Cerebral Palsy Interventions

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti and Jess Bell

Introduction[edit | edit source]

While cerebral palsy is a non-progressive disorder, it is often accompanied by comorbidities and secondary complications.[1] Improving functional ability and independence impacted by these secondary issues is the aim of CP management.[2] Interventions for children with cerebral palsy (CP) should be active. They should be task-oriented, goal-oriented (focusing on the child's and family's goals), and focused on the contexts that the child will be actively playing and working in.[3]

The most common challenges when managing CP include spasticity, pain, difficulty swallowing, nutrition and dystonia. It is also important to ensure that hip surveillance is undertaken due to an increased risk of hip displacement.[1] An individual with CP may work with a multidisciplinary team including:[2]

  • Physical therapists
  • Occupational therapists
  • Orthopaedic surgeons
  • Audiologists
  • Medical social workers
  • Nurses
  • Paediatric neurologists
  • Speech-language therapists
  • Special educators
  • Paediatricians
  • Paediatric pulmonologists
  • Nutritionists
  • Paediatric gastroenterologists

They may also require the use of assistive technology.[2]

Spasticity[edit | edit source]

Spasticity and dystonia lead to difficulties in coordination, strength and selective motor control, and they are the most common movement disorders seen in CP. Spasticity causes joint and bone deformity, functional loss and pain, and is the prime challenge in managing CP.[2] A multi-factorial approach is used to combat spasticity including pharmacotherapy, physiotherapy or surgical interventions.[4]

Pharmacology[edit | edit source]

The common medications used for spasticity include baclofen, diazepam, clonazepam, dantrolene and tizanidine.[2] These medications target general spasticity.[4]

Botulinum Toxin[edit | edit source]

To combat focal spasticity, botulinum toxin (botox) is one of the basic therapies used intramuscularly. Decreased spasticity can last from 3-8 months. During this time, rehabilitation is needed to make full use of the reduced spasticity. The effects of botox include increased passive and active motion, reduced discomfort and pain related to muscle tension. It also facilitates posture correction.[4] Optimal effectiveness has been show between the ages of 1-6 years for lower extremity spasticity and between 5-15 years for spastic hemiplegia.[5]

Surgeries[edit | edit source]

Selective dorsal rhizotomy is a surgical procedure aimed at reducing spasticity that impairs gait. This procedure improves the range of movement and walking ability of individuals with CP.[2] It is most effective in children aged between 3-8 years old, and typically with a GMFCS level of between three and four.

Other surgical management options for CP children include:[2]

  • Lengthening of the soft tissues such as adductors and hamstrings
  • Multilevel surgery of the ankle and foot
  • Nerve blocks
  • Tendon transfer
  • Joint stabilisations

Management of Hand Dysfunction[edit | edit source]

The hand function of individuals can be affected, either bilaterally or unilaterally. Two common techniques to help hand function are constraint-induced movement therapy and hand-arm intensive bimanual therapy.[2]

Constraint-Induced Movement Therapy[edit | edit source]

Constraint-induced movement therapy (CIMT) is based on the idea that intensively using the affected hand rather than the unaffected hand, will improve hand function in the affected hand. Protocols vary, but a child's less affected arm is restrained in some way (e.g. mitt, sling, cast, glove) for a number of hours each day and they perform intensive structured training.[6] Research has shown that CIMT is an effective way of improving hand function, but its effect on muscle tone has not be determined.[2]

Hand-Arm Intensive Bimanual Therapy[edit | edit source]

Hand-arm intensive bimanual therapy is another technique used to improve hand function by using both hands. It refers to "repetitive task practice using two hands, rather than one hand, to complete functional activities." [7] It is a child-friendly technique without the physical constraint of the less-affected hand. Hand-arm intensive bimanual therapy is more tolerable than CIMT.[2]

Management of Hip and Ankle Deformities[edit | edit source]

Hip[edit | edit source]

Hip dislocation, subluxation and other related problems are common in children with CP. It is recommended to screen for cases of hip deformities using a hip surveillance programme.[2] Surgical management for hip disorders include reconstructive procedures such as osteotomy and arthroplasty.

Ankle[edit | edit source]

Orthotic devices can help to improve ankle range of motion and, thus, gait. Ankle foot orthosis (AFOs) can help children with spastic CP decrease their energy expenditure.[2]

Physiotherapy[edit | edit source]

Research has shown that children with CP can benefit from physiotherapy by:[5]

  • Improving local muscular endurance: low resistance, high repetition exercises of major muscle groups
  • Preventing joint contractures: passive gentle range of motion exercises and stretches across major joints; stretching needs to last for 6 hours to have an impact[3][8]
  • Increasing muscle strength: increasing resistance exercises progressively through all major muscle groups

In addition, physiotherapy can help improve balance, postural control, gait and assist with mobility and transfers.[5]

Occupational Therapy[edit | edit source]

Occupational therapy (OT) is an essential part of CP rehabilitation to help children improve fine motor function of their upper extremities. Additionally, occupational therapists can provide adaptive equipment for learning and self-care, and can help modify a child's learning environment to improve information processing and attention.[5]

** Physiotherapy and occupational therapy started in children with CP by the age of 4-5 is more effective than if it is started in older children.[5]

Summary of Cerebral Palsy Interventions[edit | edit source]

Novak et al., (2013)[9] reviewed the available interventions for children with CP. They organised these interventions into a traffic light system based on a systematic review of the evidence. Green light interventions are shown to be effective, yellow light interventions had either lower-level evidence supporting their effectiveness or inconclusive evidence and red light interventions were shown to be ineffective.

Green Light Interventions - i.e. "go"[edit | edit source]

  1. Botulinum toxin (BoNT), diazepam, and selective dorsal rhizotomy for reducing muscle spasticity
  2. Casting for improving and maintaining ankle range of motion
  3. Hip surveillance for maintaining hip joint integrity
  4. Constraint-induced movement therapy, bimanual training, context-focused therapy, goal-directed/functional training, occupational therapy following BoNT, and home programmes for improving motor activity performance and/or self-care
  5. Fitness training for improving fitness
  6. Bisphosphonates for improving bone density
  7. Pressure care for reducing the risk of pressure ulcers
  8. Anticonvulsants for managing seizures[9]

Yellow Light Interventions - i.e. "probably do it"[edit | edit source]

  1. Acupuncture
  2. Alcohol (intramuscular injections for spasticity reduction)
  3. AAC; animal-assisted therapy; assistive technology
  4. Baclofen (oral)
  5. Hippotherapy
  6. Cognitive behaviour therapy
  7. Communication training
  8. Conductive education
  9. Dysphagia management
  10. Early intervention (for motor outcomes)
  11. Electrical stimulation[9]

Red Light Interventions - i.e. "probably do not do it"[edit | edit source]

  1. Craniosacral therapy
  2. Hip bracing
  3. Hyperbaric oxygen
  4. Neurodevelopmental therapy
  5. Sensory integration[9]

Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 Graham D, Paget SP, Wimalasundera N. Current thinking in the health care management of children with cerebral palsy. Medical Journal of Australia. 2019 Feb;210(3):129-35.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Paul S, Nahar A, Bhagawati M, Kunwar AJ. A Review on Recent Advances of Cerebral Palsy. Oxidative Medicine and Cellular Longevity. 2022 Jul 30;2022.
  3. 3.0 3.1 Eskay, K. Cerebral Palsy General Assessment and Interventions. Plus. 2022
  4. 4.0 4.1 4.2 Sadowska M, Sarecka-Hujar B, Kopyta I. Cerebral palsy: Current opinions on definition, epidemiology, risk factors, classification and treatment options. Neuropsychiatric disease and treatment. 2020;16:1505.
  5. 5.0 5.1 5.2 5.3 5.4 Patel DR, Neelakantan M, Pandher K, Merrick J. Cerebral palsy in children: a clinical overview. Translational pediatrics. 2020 Feb;9(Suppl 1):S125
  6. Eliasson AC, Krumlinde-Sundholm L, Gordon AM, Feys H, Klingels K, Aarts PB, et al. Guidelines for future research in constraint-induced movement therapy for children with unilateral cerebral palsy: an expert consensus. Dev Med Child Neurol. 2014 Feb;56(2):125-37
  7. Ouyang RG, Yang CN, Qu YL, Koduri MP, Chien CW. Effectiveness of hand-arm bimanual intensive training on upper extremity function in children with cerebral palsy: A systematic review. Eur J Paediatr Neurol. 2020 Mar;25:17-28
  8. Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental medicine & child neurology. 2013 Oct;55(10):885-910
  9. 9.0 9.1 9.2 9.3 Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental medicine & child neurology. 2013 Oct;55(10):885-910