There are several kinds of therapeutic approaches to treating cerebral palsy. Physical and occupational therapy can take various forms: muscle strength training, constraint-induced movement therapy, physiotherapy, and several others. Participation in such therapies has been shown to reduce stiffness, increase joint range, increase strength and enhance muscular coordination in the cerebral palsy sufferer. In these ways, physical and occupational therapy can augment overall motor control--specifically, improving gait function, hand function and posture. In some cases of cerebral palsy, the patient is communication disabled. In these cases, language and speech therapy may be utilized.
BACKGROUND AND PURPOSE: This case report describes the use of "Pediatric Constraint-Induced Therapy (Pediatric CI Therapy)" given on 2 separate occasions for a young child with quadriparetic cerebral palsy.
CASE DESCRIPTION: The child was 15 months of age at the beginning of the first episode of care. She had previously received weekly physical therapy and occupational therapy for 11 months, but she had no functional use of her right upper extremity (UE), independently or in an assistive manner. She scored from 5 to 7 months below her chronological age on developmental assessments in gross motor, fine motor, and self-help skills.
INTERVENTION: Pediatric CI Therapy involved placement of a full-arm, bivalved cast on the child's less affected UE while providing 3 weeks of intensive intervention (6 hours a day) for the child's more affected UE (intervention 1). Therapy included activities that were goal oriented but broken down into progressively more challenging step-by-step tasks. Pediatric CI Therapy was administered again 5 months later to promote UE skills and independence (intervention 2).
OUTCOMES: The child developed new behaviors throughout both interventions. During intervention 1, the child developed independent reach, grasp, release, weight bearing (positioned prone on elbows) of both UEs, gestures, self-feeding, sitting, and increased interactive play using both UEs. During intervention 2, she had increased independence and improved quality of UE movement, as supported by blinded clinical evaluations and parent ratings.
[DeLuca, S. C., Echols, K., Ramey, S. L. & Taub, E. (2003). Pediatric constraint-induced movement therapy for a young child with cerebral palsy: Two episodes of care. Physical Therapy, 83(11), 1003-13.]
OBJECTIVES: To describe the use of physiotherapy services and alternative therapies by a population of children with moderate to severe cerebral palsy (CP). DESIGN: Descriptive cross-sectional survey.
SUBJECTS: A total of 212 parents of children aged 4-14 years with moderate to severe CP were identified from the Northern Ireland Cerebral Palsy Register (NICPR) and a random subsample of their paediatric physiotherapists.
MAIN MEASURES: A standardized description of motor impairment or assessment form; a postal questionnaire to parents and paediatric physiotherapists (to validate parents' reports of service use).
RESPONSE RATES: In total, 85% of parent questionnaires were returned and 100% of paediatric physiotherapists responded.
RESULTS: Service use among families was high; on average the families had contact with approximately seven services in a 6-month time interval. The overwhelming majority of children (96%) received physiotherapy during the school term and most (59%) received treatment at least twice a week for 30 min; 43% of children had their physiotherapy discontinued over the summer holidays. Over one-quarter (28%) of families had opted out of the NHS and bought alternatives like conductive education (21%) or private forms of conventional physiotherapy (16%). Children with more severe forms of CP, in special education, particularly at schools for physical disability, were high-intensity users of the physiotherapy service. Despite this, 74% of parents wanted more physiotherapy for their child.
CONCLUSIONS AND IMPLICATIONS: The demand for physiotherapy services is likely to continue given the relatively stable prevalence rate of CP, the proportion of children with disabling CP and the level of parent interest in the service. A number of quality aspects and gaps in the service have been identified.
[Parkes, J., Donnelly, M., Dolk, H. & Hill, N. (2002). Use of physiotherapy and alternatives by children with cerebral palsy: A population study. Child: Care, Health and Development, 28(6), 469-77.]
The purpose of this prospective case study design was to describe the changes in dressing skills for five Kenyan children with cerebral palsy who participated in a 10-week occupational therapy intervention programme. The training sessions were individually designed to meet the needs of the child. The children's performances on undressing and dressing and the time these tasks took was used as a baseline and outcome measure. These measurements were documented by video films and then analysed using visual inspection and converted into the scores of the Klein-Bell Activities of Daily Living (ADL) Scale. The results for each child were analysed using a simplified version of the Reliability Change Index. The results showed that four of the five children improved their ability to dress and that the children increased their time to undress significantly (p<0.05). Three children needed more time and two children needed less time for dressing (p<0.05). The results were influenced by the activity limitations among these children and the environmental, social backgrounds, cultural and economic situation unique to Kenya. It is recommended that case study research be used to validate clinical practice in paediatric occupational therapy and to understand cultural differences and its impact on health care.
[Guidetti, S. & Derback, I. (2001). Description of self-care training in occupational therapy: Case studies of five Kenyan children with cerebral palsy. Occupational Therapy International, 8(1), 34-48.]
The purpose of this article is to present the basics of Bobath Neurodevelopment Therapy (NDT) for the rehabilitation of patients with cerebral palsy, based on the fundamentals of neurophysiology.<br /> Two factors are continually stressed in therapy: first, postural tension, whose quality provides the foundation for the development of motor coordination, both normal and pathological, and plays a role in shaping the mechanism of the normal postural reflex; and secondly, the impact of damage to the central nervous system on the process of its growth and development.<br /> The practical application of the theoretical assumptions includes the use of inhibition, facilitation, and stimulation by key points of control, preparatory to evoking more nearly normal motor responses.
[Klimont, L. (2001). Principles of Bobath neuro-developmental therapy in cerebral palsy. Ortopedia, Traumatologia, Rehabilitacja, 3(4), 527-30.]
PURPOSE: To explore therapists' goal setting and intervention with children with cerebral palsy, and to examine their acceptance of children's use of compensatory movement strategies.
METHODS: Interviews were conducted with 23 occupational therapists and 31 physical therapists. Goals and assumptions of relationships between intervention approaches and expected outcomes were coded using the International Classification of Functioning, Disability, and Health (ICF). Therapists' acceptance of compensatory movement strategies was rated.
RESULTS: Thirty-three therapists identified goals representing the ICF activity component. Therapists working with younger children identified goals representing the ICF body function/structure component. Twenty-four therapists assumed that an intervention targeted at 1 ICF component would affect an outcome in a different component. Eleven therapists would not accept compensatory movement strategies.
CONCLUSIONS: Most therapists' goals are congruent with principles encouraging functional goals. The ICF matrix developed for this study may be useful for clinical evaluation and documentation of assumed relationships among interventions and outcomes.
[Darrah, J., Wiart, L. & Magill-Evans, J. (2008). Do therapists’ goals and interventions for children with cerebral palsy reflect principles in contemporary literature? Pediatric Physical Therapy, 20(4), 334-9.]
The purpose of this article was to conduct a systematic review of studies that examined the efficacy and effectiveness of postural control intervention strategies for children with CP. Only physical therapy interventions were included, e.g. adaptive seating devices, ankle foot orthoses, neurodevelopmental treatment. A multifaceted search strategy was employed to identify all potential studies published between 1990 and 2004. The search strategy included electronic databases, reference list scanning, author and citation tracking of relevant studies, and hand searching of pediatric physical therapy journals and conference proceedings. Twelve studies (1991-2004), comprising ten group design studies and two single subject studies, met our inclusion criteria. A variety of age ranges and severity of children with cerebral palsy (n=132) participated in the studies. The study quality scores ranged from 2 to 7 (total possible range of 0 to 7) with a median score of 5.5 and a mode of 6. As was true in an earlier systematic review on adaptive seating, most of the 12 'experimental' studies published since 1990 that were aimed at evaluating the effectiveness of postural control strategies provided lower levels of evidence, i.e. Sackett Levels III to V. Additional studies with stronger designs are needed to establish that postural control interventions for children with CP are effective.
[Harris, S. R. & Roxborough, L. (2005). Efficacy and effectiveness of physical therapy in enhancing postural control in children with cerebral palsy. Neural Plasticity, 12(2-3), 229-43.]
BACKGROUND: The production of speech, language and gesture for communication is often affected by cerebral palsy. Communication difficulties associated with cerebral palsy can be multifactorial, arising from motor, intellectual and / or sensory impairments, and children with this diagnosis can experience mild to severe difficulties in expressing themselves. They are often referred to speech and language therapy (SLT) services, to maximise their communication skills and help them to take an independent a role as possible in interaction. This can include introducing augmentative and alternative communication (AAC) systems, such as symbol charts or speech synthesizers, as well treating children's natural forms of communication. Various strategies have been used to treat the communication disorders associated with cerebral palsy but evidence of their effectiveness is limited.
OBJECTIVES: To determine the effectiveness of SLT that focuses on the child or their familiar communication partners, as measured by change in interaction patterns. To determine if individual types of SLT intervention are more effective than others in changing interaction patterns.
SEARCH STRATEGY: Searches were conducted of MEDLINE, CINAHL, EMBASE, PSYCH INFO, LLBA, ERIC, WEB of SCIENCE, NRR, BEI, SIGLE up to December 2002. References from identified studies were examined and relevant journals and conference reports were hand-searched.
SELECTION CRITERIA: Any experimental study containing an element of control was included in this review. This includes non-randomised group studies and single case experimental designs in which two interventions were compared or two communication processes were examined.
DATA COLLECTION AND ANALYSIS: L Pennington searched for and selected studies for inclusion. J Goldbart and J Marshall independently assessed separate random samples each comprising 25% of all identified studies. Two reviewers independently abstracted data from each selected study. Disagreements were settled by discussion between the three reviewers.
MAIN RESULTS: Eleven studies were included in the review. Seven studies evaluated treatment given directly to children, four investigated the effects of training for communication partners. Subjects in the studies varied widely in age, type and severity of cerebral palsy, cognitive and linguistic skills. Studies focusing directly on children suggest that this model of therapy delivery has been associated with increases in treated communication skills by individual children. However, methodological flaws prevent firm conclusions being made about the effectiveness of therapy. In addition, maintenance of these skills was not investigated thoroughly. The studies targeting communication partners describe small exploratory group projects which contain insufficient detail to allow replication, have very low power and cannot provide evidence of effectiveness of this type of treatment.
REVIEWERS' CONCLUSIONS: Firm evidence of the positive effects of SLT for children with cerebral palsy has not been demonstrated by this review. However, positive trends in communication change were shown. No change in practice is recommended from this review. Further research is needed to describe this client group, and its possible clinical subgroups, and the methods of treatment currently used in SLT. Research is also needed to investigate the effectiveness of new and established interventions and their acceptability to families. Rigour in research practice needs to be extended to enable firm associations between therapy and communication change to be made.
[Pennington, L., Goldbart, J. & Marshall, J. (2004). Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database of Systematic Reviews (online), 2, CD003466.]
The aim of the study was to investigate the influence of muscle strength training on gait outcomes in children with cerebral palsy. Sixteen children (two females, 14 males, Gross Motor Function Classification System levels I-II, mean age 12y 6mo, range 9y 4mo-15y 4mo) underwent muscle strength measurement using a handheld device, Gross Motor Function Measure (GMFM) assessment, three-dimensional gait analysis, joint range of motion assessment, and grading of spasticity before and after 8 weeks of training. All participants had a diagnosis of spastic diplegia and could walk without aids. Training consisted of exercises for lower extremity muscles with free weights, rubber bands, and body weight for resistance, three times a week. Values for muscle strength below normal were identified in all children; this was most pronounced at the ankle, followed by the hip muscles. After training, muscle strength and GMFM scores increased, velocity was unchanged, stride length increased, and cadence was reduced. There was an increase in hip extensor moment and power generated at push off. Eight weeks of muscle strength training can increase muscle strength and improve gait function.
[Eek, M. N., Tranberg, R., Zugner, R., Alkema, K. & Beckung, E. (2008). Muscle strength training to improve gait function in children with cerebral palsy. Developmental Medicine and Child Neurology, 50(10), 759-64.]
Children with hemiplegic cerebral palsy (CP) have impairments in bimanual coordination above and beyond their unilateral impairments. Recently we developed hand-arm bimanual intensive therapy (HABIT), using the principles of motor learning, and neuroplasticity, to address these bimanual impairments. A single-blinded randomized control study of HABIT was performed to examine its efficacy in children with hemiplegic CP with mild to moderate hand involvement. Twenty children (age range 3 y 6 mo-15 y 6 mo) were randomized to either an intervention (n=10: seven males, three females; mean age 8 y 7 mo, SD 4 y) or a delayed treatment control group (n=10: seven males, three females; mean age 6 y 10 mo, SD 2 y 4 mo). Children were engaged in play and functional activities that provided structured bimanual practice 6 hours per day for 10 days. Each child was evaluated immediately before and after the intervention, and again at 1-month post-intervention. Children in the intervention group demonstrated improved scores on the Assisting Hand Assessment, increased involved extremity use measured using accelerometry and a caregiver survey, bimanual items of the Bruininks-Oseretsky Test of Motor Proficiency, and the simultaneity of completing a draw-opening task with two hands (p<0.05 in all cases). The results suggest that for this carefully selected subgroup of children with hemiplegic CP, HABIT appears to be efficacious in improving bimanual hand use.
[Gordon, A. M., Schneider, J. A., Chinnan, A. & Charles, J. R. (2007). Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: A randomized control trial. Developmental Medicine and Child Neurology, 49(11), 830-8.]
Constraint-induced (CI) movement therapy is a physical intervention that has been receiving increasing attention in pediatric rehabilitation. So far, the evidence suggests that practice associated with CI therapy may improve impaired unimanual hand function in some children with hemiplegic cerebral palsy (CP). However, CI therapy has several important limitations. Most importantly, children with hemiplegia have impairments in bimanual coordination beyond their unilateral impairments. Thus, an intervention approach to increase functional independence during activities of daily living by using both hands in cooperation is needed. Here we briefly review the etiology of hemiplegic CP, describe studies of pediatric CI therapy efficacy in relation to the etiology, discuss the conceptual and practical limitations of CI therapy for this population, and describe bimanual coordination impairments in children with hemiplegia. Finally, we introduce a new intervention for children with hemiplegia, hand-arm bimanual intensive training (HABIT), to address the limitations of CI therapy and to improve bimanual coordination. HABIT retains the two major elements of pediatric CI therapy (intensive structured practice and child-friendliness). The proposed methodology demonstrates that extensive targeted practice can be provided in a child-friendly manner without using a physical restraint, although the efficacy of such an approach remains to be determined.
[Charles, J. & Gordon, A. M. (2006). Development of hand-arm bimanual intensive training (HABIT) for improving bimanual coordination in children with hemiplegic cerebral palsy. Developmental Medicine and Child Neurology, 48(11), 931-6.]
Constraint-induced (CI) movement therapy is a promising therapy for improving upper limb function in adults after stroke. It involves restraint of the non-involved limb and extensive movement practice with the involved limb. In this study, a single-blinded, randomized, control study was performed to examine the efficacy of CI therapy, modified to be child friendly, in children with hemiplegic cerebral palsy (CP). Twenty-two children (8 females, 14 males; mean age 6 y 8 mo [SD 1 y 4 mo]; range 4-8 y) were randomized to either an intervention group (n=11) or a delayed treatment control group (n=11). Children wore a sling on their non-involved upper limb for 6 hours per day for 10 out of 12 consecutive days and were engaged in play and functional activities. Children in the treatment group demonstrated improved movement efficiency and dexterity of the involved upper extremity, which were sustained through the 6-month evaluation period, as measured by the Jebsen-Taylor Test of Hand Function and fine motor-subtests of the Bruininks-Oseretsky Test of Motor Proficiency (p<0.05 in both cases). Initial severity of hand impairment and testing compliance were strong predictors of improvement. Caregivers reported significant increases in involved limb frequency of use and quality of movement. However, there was no change in strength, sensibility, or muscle tone (p>0.05 in all cases). Results suggest that for a carefully selected subgroup of children with hemiplegic CP, CI therapy modified to be child-friendly, appears to be efficacious in improving movement efficiency of the involved upper extremity.
[Charles, J. R., Wold, S. L., Schneider, J. A. & Gordon, A. M. (2006). Efficacy of a child-friendly form of constraint-induced movement therapy in hemiplegic cerebral palsy: A randomized control trial. Developmental Medicine and Child Neurology, 48(8), 635-42.]
Nine children with spastic hemiplegic cerebral palsy underwent 24 sessions of wrist muscles strengthening in the extended wrist range aided by electrostimulation. Isometric strength of flexors and extensors was registered in three wrist positions (30 degrees of flexion, neutral, and 30 degrees of extension) to infer on angle-torque curves. Passive stiffness of wrist flexors and wrist flexion angle during manual tasks and hand function were also documented. Significant strength gains were observed at 30 degrees of wrist extension for flexors (p= 0.029) and extensors (p= 0.024). No gains were observed at 30 degrees of flexion. The difference in extensor strength between the three test positions changed after intervention (p< 0.034), suggesting a shift in the angle-torque curve. No changes were observed in passive stiffness (p= 0.506), wrist angle (p< 0.586), or hand function (p= 0.525). Strength training in specific joint ranges may alter angle-torque relationships. For functional gains to be observed, however, a more aggressive intervention and contextualized task training would probably be needed.
[Vaz, D. V., Mancini, M. C., da Fonseca, S. T., Arantes, N. F., Pinto, T. P. & de Araujo, P. A. (2008). Effects of strength training aided by electrical stimulation on wrist muscle characteristics and hand function of children with hemiplegic cerebral palsy. Physical & Occupational Therapy in Pediatrics, 28(4), 309-25.]