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Neurological disorders

TREATMENT AND THERAPY OF CEREBRAL PALSY– maximizing function and quality of life

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There is no cure for cerebral palsy, and the treatment is mostly symptomatic with a focus on quality of life and participation in society. It’s important to start as early as possible after diagnosis. The clinical management of children with cerebral palsy requires a multidisciplinary approach that focuses not only on physical health and development, but also on maintaining or improving the child’s quality of life to help the child reach his or her full potential.

TL;DR – the highlights:

  • there is no cure for CP, but the condition will not get worse with time
  • it is not a progressive disease, and early therapies and treatments can reduce symptoms and disabilities while improving mobility
  • management of children with CP requires a multidisciplinary approach
  • we must adapt the care plan to the needs of the child and family
  • it’s important to discuss expectations with families to help them develop realistic goals
  • the goal is to help the child achieve as much independence as possible

How is cerebral palsy treated?

Clinical management of children with cerebral palsy (CP) is aimed at maximizing function and participation in activities and minimizing the effects of factors that can worsen the condition, such as epilepsy, feeding problems, hip dislocation and scoliosis. These management strategies include improving neurologic function early in development, managing comorbidities, weakness, and hypertonia, using rehabilitation techniques to improve motor function, and preventing secondary musculoskeletal problems.1

Management of children with CP requires a team approach that includes a list of multidisciplinary team members such as pediatrician, pediatric orthopedic, pediatric surgeon, pediatric neurologist, physical therapist, occupational therapist, psychologist, nutritionist, speech therapist, and special educator as well. The best outcomes will be achieved when clinical care is organized, evidence-based and multidisciplinary, with an individualized plan of care that meets the needs of the child and family.

We must also be aware that there may be conflicts between what you as a parent expect and hope for and what the evidence suggests will be beneficial or realistically possible given the severity of the CP and the child’s needs. The physical therapist should be an informative resource for the family, including an honest and open discussion about the child’s prognosis and functional abilities. This will help create a care plan based on the goals the family has set.

In the article below, we will focus more on physical therapy management of children with CP.

Physical therapy

Child’s brains are incredibly plastic, which means they are constantly learning and evolving. Therefore, rehabilitation should be encouraged through repeated practice of functionally relevant tasks. It’s supposed to encourage motor learning and the practice of different movement strategies. It’s important to create an environment that encourages the identification of functional goals at the level of activity and participation, rather than solely at the level of impairment, which led to the task-oriented approach.2 The focus of therapy has thus shifted from eliminating deficits to improving function in all areas of functioning, to promote functional independence and a good quality of life despite existing impairments.3

In addition, physical therapy can help improve balance, postural control, gait and assist with mobility and transfers. Increasing lower limb muscle strength through strength training may improve strength and endurance but improving functional mobility will primarily require a targeted functional mobility training intervention.4 Physical therapy should focus on gross motor skills, strengthening and providing mobility aids and other equipment needs.

– improving posture and integraing the child’s reflexes– improving balance and coordination
– training more typical movement patterns and making movement easier– improving range of motion
– improving gross motor skills– improving muscle tone
– improving functional mobility– improving gait and gait training
– improving muscle balance and muscle strength– equipping children with assistive devices
Table 1: What is our job as a pediatric physical therapists

Spasticity

The most common movement disorders in CP are spasticity and dystonia, which affect coordination, muscle strength, and selective motor control. First-line treatment for spasticity and dystonia should include non-pharmacological interventions such as physical therapy and occupational therapy as well as the use of splints and orthotics.5,6

Botulinum toxin injections can be useful for treating spasticity and dystonia, especially when these are focal (limited to individual muscles or groups of muscles) and affect the child’s function or comfort.5 Selective dorsal rhizotomy is a neurosurgical procedure that reduces sensory input in the lumbar and sacral nerve roots, resulting in a significant and permanent reduction in spasticity in the legs, improving walking ability and range of motion.5,6 Another intervention is the administration of intrathecal baclofen via an implantable pump, which allows high concentrations of baclofen to be delivered directly into the cerebrospinal fluid, avoiding many of the side effects of high-dose oral baclofen and acting on both spasticity and dystonia. Medications such as baclofen and diazepam are also commonly used in children with generalized spasticity, but the evidence for the effectiveness of these drugs is less clear.5

You’re probably wondering why we’re talking about surgeries, when we said we’re going to talk about physical therapy interventions. Although these interventions are more medical, it is important to start physical therapy treatment as soon as possible after surgery. After botulinum toxin injection, rehabilitation is required to take full advantage of the reduced spasticity. The effects of botulinum toxin include increased passive and active range of motion, decreased discomfort and pain associated with muscle tension. After selective dorsal rhizotomy, early mobilization should be aimed at maintaining and improving range of motion. We must address weak muscles, especially weak extensor groups and encourage normal movement, postural control, and functional activities such as gait training.

Improving range of motion and contracture prevention

Contractures are a common complication, especially in children with spastic CP. Musculoskeletal deformation leads to biomechanical deficits and more energy-inefficient gait patterns, such as crouch gait. These changes along with increases in height, weight and the natural age-related decline in muscle strength, further reduce mobility.7

Prolonged muscle stretching in children with CP is believed to reduce the risk of deformities. Studies have shown that stretching a spastic muscle for 30 minutes a day maintains its length.8,9 Stretching can be achieved by a number of methods, including manual stretching, weight bearing, splinting, and serial casting. Prolonged stretch can be done manually, using the effect of body weight and gravity, or mechanically, using casts or braces. Weight bearing has been reported to reduce lower limb contracture using tilt-tables and standing frames through prolonged stretching. Serial casting is a common technique used and is most effective in managing contracture associated with spasticity. Serial casting involves repeated applications of casts, usually every one to two weeks, as range of motion is restored.10,11

Management of hip and ankle deformities

Hip disorders are among the most common musculoskeletal problems in children with CP. Approximately 36% of children with CP suffer from hip disorders and the incidence increases with higher GMFCS level.12 This often leads to problems such as dislocation, subluxation, and other related problems that can be solved surgically. It’s recommended to screen for cases of hip deformities using a hip surveillance program. Surgical treatment of hip disorders includes reconstructive procedures such as osteotomy and arthroplasty.6 Research shows that a lack of independent standing can increase the risk for hip dislocation, osteopenia (= loss of bone mineral density that weakens the bones), and lower extremity contractures. Using standers has been shown to reduce contractures in lower limbs and hip dislocations.13

An ankle deformity often seen in children with CP is called equinus. An orthosis can help improve the ankle’s range of motion, which is helpful for improving your child’s gait. Special types of AFO (= ankle and foot orthosis) improve joint function and gait parameters. AFO reduces energy expenditure in children with spastic CP. HKAFO (= hip, knee, ankle, and foot orthosis) is extremely useful in improving gait parameters and is evident in energy saving in children with hemiplegic CP.6

Scoliosis

Spinal deformities in non-ambulatory patients with CP are common and cause postural problems such as pain and unbalanced sitting. Seat adjustments and spinal bracing can be helpful to improve trunk balance, maintain upright posture, and facilitate patient care and function. Improved trunk support leads to better head and neck control and better use of upper limbs.14 It has also been shown that the upright position has a positive effect on respiratory parameters.15 However, we must keep in mind that conservative treatment with braces and adapted trunk supports improves the sitting position but doesn’t prevent curve progression.16

Improving movement and balance

Balance and movement disorders are key coping issues in children with CP as they are necessary for most activities of daily living. Two treatment techniques, whole-body vibration and core stability exercises, have been found to be effective in managing balance problems, with the former being more effective.17 Another therapy that has the potential to improve balance is virtual reality combined with physical therapy, which can be considered an effective treatment for improving functional and dynamic balance.18

Muscle strengthening

In the past, it was believed that excessive effort increases spasticity, that’s why you shouldn’t use strengthening exercises for weak muscles. But studies have shown that weight lifting in children and adolescents with CP can strengthen their knee extensors without a concomitant increase in spasticity of the hamstring muscles.19 Apart from that, increased quadriceps strength has been shown to be associated with improved in crouch gait (less knee flexion), longer strides, and increased walking speed.20 However, we must keep in mind that muscle-strengthening exercises must be task-specific in order to affect functions, such as walking or other activities.

Management of hand dysfunction

Brain damage can cause impairments in hand function, which can be unilateral or bilateral. In the first case, motor control and function on one side of the body are affected. With this type of CP, children have difficulty using their hands on the affected side. Constraint-induced movement therapy (CIMT) is a technique used to improve the function of the affected hand. It’s based on the principles that disuse of the good hand and intensive use of the affected hand improves hand function through brain neuroplasticity. Hand-arm bimanual intensive therapy (HABIT) is a similar technique that improves hand function; however, this technique requires the use of both hands. In a study of children with hemiplegic CP, both strategies were found to be promising techniques for improving hand function; however, the latter is more tolerable than CIMT in children.21,22,23

Assistive devices for children with CP

Many children with CP can be more independent with the help of (simple) equipment. The purpose of these devices is to help improve the child’s quality of life and lead to a more independent lifestyle.

The walking aid is used to stabilize children with poor balance and mobility or with impairment of the lower limbs. There are two types of walkers: anterior walker and posterior or reverse walker. The posterior walker is the most suitable for most children with CP as it provides the best gait pattern and is less energy-consuming. Anterior walkers lead to increased weight bearing on the walker and, as a result, increased hip flexion during gait.

We’ve already mentioned that using standers helps reduce contractures and hip dislocations, but there are many other benefits associated with standing. These include improving bone mineral density, improving bowel function, respiratory function, and circulation, preventing, or improving contractures in the lower limbs, as well as reducing spasticity in lower limbs.

Orthosis are used to maintain the foot in a plantigrade position. This provides a stable base of support that facilitates function and reduces tone during the stance phase of the gait. The ankle orthosis supports the foot and prevents the foot from dropping during the swing phase. When worn at night, a rigid orthosis can prevent contracture. As already mentioned, they also ensure more energy-efficient gait. The brace should be simple, light, yet strong and easy to use. Most importantly, it must ensure and increase functional independence.

There are several types of braces used for spinal deformity as well. These braces are not prescribed to stop the progression of scoliosis, but to improve balance when sitting.

Quality of life

Much of the management of CP has focused on improving motor function, but understanding what most impacts quality of life is important in designing care plans. This includes physical and psychological well-being, moods and emotions, self-perception, autonomy, relationships with parents, social support, school environment, financial resources, and social acceptance. The ability to perform daily life activities and function in society are important areas that also affect the quality of an individual’s life.24

Participation, social and professional, is an important aspect of quality of life. Community participation remains a significant challenge for children and adolescents with CP. Their participation in life activities is greatly reduced, to an extent proportional to the severity and number of disabilities. The inclusion of children with CP in sports activities should be encouraged and adapted accordingly. We must also prepare them for employment by identifying their interests, strengths, and ways to adapt their working environment accordingly when they enter the working age.

In adolescents with CP, it’s important to consider the increased risk of secondary conditions resulting from a sedentary lifestyle, such as obesity, poorer physical fitness, reduced bone density, and generally reduced functional reserve.

We must also pay attention to the child’s transitional phase from adolescence to adulthood. Although the transition to adult services is improving, many young people with CP unfortunately lose contact with health professionals during this time, sometimes due to the lack of specialist services available and the pressures of normal adolescence and adulthood. People with CP may therefore not transition to adult services as expected when leaving pediatric services, but may not approach adult clinicians until much later, often when things go wrong.7

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