1Graduate School of Comprehensive Rehabilitation, University of Osaka Prefecture, Habikino, Habikino City, Osaka, Japan
2Department of Physical Therapy, Faculty of Health Sciences, Kyorin University, Shimorenjaku, Mitaka City, Tokyo, Japan
Submission:June 05, 2023; Published:June 19, 2023
*Corresponding author:Kosuke Yahagi, Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University, Japan
How to cite this article:Kosuke Yahagi, Kuniharu O,Masataka K, Tomomi I, Shuji I. Effect of Training Using Repeated Rolling Movement on Muscle Tone and Range of Motion in Boccia Players with Severe Cerebral Palsy. J Phy Fit Treatment & Sports. 2023; 10(2): 555784. DOI: 10.19080/JPFMTS.2023.10.555784
Objectives: To evaluate the effect of interval rolling (IR) on physical parameters, including the range of motion (ROM), muscle tension, and throwing ability of boccia athletes with severe cerebral palsy (CP). Participants: This study included 10 boccia athletes with CP (GMFCS III–V). Main outcome measures: IR, wherein rolling movements are repeated using an interval training format, was performed on each participant to determine the effect of IR on the athlete’s ROM, muscle tone, and throwing ability. esults: Athlete ROM improved significantly in many directions. muscle on, a significant improvement in muscle tone was observed in the hip extensor muscle groups bilaterally. A comparison between pre- and post-intervention throwing distances using the average value showed a significant improvement in throwing ability. onclusions: The throwing distance of all athletes improved. IR presents an effective training method for boccia athletes with severe CP and may improve physical function and throwing distance.
Keywords:Boccia; Cerebral Palsy; Interval Training; Rolling Movement
Highlights:Interval rolling improved ROM in boccia athletes with CP.
Pre- and post-intervention throwing ability showed a significant improvement.
IR training can improve physical function in boccia athletes with severe CP.
Boccia is a Paralympic sport developed in Europe for people with severe cerebral palsy (CP) or similar motor skill limitations. It is a target sport where players compete for how close one can get to each other. Boccia’s competition classes are classified into four categories: BC1 to BC4. (Table 1) In BC1, BC2, and BC4, players can grasp the ball and throw themselves. BC1 and BC2 are classes of CP. BC4 includes non-CP-associated impairments. BC3 is a class with the most severe disabilities, and because affected people cannot be thrown by themselves, it is thrown using a gradient tool called a ramp. Athletes in BC1 and BC2 have severe disabilities at levels IV–V in the Gross Motor Function Classification System (GMFCS) (Table 1).
The conventional approach to improving the performance of boccia players with CP has primarily included passive training methods, such as stretching aimed at reducing muscle tone in the upper limbs. We [1,2] implemented an exercise plan aiming to improve the strength of boccia athletes by focusing on the trunk, lower limbs, and upper limbs. According to the CP Rehabilitation Guidelines , muscle strength and endurance training for CP is effective, but only for relatively mild CP at GMFCS levels I to III. The effect of muscle strength and endurance training in severe
CP (GMFCS levels IV to V), the target of boccia, is unknown. Most reports have focused on mild CP at the GMFCS I-III level, and the primary training methods used were walking , ergometer, and
swimming . There are no current reports on the efficacy of
muscle strength training in patients with severe CP.
In addition, severe CP has been reported to cause secondary
muscle weakness, muscular endurance deficiencies, and
cardiopulmonary function deterioration due to immobility [6,7].
Training for athletes with severe CP is often like those with mild
CP. However, many movements are difficult to perform, and it is
essential to select training items according to the participant’s
motor function level . Therefore, movements that can be
performed even for severe CP are incorporated into the training
protocol and the training effect; therefore, it is necessary to
incorporate actions that can be performed even in severe CP into
the training protocol and verify the training effect. We introduced
interval rolling (IR) as a training method for boccia athletes with
severe CP. IR utilizes a series of rolling movements applied using
the interval training method. As a result, we confirmed an increase
in heart rate due to an increased exertion level in participants
with severe CP  However, the physical effects of IR and its
impact on throwing ability have not been clarified. Therefore, the
purpose of this study was to evaluate the effect of IR on physical
parameters, including the range of motion (ROM), muscle tension,
and throwing ability of boccia athletes with severe CP.
(BISFed official HP: http://www.bisfed.com/about-boccia/classification/)
Participants included 10 CP players from the Japan Boccia
Association, who throw in sitting positions that do not correspond
to the BC1, BC2, and non-BC categories (Japan’s class, from now
on OP sitting class) (Table 2). The participants were athletes with
no history of heart disease or respiratory illness. We obtained
permission from their doctors to carry out training. At the start of
the intervention, items related to ethical considerations, such as
risks, burdens, benefits, and personal information confidentiality,
were clarified. This study was carried out in accordance with
the Declaration of Helsinki and was approved by the Research
Ethics Committee of the Graduate School of Comprehensive
Rehabilitation, Osaka Prefecture University (approval number:
2019-102). The study’s purpose, method, and risks were explained
to the participants in writing, and consent was obtained. If the
subjects were minors, the same explanation was given to their
parents and consent was obtained (Table 2).
Before starting the training, each participant’s shoulder
and hip joint ROM was measured. The muscle tone of the
elbow, hip flexor, and extensor muscles was measured using
the Modified Ashworth Scale (MAS). In addition, the athlete’s
boccia ball throwing distance was measured. The training was
conducted three times a week for one month, and measurements
were recorded following the training period. ROM and MAS
measurements were performed according to guidelines. The IR
training protocol consisted of workouts with 1 min of exercise to
30 sec of rest (Figure 1). One set included three workout intervals,
and three sets were performed at each training session with 5min
of rest between each set  It was assumed that turning over to
the lateral decubitus position was repeated alternately on the left
and right at the maximum speed (Figure 1).
SPSS ver.25 (IBM, Armonk, New York, USA) was used for data
analysis. The Shapiro-Wilk test was used to confirm normality.
Then the corresponding t-test was performed for comparison of
the changes in ROM and throwing distance before and after the
training intervention. Muscle tone was compared using the Mann-
Whitney U test. The significance level was set at < 5%.
The overall training implementation rate was 100%, with no
dropouts. In addition, none of the participants had any hypertonia
or other physical abnormalities before or after the intervention.
Joint range of motion (Figure 2) shows the change in the ROM of
the shoulder joint before and after IR intervention. Fig. 3 shows
the change in the ROM of the hip joint. In the shoulder joint,
throwing side flexion (p <0.05), abduction (p <0.01), abduction (p
<0.01), non-throwing side flexion (p <0.05), extension (p <0.01),
abduction (p <0.01) significantly improved. In the hip joint,
throwing side flexion (p <0.01), extension (p <0.05), adduction
(p <0.01), abduction (p <0.01), internal rotation (p <0.05), nonthrowing
side flexion (p <0.01), adduction (p <0.01), internal
rotation (p <0.05), and external rotation (p <0.05) significantly
improved. ROM improvement tended to be seen in both the
shoulder and hip joints in the direction of movement, but there
was no statistically significant difference. No reduction in ROM
was observed in any of the participants compared to the preintervention
measurements (Figure 2,3).
Comparing the muscle tone before and after the IR intervention,
a significant difference was observed in the muscle tone of the hip
extensor muscle group bilaterally, and muscle tone improvement
was observed in all athletes. (Right: Figure 4, Left: Figure 5). No
significant difference was observed between the elbow joint on
the throwing side and the flexor muscles of the bilateral hip joints.
No increase in muscle tone was observed in any of the participants
compared to before the intervention (Figure 4,5).
There was a significant difference in throwing distance
observed before and after IR intervention (Figure 6). In addition,
throwing distance was improved in all players (Figure 7). None
of the participants experienced a reduction in throwing distance
This study focuses on activities of daily living movements
that can be performed even in cases of CP. IR training repeatedly
performs rolling movements in an interval format impacting
physical parameters such as ROM and muscle tone. This study
clarified the impact of IR training on the throwing ability of boccia
athletes with severe CP. It was hypothesized that if ROM, muscle
tone, and throwing distance improved following the intervention
period, IR would be an effective training method for improving
physical function and throwing ability in boccia athletes with
severe CP. Significant differences were observed in many
directions of motion before and after IR intervention, and there
was a tendency for improvement in directions where there was
no significant difference.
In addition, there was a significant difference in muscle
tone between the hip extensor muscle groups bilaterally. The
average throwing distance before and after IR intervention
was significantly different, and the players’ throwing distance
improved following the training cycle. These results suggest that
IR is an effective training method for improving physical function
and throwing distance in boccia athletes with severe CP. Our
study has shown that at least once weekly IR intervention for
boccia athletes with severe CP is an effective training method for
increasing heart rate and relative exertion. The IR intervention in
this study was performed three times a week, and an associated
increased heart rate due to greater exertion levels can be expected.
IR is a repetition of rolling movements, which involves the whole
Nitta et al.  reported that the rolling motion impacts the
trunk muscles, the reach or shoulder extension of the upper limbs
for weight transfer, and the flexion or extension of the lower limbs
for pelvic rotation. It is considered that the ROM and muscle tone
were improved by repeating dynamic stretching in the shoulder
and hip joints from continuous intrabody rotation, accomplished
by repeating the rolling movement alternately on the left and
right. Previous studies on baseball and softball athletes [10,11]
have shown that external rotation of the scapula- brachial joint,
posterior tilt of the scapula, and extension of the thoracic spine
contribute significantly to throwing performance. In addition,
when an athlete’s trunk movement is insufficient, the force from
the lower limbs is not sufficiently transmitted.
Without adequate trunk movement, the force exerted at
the time of throwing depends on the power generated by the
upper limbs. Boccia players have decreased trunk function due
to disabilities, and since they throw in a sitting position, the
transmission of force from the lower limbs to the trunk and
upper limbs is poor. Therefore, it is considered that improving
the upper limb ROM by IR facilitated exertion of greater force
during the throwing motion, leading to an improvement in the
throwing distance. Furthermore, it is considered that the activity
of the rotator muscles of the trunk increased due to the rolling
movement, and it became easier to transmit the force from the
trunk to the upper limbs during the throwing motion. This stud
muscles and that IR for boccia athletes with severe CP is useful
for improving ROM of the shoulder and hip joints, muscle tone in
the hip extensor muscles, and throwing distance. In the future, we
will evaluate the strength of the trunk muscles, check the muscle
activity during throwing, and examine the relationship with
the IR effect and the differences due to CP patterns (spasticity
type, athetosis type, etc.). By verifying this, we can build a more
functional training method.
This study introduced a training Programme in which a rolling
movement was repeated in an interval format for boccia athletes
with severe CP. As a result, it was found that IR is an effective
training method to improve physical function and throwing
distance in boccia athletes with severe CP.
Yahagi K, Okuda K, Kataoka M, Imura S, Ichiba T (2021) Research of training method using repeated rolling movement for Boccia players with severe cerebral palsy. Japanese Journal of Physical Fitness and Sports Medicine 70: 229-235.
The Japanese Association of Rehabilitation Medicine (2014) Japanese guidelines for rehabilitation of cerebral palsy second edn, Tokyo: Kanehara, & Co., Ltd, pp. 131-134.
Miyashita K, Kobayashi H, Koshida S, Urabe Y (2009) Proportion of joint ankles in shoulder complex to shoulder maximum eternal rotation angle in throwing. Japanese Journal of Physical Fitness and Sports Medicine 58(8): 379-386.