Physiotherapy Treatment Approaches for Individuals with Cerebral Palsy

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Introduction

Cerebral palsy (CP) is one of the most common developmental disabilities. CP is the term given for a set of neurological disorders characterised by of movement and posture disorders causing activity limitation due to a static disturbance in the developing brain. This is often accompanied by associated impairments and secondary health conditions. CP is not a single pathological entity and described disorders in various motor functions including but not limited to body movement, muscle control, muscle coordination, muscle tone, reflex, fine motor skills, gross motor skills, oral motor functioning, posture, and balance.

As highlighted by Gunel (2011) paediatric rehabilitation requires a multidisciplinary (MDT) Approach to promote independence, both functionally and psychologically, and to improve the quality of life of both the child and their family. Early intervention is important and should start as early as possible to be more effective in improving motor function, strength, and mobility. Therapies should be goal- and task-oriented, focusing on the needs of the child. These approaches are often incorporated into play-based interventions, providing opportunities for learning and development.

Physiotherapists, seen as 'movement experts', play a key role within this MDT. The main aim of physiotherapy, as identified by Gunel (2011), is to support the child with CP in achievin their potential for physical independence and fitness levels within their community, minimising the effect of their physical impairments, and to improve the quality of life of the child and their family, who also play a major role in setting goals and guiding the treatment plan.

Physiotherapy focuses on function, movement, and optimal use of the child's potential. It uses physical approaches to promote, maintain and restore physical, psychological and social well-being within all environments including home, school, recreation, and community environments. Other members of the team also play a vital role in treatment planning. Occupational therapy improves daily living skills using adaptive equipment and modifying the learning environment to improve information processing and attention. Speech therapy addresses communication issues and feeding/eating problems common in children with CP. Cognitive-behavioural therapy and early intervention strategies can be effective in improving overall outcomes. [ref]

Physiotherapists work on gross motor skills, functional mobility, positioning, sitting, transitioning from sitting to standing, walking with or without assistive devices and orthoses, wheelchair use and transfers. They use a wide range of approaches to influence functional ability.  

Treatment Approaches

According to Patel (2005) a wide range of therapeutic interventions have been used in the treatment and management of children with cerebral palsy. They show that there is evidence to support the use and effectiveness of neuromuscular electrical stimulation, while evidence in support of the effectiveness of the neurodevelopmental treatment is equivocal at best. The effectiveness of many other interventions, including include: sensory integration, body-weight support treadmill training, conductive education, constraint-induced movement therapy, hyperbaric oxygen therapy used in the treatment of cerebral palsy have not been clearly established based on well-controlled trials.  

Antilla (2008) identifies a wide range of choices and availability of various techniques which may vary both between therapists and from country to country.

Incorporating Evidence-Based Interventions

The "State of the Evidence Traffic Lights 2019" review categorises interventions for CP into green, yellow, and red lights based on the strength of evidence.

Green Light Interventions (Effective)

These interventions have strong evidence supporting their effectiveness in improving outcomes for children with cerebral palsy (CP).

1. Constraint-Induced Movement Therapy (CIMT)
   • Description: CIMT is primarily used for individuals with Hemiplegic Cerebral Palsy to improve the use of the affected upper limb. The stronger or non-impaired upper limb is immobilized for a variable duration in order to Force Use of the impaired upper limb over time Antilla et al (2008)  identified one high and one lower-quality trials which measured both body functions and structures, and activity and participation outcomes through use of CIMT. Use of a cast with CIMT showed positive effects in the amount and quality of functional hand use in the impaired limb and new emerging behaviour as compared to the no-therapy group, but no effects were found on QUEST. Use of sling during CIMT also had positive effects on functional hand use on the impaired upper limb, time to complete tasks, and speed and dexterity, but no effects on sensibility, handgrip force, or spasticity.
   • Effectiveness: Antilla et al (2005) found there is moderate evidence for the effectiveness of CIMT therapy on functional hand use in the impaired upper limb . According to Patel (2005) the efficacy of this approach has not been established, in particular in relation to the adverse effects of prolonged immobilisation of the normally developing upper limb .
2. Bimanual Training
   • Description: Bimanual training involves structured tasks to improve the coordination of both arms. Programs like HABIT-ILE combine upper and lower extremity training. These tasks focus on improving the coordination of both arms using structured tasks in bimanual play and functional activities with intensive practice. Recently has an intensive bimanual training program, the hand-arm bimanual intensive training (HABIT) been published to substantiate its effectiveness. This approach is based on motor learning theory (practice specificity, types of practice, and feedback), neuroplasticity (i.e., the potential of the brain to change by repetition, increasing movement complexity, motivation, and reward), and focuses on the equal use of both arms in bimanual tasks. Intensive BIT (e.g., HABIT), was developed with recognition that increased functional independence in the child’s environment requires the combined use of both hands. It also focuses on improving coordination of the two hands using structured task practice embedded in bimanual play and functional activities. Hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) combines upper and lower bilateral extremity training. Frequently used bilateral lower extremity tasks are ball sitting, standing, balance board standing, virtual reality (wii-fit, kinect), walking/running, jumping, cycling, and making scooter. Bimanual activities that require trunk and LE postural adaptations are performed at a table of appropriate height (50% of the time) on unstable supports: sitting on fitness balls or standing on balance boards. Furthermore, 30% of the time is devoted to activities of daily living where standing and/or walking is required (dressing, brushing teeth, doing one’s hair, transporting objects such as a tray, and household chores such as sweeping and washing dishes). Finally, the remaining time (20%) is spent in gross motor physical activities/play, such as bowling, ball playing, jumping rope, street hockey, use of wii-fit, balance bike (without pedals), scooter use, and wall climbing. These are performed in standing, walking, and running (or jumping) with the LE and simultaneously involving bimanual coordination. These activities are graded toward more demanding tasks for the LE.
   • Effectiveness: This therapy has strong evidence for enhancing functional independence and coordination.
3. Task-Specific Training
   • Description: Focuses on specific tasks and activities relevant to the child's daily life, improving overall functional abilities. The aim of this therapy for children with CP, as for most children with developmental disabilities, is to facilitate the child’s participation in everyday life situations, e.g., to communicate with parents, siblings, and peers; to move from one place to another; to dress and undress; to eat; and to play. The choice of goals for therapy is dependent on many factors: the child’s likings and the family’s preferences, the society and environment in which the family lives, and the child’s degree of disability. Thus, it is important to integrate principles of motor learning in the treatment concept and adapt the principles to the prerequisites of each specific child. The set goals should be specific, measurable, attainable, relevant, and timed (SMART).
   • Effectiveness: Task-specific training has a strong evidence base supporting its effectiveness.
4. Serial Casting
   • Description: Serial casting is used to manage spasticity-related contractures by providing an increased range of joint motion through repeated applications of casts. It involves a joint or joints that are tight, which are immobilised with a semi-rigid, well-padded cast. Serial casting involves repeated applications of casts, typically every one to two weeks as range of motion is restored.
   • Effectiveness: Evidence suggests improvements in passive range of motion and reduced hypertonicity. The duration of the stretch to reduce both spasticity and to prevent contracture are not yet clear from the research and require further research to determine the most appropriate technique and duration to produce the required effect.

Yellow Light Interventions (Promising but Limited Evidence)

These interventions show promise but require more research to establish their effectiveness conclusively.

1. Virtual Reality
   • Description: Utilises interactive simulations to create engaging therapy sessions that mimic real-world activities. Virtual reality can improve the patient’s motivation and achievement in activities of daily living (ADLs). Preliminary data suggest that this type of therapy also improves motor function in the upper and lower extremities that are caused by CP.
   • Effectiveness: Preliminary data suggest improvements in motor function in both upper and lower extremities.
2. Robot-Assisted Therapy
   • Description: Uses robotic devices to assist in performing specific limb movements, providing high-intensity, repetitive therapy. The main interest in using robots is to allow the patients to achieve a large amount of movement in a limited time. Additionally, the attractive human-machine interface has the capacity to motivate the child to perform his or her therapy through playful games, such as car races, or to perform exercises that mimic ADLs. Moreover, robotic devices allow the patient to receive visual, auditory, or sensory feedbacks. A device specifically developed for the locomotion training is the Lokomat (Hocoma, CH), made of two active orthoses, a weight-bearing system and a treadmill. This robotic rehabilitation has been proposed to improve walking and physical fitness
   • Effectiveness: Shows promise in improving walking and physical fitness, but more evidence is needed.
3. Electrical Stimulation
   • Description: Involves the application of electrical currents to stimulate muscle contractions and improve muscle strength and motor function. Electrical stimulation is provided by Transcutaneous Electrical Nerve Stimulation (TENS) Unit which is portable, non-invasive and can be used in the home-setting by parents or the patient. Neuromuscular Electrical Stimulation (NMES) involves application of transcutaneous electrical current that results in muscle contraction. NMES has been postulated to increase muscle strength by increasing the cross-sectional area of the muscle and by increased recruitment of type 2 muscle fibers. Functional Electrical Stimulation (FES) refers to the application of electrical stimulation during a given task or activity when a specific muscle is expected to be contracting.  Mintaze (2009) proposes that neuromuscular and threshold electrical stimulation as a modality in Cerebral Palsy is used for strengthening the quadriceps muscles in ambulatory diplegic children with Cerebral Palsy, who have difficulty with specific resistive strength training .
   • Effectiveness: Some evidence supports its use, but further research is required to confirm its efficacy. Patel (2005) has shown there is some evidence to support the use and effectiveness of NMES in children with Cerebral Palsy but found that many of the studies are limited by confounding variables including concomitant use of other therapies, wide variation in methods of application, heterogeneity of subjects, difficulty in measuring functional outcomes and lack of control subjects .
4. Hippotherapy
   • Description: Therapeutic horseback riding aims to improve gross motor function including muscle tone, balance, coordination, and postural control. Many non-physical benefits may also be developed through enjoyment and providing a setting for increased social interaction, cognitive and psychosocial development . Sharan et al (2005) have noted satisfactory results with Hippotherapy in Bangalore, especially in post-surgical rehabilitation .
   • Effectiveness: Shows potential benefits but limited high-quality evidence available with two lower-quality trials on saddle riding on a horse found no between-group differences in muscle symmetry or in any of the seven different outcome measures, except on a sub-item of grasping. 
5. Passive Stretching
   • Description: Aims to relieve soft tissue tightness and improve range of motion through manual application. It is a manual application for spastic muscles to relieve soft tissue tightness. Manual stretching may increase range of movements, reduce spasticity, or improve walking efficiency in children with spasticity.
   • Effectiveness: Evidence is mixed, with some studies indicating benefits in reducing spasticity and improving walking efficiency. Studies in Mice show that a stretch of 30 mins daily will prevent the loss of sarcomeres in the connective tissue of an immobilised muscle, although the timescale in humans may not relate directly. The study by Johannes M N Enslin et al. discusses the current literature on possible stretching interventions in children with Cerebral Palsy and highlights additional research that has the potential to improve non-invasive treatment outcomes.
6. Static Weight-Bearing Exercises
   • Description: Includes exercises such as Tilt-Table and Standing Frame to stimulate antigravity muscle strength and improve motor function. Stimulation of antigravity muscle strength, prevention of hip dislocation, reduction in spasticity and improvements in bone mineral density, self-confidence and motor function have all been achieved through the use of Static Weight-Bearing exercises such as Tilt-Table and Standing Frame.
   • Effectiveness: Some evidence supports improvements in bone density and motor function.

Red Light Interventions (Ineffective or Not Recommended)

These interventions lack sufficient evidence to support their use or have been shown to be ineffective.

1. Neurodevelopmental Treatment (NDT) / Bobath Approach
   • Description: Developed in the 1940s by Berta and Karl Bobath, this approach aims to facilitate typical motor development by addressing postural control and reflexes. This was a very common treatment intervention that suggested motor abnormalities seen in children with Cerebral Palsy are due to atypical development in relation to postural control and reflexes because of the underlying dysfunction of the central nervous system. This approach aimed to facilitate typical motor development and function and to prevent development of secondary impairments due to muscle contractures, joint and limb deformities.
   • Effectiveness: Current evidence does not support the effectiveness of NDT for CP, and it is not recommended.
2. Patterning
   • Description: Involves passively moving children through typical developmental sequences to promote motor development.
   • Effectiveness: Although patterning therapy has been used for many years it is now seen as controversial, labour-intensive, and has not been proven effective. It is a very passive therapy, with little opportunity to encourage the child in their active involvement and its use in children with Cerebral Palsy is not recommended.
3. Sensory Integration Training
   • Description: Exposes children to sensory stimulation to improve sensory processing and response. Sensory integration therapy is based on the idea that some children experience “sensory overload” and are oversensitive to certain types of stimulation. When children have sensory overload, their brains have trouble processing or filtering many sensations at once. Meanwhile, other children are undersensitive to some kinds of stimulation. Children who are undersensitive do not process sensory messages quickly or efficiently. These children may seem disconnected from their environment. In either case, children with sensory integration issues struggle to organize, understand, and respond to the information they take in from their surroundings. Sensory integration therapy exposes children to sensory stimulation in a structured, repetitive manner. The theory behind this treatment approach is that, over time, the brain will adapt and allow them to process and react to sensations more efficiently. In this concept, difficulties in planning and organizing behavior are attributed to problems of processing sensory inputs within the CNS, including vestibular, proprioceptive, tactile, visual, and auditory. Children with sensory integration dysfunction frequently use different sensory combination strategies. Treatment focuses on integration of neurological processing by facilitating the individual to process the type, quality, and intensity of sensation.
   • Effectiveness: Although there have been some promising results, but more research is needed to establish its effectiveness conclusively. Current evidence does not support the effectiveness of sensory integration training for CP.

By incorporating this information, we can ensure that the treatment is reliable, evidence-based, and aligned with current best practices, ultimately supporting better outcomes for children with CP and their families.

For more detailed information on the traffic light system and the evidence supporting various interventions, please refer to the full article: State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy.