (intensity). The level of stimulation has to be above threshold level. What it really means is that the intensity of performed exercises has to be high enough to induce a physiological response from our body. If during an exercise session the intensity is too low, there will be no adaptive changes and no progress.

After undergoing intensive exercises the body experiences fatigue. In the following period our body rests. During the resting process all body systems are recovering. The body is anticipating the next exercise session and prepares all systems for the next stress. The lungs increase capacity to be able to intake more oxygen. Muscles become stronger to be able to work against higher resistance. There are more stored energy sources. This phase is called supercompensation. During the next exercise session an individual can work harder, longer, and is able to perform more complex tasks. This is called adaptation. During the next session we can apply even a higher stimulation (intensity) on the body. The response is further adaptation. In our case when working wiht individuals with CP, further adaptation can result in the ability to roll, sit and walk sometimes for the first time in their life.

Also of importance is the time of recovery. Usually the recovery period, including supercompensation, is 24 hours (Herberger 1977). Variations in supercompensation depend on the type and intensity of the exercises. For instance, after endurance exercises supercompensation may occur after 6 to 8 hours. After a intensive session that places high demands on the CNS (Central Nervous System), it may take more than 24 hours, and occasionally even 48 hours. In order to achieve progress the next exercise session has to occur during supercompensation. If the rest period is too long, all the benefits from the supercompensation phase are decreasing and the body returns to its normal state.

Now we can understand why regular therapy sessions can not be effective in the current model (1 hour, 1-2 times per week). First, it does not apply enough stimulation to induce physiological responses. Second, the rest time between sessions is too long. We can also now understand why regular therapy even 3-4 hours per day will not give us the expected results. The intensity of the exercise session is not related to only one factor - length of session. There are many other elements characterizing the intensity of the exercises:

• length of rest periods between exercises
  
• number of exercises
  
• number of repetitions
  
• number of sets
  
• amount of resistance
  
• technical difficulties and complexity of exercises

Generally we can increase the intensity of the exercise session through an increase in volume (time and frequency) and muscle force (resistance training). Utilizing those elements, we can modify and intensify each session to meet the requirements of the progressive overload principle........................................

To design an effective intensive exercise program for individuals with disabilities, it is necessary to combine the knowledge from a few disciplines. A good therapist has to know and understand how the body works, how to assess the influence of disabilities on functional potential, but also has to know how to train the body, what exercises to choose, and how to modify them. He/she has to work as a coach and trainer. I have found in recent physical therapy literature and magazines that many therapists understand this and support this approach.

RESULTS OF AN INTENSIVE PROGRAM
In recent years, mainly through the media and internet, many of us were able to gather information about significant progress noted as a result of intensive exercise programs. Many of those sources are anecdotal and not supported or confirmed by the medical society.

In reality the results of an intensive exercise program can vary depending on the program, severity of disabilities, and the exercise method and equipment used. The common observed improvements are: increased strength, endurance, balance, coordination, better functional skills, speech, cognition, decreased muscle tone, and better alignment of the body. Generally up to 90% of the children and teenagers undergoing intensive programs improve in strength and functional skills. To explain this please read the article in this issue on Strength Training for CP.

Does the improvement achieved during an intensive exercise program last long? What are the long-term effects of this approach? Those are common questions from parents and professionals. I have to be honest. Intensive therapy is not a magic pill. It will not fix all the problems and the results will not last forever.Those positive changes can be maintained sometimes only for a few months.

Why?

Because as I mentioned before, we do not cure CP. We treat individuals with CP as nondisabled people. An able bodied person in order to improve his/her own fitness level or participate in a competition has to change his/her own life style. He goes to the gym a few times a week for a few months and changes nutritional habits. It improves his fitness condition. He is stronger, faster, more flexible and able to perform activities never done before. Then he gave up. No more exercises. No maintenance program, no gym. Fast food. In a few months his body goes back to normal. He loses strength, flexibility, endurance, and all his new skills. His body's systems return to the level before exercises. If he chooses an even more sedentary life style, his body will deteriorate even more. The same rules apply to individuals with CP.

For many individuals with CP to learn how to walk is like training to win a gold Olympic medal. If after achieving their goals they go back to the previous life style in a few months they will be back walking with a walker or sitting in the wheelchair. This is true about CP. This condition requires a lifetime management and constant exercises. Also, parents have to understand that in order to maintain the progress achieved during an intensive program, they have to commit their time and effort and continue the prescribed home exercise program. I have to admit based on my years of experience that this is the main factor why the results of intensive therapy do not last too long.

There is also another important factor related to the short life span of the achieved progress. During exercises individuals learn new motor skills. The learning process of a new movement has a few phases. First we are receiving external information about movement (verbal description, visual presentation, observation). Then we try to repeat certain movements through activation of different muscles. Slowly through repetition and guidance we gain strength, balance, coordination, and learn how to perform the movement.

In this phase we have to constantly control the quality of the movement and think (control muscles). This phase is called generalization. It can occur after a few weeks of exercises.

In the next phase after hundreds of repetitions, we are able to perform certain motor tasks without thinking. This phase is called automatization. For Cerebral Pasly individuals it can take thousands of repetitions, sometimes months or years, of exercises to reach this phase.

Because of the short duration (2-4 weeks), intensive exercise programs are able to reach only the generalization phase of motor learning. Skills learned during this phase do not last long if they are not repeated and reinforced. Without a proper maintenance program provided by parents, school, or therapist, we cannot expect any long-term results. I am sure that this will answer and help to explain why intensive therapy research failed to prove the long-term effectiveness of this approach.

As a last word in this section, I would like to add that very often the results of intensive programs are enhanced by using special exercise equipment (e.g. Universal Exercise Unit, weights, fitness machines, different types of Suits: UpSuit, TheraSuit, Spiral Suit, Benik vest, splints, braces and other devices).

SPECIAL CONSIDERATION
Many parents who look for new hope for their children face dilemmas with new alternative methods or programs to choose from. It's hard to make a decision that in consequences can cost thousands of dollars and when outcomes are uncertain. Before making any decisions I would advise you to do the homework. Find as much information as possible about the method. Start with the Internet. Visit web sites. Visit chat rooms and parents to parents e-mail groups. Call the facility providing the program. Ask for information, and ask somebody to explain the method. If you don't understand, ask again.

If somebody is not able to explain his/her program in clear simple language, it means that probably he/she does not fully understand what he/she does. Ask your therapist or physician about the method and outcomes. Being a parent and therapist, I look for one simple program, not a combination of many different methods at the same time. This is one of the current trends to attract more parents. I can agree to a combination of intensive exercises and manual therapy with other recreational activities and non-intensive approaches in the same day.

Example: 3-4 hours of treatment in the morning and in the afternoon other activities like aquatics, horseback riding, and maybe also HBOT.

It is important that the adjunctive methods being utilized are geared to the individual's specific condition and towards their goals. They should enhance the progress , not hinder it. Refer to page 18, the article on INRS to see an example of an intensive program with added methods that all complement each other with the individual's main goal in mind. But offering 6 or more hours of therapy in one day including different methods and techniques can be too much. It looks like somebody is trying to treat a headache by taking many different pills at the same time (Motrin, Tylenol, Advil, Aspirin). This approach can be too intensive and it can lead to overstimulation.

The patient will become too tired.The body does not have enough time to rest. The consequence is the supercompensation phase does not occur and there are no adaptive changes and expected progress. When the fatique level cumulates, the body is more prone to injury. The patient can react negatively to treatment (uncooperative, crying). If someone claims that all methods offered by their facility help individuals with CP, it means that probably none of them are good enough.

Another very important aspect of using a combination of a few methods in the same day is a possibility of counter actions and side effects. Example: Free radicals from low pressure hyperbaric oxygen treatment are not desired when applying electromagnetic resonance therapy. There are almost no studies showing which combination of treatment methods are safe or most effective. My intention is not to scare or discourage parents. So far the intensive therapy provided in many facilities proved to be very safe and highly effective.

To summarize, I would like to encourage parents to try an intensive exercise program for their children. I advise therapists to learn more about it and practice it in their own clinics. For older individuals with CP, this approach could be a new door to achieve greater functional independence in their life. However, intensive exercise programs show only short term effects. It is very encouraging that those effects occur and with proper management can be sustained. For many individuals frustrated with the lack of progress after years of therapy, this fast progress in a short time will give them hope for the future.

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