Authors:

Phoebe Runciman, BA (Hons)

Wayne Derman, MBChB, PhD
Suzanne Ferreira, PhD
Yumna Albertus-Kajee, PhD
Ross Tucker, PhD

Affiliations:

Cerebral Palsy

ORIGINAL RESEARCH ARTICLE

From the UCT/MRC Research Unit for

Exercise Science and Sports Medicine,
University of Cape Town (PR, WD,
YA-K, RT); International Olympic
Committee Research Centre, Cape
Town (WD); and Department of Sport
Science, Stellenbosch University,
South Africa (SF).

Correspondence:
All correspondence and requests for
reprints should be addressed to Phoebe
Runciman, BA (Hons), UCT/MRC
Research Unit for Exercise Science and
Sports Medicine, University of Cape
Town, Boundary Road, Newlands,
7700 Cape Town, South Africa.

Disclosures:
Funded by the University of Cape
Town, National Research Foundation
(NRF) and the German Academic
Exchange Service (DAAD).
Financial disclosure statements have
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in control
of the content of this article.

0894-9115/15/9401-0028
American Journal of Physical
Medicine & Rehabilitation
Copyright * 2014 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0000000000000136

A Descriptive Comparison of Sprint

Cycling Performance and
Neuromuscular Characteristics in
Able-Bodied Athletes and Paralympic
Athletes with Cerebral Palsy
ABSTRACT
Runciman P, Derman W, Ferreira S, Albertus-Kajee Y, Tucker R: A descriptive
comparison of sprint cycling performance and neuromuscular characteristics in
able-bodied athletes and Paralympic athletes with cerebral palsy. Am J Phys Med
Rehabil 2015;94:28Y37.

Objective: This study investigated the sprint cycling performance and neuromuscular characteristics of Paralympic athletes with cerebral palsy (CP) during a
fatiguing maximal cycling trial compared with those of able-bodied (AB) athletes.
Design: Five elite athletes with CP and 16 AB age- and performance-matched
controls performed a 30-sec Wingate cycle test. Power output (W/kg) and fatigue
index (%) were calculated. Electromyography was measured in five bilateral
muscles and expressed in mean amplitude (mV) and median frequency (Hz).

Results: Power output was significantly higher in the AB group (10.4 [0.5] W/kg)
than in the CP group (9.8 [0.5] W/kg) (P G 0.05). Fatigue index was statistically
similar between the AB (27% [0.1%]) and CP (25% [0.1%]) groups. Electromyographic mean amplitude and frequency changed similarly in all muscle groups
tested, in both affected and nonaffected sides, in the CP and AB groups (P G 0.05).
Neuromuscular irregularities were identified in the CP group.

Conclusions: The similarity in fatigue between the CP and AB groups indicates that elite athletes with CP may have a different exercise response to others
with CP. The authors propose that this may result from high-level training over
many years. This has rehabilitative implications, as it indicates near-maximal adaptation of the CP body toward normal levels.
Key Words:
Activation

28

Wingate, Elite, Disability, Electromyography, Fatigue, Spasticity, Muscle

Am. J. Phys. Med. Rehabil. & Vol. 94, No. 1, January 2015
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

erebral palsy (CP), with an incidence of 2.5 per

1000 live births, is one of the most common conditions affecting the neuromuscular system.1 Damage before, during, or directly after birth to one
of three areas of the brain controlling movement
and coordination leads to various movement impairments, including spasticity, dyskinesia, and ataxia.2,3
It has been proposed that exercise performance is
impaired in individuals with CP, purportedly because
of the central inhibition of motor unit activation4,5
caused by these brain lesions. This hypothesis has,
however, been tested in sedentary children, with little
research existing on the effect of CP on exercise
performance and neuromuscular control in welltrained, adult individuals.
Several studies using pediatric participants
have described marked impairments in exercise
performance. Isometric strength5 and sprint running speed6 have been found to be 39% to 56%
lower in individuals with CP than in able-bodied
(AB) controls. Deficits ranging between two and
four standard deviations have been found in Wingate anaerobic performance of children with CP
when compared with age- and activity-matched
children without CP.7,8 Furthermore, Verschuren
et al.9 found that aerobic endurance performance
(VO2peak) using a progressive maximal treadmill test
was 15% lower in individuals with CP.
There is, however, evidence that regular physical training has functional benefits in children
with CP. Intervention studies using sedentary, pediatric samples have found dramatic improvements
in strength, aerobic capacity, and anaerobic capacity in both diplegic and hemiplegic groups, with as
little as 6 wks of training.10Y12 Elite athletes, with
and without disabilities, train at very high volumes
for many years to compete at Olympic level. As no
research exists on this caliber of athletes with CP, it
is intriguing to consider whether elite levels of
training in individuals with CP alter factors that
contribute to performance, compared with AB individuals. These factors include fatigue profiles,
peak power output capacity, and neuromuscular
characteristics. A comparison between performancematched athletes would improve understanding of
the persistence of the effects of CP, despite elite
level training.
The aim of this descriptive study was to investigate the sprint cycle performance and neuromuscular characteristics of elite Paralympic
athletes with CP during a fatiguing maximal cycling
trial compared with those of well-trained, sprint
performance-matched AB athletes. The athletes
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with CP (CP group) were internationally competitive track and field athletes who have trained for
between 6 and 15 hrs/wk over many years. Power
output, muscle activation, and fatigue characteristics, as well as the presence of neuromuscular irregularities, were investigated between the groups.
It was hypothesized that the CP group would perform the Wingate cycle test at a significantly lower
power output than the AB group would and would
show a flatter fatigue profile in power output over
the course of the test. It was further hypothesized
that the lower power output would be associated
with a significantly lower level of muscle activation,
as measured by electromyography (EMG). This
would be in keeping with the published literature
in untrained and pediatric individuals with CP.

METHODS
Participants
Five male elite athletes with spastic hemiplegic
CP and 16 male well-trained AB controls were
recruited for the study. The participants in the CP
group were all track sprinters with hemiplegic CP,
as diagnosed by a physician. They all competed at
international Paralympic level. Three of the participants were classified as T38 and two as T37 athletes, in accordance with the criteria established by
the Cerebral Palsy International Sports and Recreation Association and the International Paralympic
Committee for Paralympic competition. T37 athletes are classified as having true ambulant spastic
hemiplegia and present with distinctive hemiplegic
limitations, with a fully functional nonaffected side.
T38 athletes are distinguished by limitations in
running activities in any limb distribution as a result
of hypertonia, ataxia, or athetosis. Both T38 and T37
athletes present with grade 1 to 2 spasticity on the
Modified Ashworth Scale, which indicates a mild to
moderate level of resting spasticity in the affected
limbs.13 Both T38 and T37 athletes fall into levels 1
to 3 on the Gross Motor Function Classification
System.14 AB participants were selected from
rugby, cricket, and hockey and were additionally
selected only if they played in positions where sprint
ability was an important attribute for performance.
They competed from club to international level.
All participants were unaccustomed to leg cycling exercise, as their main form of exercise was
running-based sprint exercise. Cycling was used as a
modality as the Wingate test is a validated method
for assessing sprint performance and allows the
capture of data at a high sampling rate. The use of
Exercise Performance Comparison Between Athletes

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

29

the Wingate cycle test minimized the effect of experience of cycling on performance in either group.
The groups were matched for age (21.6 [4.2] yrs
and 23.4 [3.0] yrs for the CP and AB groups, respectively) and current 100-m running sprint performance (12.2 [0.9] and 12.3 [1.1] for the for CP
and AB groups, respectively). However, the AB
participants were significantly heavier than the CP
group (body mass index of 25.9 [2.4] kg/m2 vs. 21.1
[1.4] kg/m2). Each participant provided written informed consent before the study. The study was
approved by the universitys Research and Human
Ethics Committee (Ref: 156/2011).

General Overview of Testing

Participants reported to the laboratory on one
occasion. Their height and body mass were measured on calibrated equipment (Seca, Model 708,
Hamburg, Germany). Participants performed a 10sec sprint test, adapted from the standard 30-sec
Wingate anaerobic sprint test (WIN30). After this,
participants rested for 15 mins and then performed
a traditional WIN30. The 10-sec sprint was used to
ensure a maximal effort in WIN30 through a comparison of the first 10 secs power output of both
tests. It was also used for normalization of the EMG
signal recorded during WIN30. Bilateral EMG activity of five muscles was measured during both
tests. The specific details of these measurements are
described subsequently.

Wingate Anaerobic Test

The WIN30 was performed using an electromagnetically braked cycle ergometer (Velotron
Dynafit Pro; Racermate Inc, Seattle, WA). This test
has been validated in many populations, including
CP, and has an interclass correlation coefficient of
0.95 in trained and nontrained individuals with
CP.15,16 A standardized warm-up comprised cycling
at a constant workload of 1.5 W/kg at a self-selected
cadence for 5 mins, followed by a 2-min rest period
before commencement of the 10-sec sprint. Upon
completion of the sprint a break of 15 mins, WIN30
was performed. For standardization in both the
sprint and WIN30, the participants were given
20 secs to reach 100 rpm and then were instructed
to maintain 100 rpm for 10 secs, after which time a
load of 0.075 kg/kg body mass was applied, commencing the test. Participants were instructed to
pedal as hard and as fast as they could against the
resistance for the set period (10 or 30 secs). They
were instructed to remain in a seated position

30

Runciman et al.

throughout the test. Power output was expressed

relative to body mass (W/kg).

Fatigue Index
The fatigue index (FI) was calculated as the
highest power output (W/kg) achieved during the test
minus the power output (W/kg) achieved in the
final second of the test. This was divided by the peak
power. The FI is expressed as a percentage.

Electromyography
Amplitude
The EMG activity of five muscles, namely,
erector spinae (ES), gluteus medius, biceps femoris
(BF), gastrocnemius, and vastus lateralis (VLO), was
recorded in both legs using a telemetric EMG system (GT2400 G2; Noraxon, USA Inc, Scottsdale,
AZ), to allow comparison of affected and nonaffected
sides in the participants with CP. Affected and
nonaffected sides corresponded to their nondominant and dominant sides. In the AB group, the
nondominant and dominant legs were similarly
compared. Before the placement of the electrodes,
the area was shaved and cleaned with ethanol. Two
electrodes (Blue Sensor; Medicotest, Klstykke,
Denmark) were placed over the muscle belly while a
reference electrode was placed on the anterior superior iliac spine of the right leg. Placement was in
accordance with Surface Electromyography for the
Non-Invasive Assessment of Muscle recommendations.17 As with previous research using EMG during
cycling, each test was divided into 5-sec periods for
processing and analysis.18Y20 For analysis of the EMG
signal, the raw EMG signals were band pass filtered
between 20 and 500 Hz. All signals were rectified and
smoothed using root mean square analysis for a
50-msec time window.
The EMG in WIN30 was normalized to the
highest mean amplitude 5-sec period of the 10-sec
sprint. The use of a 10-sec sprint for EMG normalization establishes a constant baseline of EMG
activity to which all subsequent activity is compared
and expressed as a percentage. This has been shown
to be a valid method of normalization for dynamic
exercise.21 To ensure reliable EMG data reporting,
EMG was measured in a rested state as well as
during manual isolation of every muscle. This ensured that the signals recorded were not artefacts of
incorrect placement, movement, or noise generated
by external variables. Mean normalized amplitude of
the 5-sec periods as well as individual root-meansquared EMG signals to identify irregularities were
analyzed for the present study.

Am. J. Phys. Med. Rehabil. & Vol. 94, No. 1, January 2015

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Frequency

RESULTS

Median frequency spectral analysis of the first

and last 5-sec periods of WIN30 was performed
using a Fast Fourier Transform algorithm. EMG
frequency is the rate at which action potentials are
sent to the working muscles from the central
nervous system. Higher median frequencies are a
mechanism of muscular force summation (higher
force), whereas a change in frequency indicates
a change in the type of muscle fibers activated
and, ultimately, fatigue.22,23 The analysis was therefore performed to compare frequency between nonfatigued states (in the first 5 secs of the test) and
fatigued states (in the last 5 secs of the test). The
frequency analyses were between 5 and 500 Hz,
as EMG signal outside this range contains mostly
noise and unusable signal.24 As the authors were
interested in fatigue, the change from prefatigue and
postfatigue is reported.

Wingate Anaerobic Test

Statistical Analysis
Power output and EMG were averaged over 1and 5-sec periods, respectively. All data were analyzed using statistical software (Statistica 10; Statsoft
Inc, Tulsa, OK). Significance was accepted at a
P value G 0.05. Intragroup comparisons between
affected and nonaffected sides, as well as change
over time between the groups, were performed
using repeated-measures analysis of variance (time 
side  group interaction). Descriptive data of
the two groups were compared using independent t tests.

Peak power output during WIN30 was 10.4

(0.5) and 9.8 (0.5) W/kg for the AB and CP groups,
respectively (P G 0.05), and occurred at 10 secs in
both groups (Fig. 1). Power output was significantly
higher in AB participants (P G 0.05).
Power output declined similarly between groups,
with the FI of the AB and CP groups calculated as
27% (6.9%) and 25% (7.3%), respectively.

Electromyography
Amplitude
Figure 2AYE shows normalized EMG activity
on the affected and nonaffected sides of the five
measured muscles in the CP group (left panels) and
AB group (right panels). There were no differences
in mean muscle activity over time between the affected and nonaffected sides, nor between the AB
and CP groups. In four muscle groups (ES, Fig. 2A;
gluteus medius, Fig. 2B; BF, Fig. 2C; gastrocnemius, Fig. 2D), EMG amplitude decreased significantly over the trial in both limbs and in both the
CP and AB groups (P G 0.001). In both the CP and
AB groups, VLO activity remained unchanged over
time in both the CP and AB groups (Fig. 2E).

Frequency
Median frequency decreased significantly but
similarly between the AB and CP groups and on
both the affected and nonaffected sides (Table 1, P G
0.05). Median frequency decreased significantly

FIGURE 1 Power output of 30-sec Wingate test for the able-bodied group (solid triangle) and cerebral palsy group
(open square), with peak in both groups at 10 secs. *P G 0.05, time and group effect.
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Exercise Performance Comparison Between Athletes

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31

FIGURE 2 Normalized electromyographic activation over a 30-sec Wingate test for affected and nonaffected
sides of the cerebral palsy (CP) group (left panel) and correlating nondominant and dominant sides
of theable-bodied (AB) group (right panel) for erector spinae (A), gluteus medius (B), biceps femoris
(C), gastrocnemius (D), and vastus lateralis (E). *P G 0.05, time effect.

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Runciman et al.

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TABLE 1 Percentage (%) decrease in median frequency from prefatigued to postfatigued states for
affected (A) and nonaffected (NA) sides in the cerebral palsy group (left column) and correlating
nondominant (ND) and dominant (D) sides in the able-bodied group (right column)
Cerebral Palsy
Muscle
Erector spinae
Gluteus medius
Biceps femoris
Gastrocnemius
Vastus lateralis
a
b

Able-Bodied

NA

ND

17.16%a
15.10%a
20.24%a
6.91%a
13.35%b

10.08%a
11.42%a
15.68%a
10.48%a
12.68%a

20.99%a
3.08%a
8.54%a
14.67%a
8.48%a

7.03%a
5.17%a
7.41%a
7.45%a
13.10%a

P G 0.05, time effect.

P G 0.05, side and time and group effect.

more in VLO in the affected side of the CP group

compared with the AB group (P G 0.05).

Individual EMG Trace Patterns

Figure 3A shows bilateral coactivation of the
stabilizing ES muscles on each pedal stroke in
an AB participant during WIN30. The pedal stroke
is identified by VLO activation in the bottom trace
of the panel, with the top trace depicting ES
activation. Figure 3B depicts an atypical firing
pattern of the ES observed in a participant with CP.
ES activity occurs during the pedal stroke on the
nonaffected pedal stroke only, with no activity during
the affected sides pedal stroke.
Figure 4A shows a typical firing pattern of two
power producing muscles (BF and VLO) in an AB
participant, which reciprocally activate per pedal

stroke. Figure 4B shows a trace of a participant with

CP. BF activation on both sides increases when the
affected side pedal stroke occurs. On the nonaffected
side, there is significantly less BF activation.
Figure 4C displays continuous activation of BF
muscles of both the affected and nonaffected legs,
with typical firing patterns of the VLO muscle.

DISCUSSION
The present study compared elite athletes with
CP with age- and sprint timeYmatched AB athletes,
in a fatiguing maximal cycling task. It was initially
hypothesized, based on previous literature, that
individuals with CP would present with significantly
lower power outputs and muscle activation levels as
well as display less attenuation of these parameters
with fatigue during a maximal sprint trial. It was

FIGURE 3 Electromyographic irregularities in stabilizing muscles in cerebral palsy. Typical firing pattern of
the ES in an able-bodied athlete (A) with a lack of required coactivation of the ES is observed in a
participant with cerebral palsy (B). VLO, vastus lateralis; ES, erector spinae.
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33

FIGURE 4 Electromyographic irregularities in power-producing muscles in cerebral palsy. Typical firing pattern
of vastus lateralis (VLO) and biceps femoris (BF) in an able-bodied athlete (A) in the first 5-sec epoch of
the 30-sec Wingate test (nonfatigued state) is shown. Coactivation of the BF and VLO (B) and atypical
motor drive of the BF (C) is observed in two participants with cerebral palsy.

found that the AB athletes produce higher power

output throughout WIN30 (Fig. 1) but that all other
aspects of performance, including FI and muscle
activation levels, were similar between groups,
providing evidence that athletes with CP can overcome previously documented deficits in performance and neuromuscular activation.

34

Runciman et al.

FI was similar between groups, indicative of

a similar decline in power output from peak value,
measured at similar time points in CP and AB
participants (Fig. 1). Associated mean EMG changed
similarly over the trial in all measured musclegroups (Fig. 2). Furthermore, changes in EMG
over the trial were similar between the affected

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and nonaffected sides in the CP group and corresponding nondominant and dominant sides in the
AB group.
The existing literature suggests that individuals
with similar forms of CP to the current sample exhibit lower levels of neuromuscular fatigue as a
result of suboptimal central drive and the consequent inability to produce enough isokinetic torque
to create fatigue.5,25,26 This has been attributed
to multiple factors including spasticity, coactivation, type I muscle fiber predominance, and
weakness.27Y30 This studys data suggest that despite
weakness, demonstrated by lower power outputs in
the Wingate test (10.4 [0.5] W/kg and 9.8 [0.5] W/kg
for the AB and CP groups, respectively; P G 0.05),
the associated lower neuromuscular fatigue shown
by literature was not present in this elite athletic
sample. This was demonstrated by the similarity in FI
and progressive decrease in EMG activity over the
trial between the AB and CP groups in all five muscles
tested (P G 0.05).
It is interesting to speculate whether these results may be the effect of long-term, high-level
athletic training. Research to date that shows deficits in performance and flattened fatigue profiles in
CP has been performed on sedentary children.31
However, marked changes in muscular adaptation
have been observed with exercise training in these
samples, making it clear that there is capacity to
significantly improve exercise performance and
functional capacity.10Y12 The current sample of
elite-level athletes may represent a group of individuals with CP who have reached near-maximal
muscular adaptation, including the possible movement away from type I muscle fiber predominance
muscular weakness. This may explain the similar
fatigue profiles seen between groups (FI of 27%
[6.9%] and 25% [7.3%] for the AB and CP groups,
respectively; Fig. 1) and a greater peak power output
achieved in the CP group compared with previously
published power values for soccer and cycling
nonelite athletes with CP (9.8 vs. 8.3 W/kg).16 Frequency analysis of the EMG signal further supports
that the CP and AB groups fatigued similarly, as
frequency shifts were similar between the groups.
The observed changes, a shift from higher to lower
frequencies, are typical of a shift from type II muscle
fiber activation to type I fiber activation because of
fatigue of the fast-twitch power-producing fibers.32
The similarity in frequency decline in both the CP
and AB groups may further support the hypotheses
of (1) a higher proportion of and (2) a higher use of
type II muscle fibers in this sample of elite athletes
with CP.32,33 A significantly greater reduction in
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frequency occurred in the CP groups affected side

VLO (the primary power producing muscle), further
suggesting the utilization of type II muscle fibers.
It may be argued that the similarities in physiology observed between the groups may be the
result of a sample of athletes in classes T37 and T38,
representing a group of individuals with milder
forms of CP. The authors believe that this is not the
primary origin of the results of the present study, as
they only refer to previous studies conducted using
individuals in Gross Motor Function Classification
System levels 1 to 3, which are comparable with the
level of impairment in the current sample of athletes with CP. The possibility of this contributing
factor, however, cannot be disregarded.
The second important finding was the presence
of neuromuscular irregularities identified in the
athletes with CP that are associated with CP, in both
stabilizing (ES muscles, Fig. 3) and power (VLO and
BF muscles, Fig. 4) muscles, despite the similar
response to fatigue to AB athletes. Figure 3 shows
coactivation of both ES muscles on the nonaffected
sides pedal stroke and complete lack of activation
on the affected sides pedal stroke of an athlete with
CP (Fig. 3B). The existing theory on the role of the
stabilizing ES muscles during locomotion is that
the ES muscles bilaterally coactivate with heel
strike/pedal stroke to counteract unwanted trunk
movement.34,35 They also, in conjunction with other
lower back muscles, balance external loads to decrease forces on the spine, which, when disrupted,
leads to injury.36,37 Thus, the lack of firing on the
CPs affected side may impair the stability required
for that sides pedal stroke and predispose this
athlete to injury.
Furthermore, neuromuscular irregularities in
power muscles (Fig. 4) may have an impact on injury incidence, as well as overall performance.38,39
Figure 4A demonstrates typical BF and VLO activity
in an AB participant. VLO and BF are active in a
reciprocal manner, ensuring that the application
of downward force to the pedal is timed appropriately during the upstroke. Figure 4B demonstrates
coactivation of the agonist (VLO) and antagonist
(BF) muscles on the affected side, with a lack of
activation on the nonaffected side, where it is also
required for correct pedal power production. van
Ingen Schenau et al.40 concluded that biarticular
muscles, including the BF, were involved in the
control of the direction of force application on the
pedal during cycling; therefore, coactivation may
produce counteracting torques on each pedal stroke.
That is, the BF may fire on the downward portion of
the pedal stroke, essentially exerting opposite forces
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35

to the VLO, which would result in both forces being

exerted on the pedal simultaneously with a consequent loss of economy. The observed coactivation of
this antagonist pair, however, may also be an activation strategy required for increased joint stability
on the affected side, by equalizing articular movement and pressure during force application.41Y43
Furthermore Figure 4C displays continuous activation of BF muscles of both the affected and
nonaffected legs despite typical firing patterns of
the VLO muscle, indicating an atypical motor
drive.4 The complete lack of coherent firing patterns may lead to a lack of coordinated power production for both the affected and nonaffected sides,
which would result in a reduction in power output.
There may also be an increased risk of injury owing
to compensation by the antagonist muscle groups,
which has been shown to be a major risk factor for
muscle injuries in runners.44,45
This descriptive study has identified interesting
findings in an unstudied sample, but with certain
limitations. This study was unable to obtain strokeby-stroke bilateral power output on the cycle ergometer, a measurement that would have proved
very useful in identifying neuromuscular differences between sides. The use of M-wave stimulation
would have also allowed for absolute amplitude
EMG activation comparisons between sides and is
advised for future studies in this area. Finally, it
would have been ideal to be able to conduct fiber
typing via biopsy in the athletes, which would
support this studys hypothesis, but the expensive
and invasive nature of the test needs to be taken into
consideration. Future studies in this area may elucidate mechanisms for the findings of the current
study. Future studies are also required during running exercise, applicable to the athletes involved.
The present study described performance and
neuromuscular characteristics of elite athletes with
CP during maximal sprint cycling. The similarity in
power output FI as well as neuromuscular fatigue
between the CP and AB groups indicates that the
current sample of elite athletes with CP may have a
different physiology from the previously studied
untrained individuals with CP. The authors propose
that this movement toward AB levels may be a result
of high-level training over many years. This may have
both empirical and clinical application, as it may indicate the uppermost ability of the cerebral-palsied
body to adapt toward normal levels. If so, these
findings have large implications for CP rehabilitation
and athletic participation as a form of rehabilitation.
Further research, however, is required to either
support or refute findings of the current study.

36

Runciman et al.

ACKNOWLEDGMENTS

We thank the athletes for their time and the

Sport Physiology Laboratory, Department of Sport
Science, Stellenbosch University, for their assistance.
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