Cerebral Palsy Interventions

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Jess Bell, Robin Tacchetti, Tarina van der Stockt and Kim Jackson

Introduction

While cerebral palsy is a non-progressive disorder, it is often accompanied by comorbidities and secondary complications. Improving functional ability and independence impacted by these secondary issues is the aim of CP management. 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.

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. An individual with CP may work with a multidisciplinary team including:

• 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.

Spasticity

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. A multi-factorial approach is used to combat spasticity including pharmacotherapy, physiotherapy or surgical interventions.

1. Pharmacology

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

2. Botulinum Toxin

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. Optimal effectiveness has been show between the ages of 1-6 years for lower extremity spasticity and between 5-15 years for spastic hemiplegia.

3. Surgeries

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. 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:

• 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

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.

1. Constraint-Induced Movement Therapy

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. 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

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." 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.

Management of Hip and Ankle Deformities

1. Hip

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. Surgical management for hip disorders include reconstructive procedures such as osteotomy and arthroplasty.

2. Ankle

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.

Physiotherapy

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

• 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
• 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.

Occupational Therapy

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.

** 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.

Summary of Cerebral Palsy Interventions Based on the Traffic Light System

In 2020, Novak et al. published an updated systematic review of available interventions for children with cerebral palsy. This was an update on the original article published in 2013. Novak et al. organised interventions for children with cerebral palsy into a traffic light system based on their systematic review of the evidence.

• Green light = "go"
• Yellow light, weak positive = "probably do it"
• Yellow light, weak negative = "probably don't do it"
• Red light = "don't do it"

To read the full review, please see: State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy.

Green Light Interventions - i.e. "go"

Green light motor interventions for improving function and performance of tasks in children with cerebral palsy:

Interventions are training based. For these interventions, the mechanism of action is experience-dependent plasticity with motivation and attention as crucial modulators of neuroplasticity:

1. action observation training
2. training that is bimanual
3. constraint-induced movement therapy
4. functional chewing training
5. goal-directed training including home programmes that use it
6. mobility training
7. training using a treadmill training including partial body weight support treadmill training
8. occupational therapy following botulinum toxin injections
9. environmental enrichment to promote task performance

Massage, a type of manual therapy, is a green light intervention. It seems to help reduce constipation in children with cerebral palsy.

Green light therapeutic contracture prevention and management strategies:

• After the onset of contracture, serial casting may be used to effectively reduce or resolve early to moderate contractures in the near future. However, this is dependent on the skill of the practitioner. Casting outcomes are improved if casting is applied 4 weeks after botulinum toxin injections when the spasticity has decreased; children also tolerate casting better at 4 weeks post-injection.
• Following casting, engaging in active strength training and goal-oriented training are both "green lights" to help the child use the newly acquired range of motion effectively.

Other green light allied health interventions:

• acceptance and commitment therapy
• fitness training
• goal-directed training (to improve gross motor skills)
• hippotherapy (to increase symmetry)
• home programmes
• literacy interventions
• mobility training
• oral sensorimotor
• oral sensorimotor plus electrical stimulation
• pressure care
• stepping stones triple P (to help with behaviour)
• strength training
• task-specific training
• treadmill training (partial body weight supported treadmill training and weight-bearing)

Green light medical, surgical, pharmacological, and regenerative therapy interventions include, but are not limited to:

• botulinum toxin
• botulinum toxin plus occupational therapy
• botulinum toxin plus casting (to increase range of motion)
• selective dorsal rhizotomy
• scoliosis correction
• hip surveillance

Yellow Light Interventions - i.e. weak positive "probably do it", weak negative "probably don't do it"

Yellow light motor inventions for improving function and performance of tasks in children with cerebral palsy:

Changing the task and the environment to allow for task performance using context-focused therapy is considered a yellow light intervention.

The following interventions can be combined with task-specific motor training to assist in augmenting the positive effects of training in children with cerebral palsy. They are listed as yellow lights, weak negative and further research is required.

• acupuncture
• animal assisted therapy
• assistive technology virtual reality and gaming
• electrical stimulation
• hydrotherapy
• taping
• transcranial direct current stimulation
• virtual reality serious gaming

Yellow light interventions to improve motor skills in children with cerebral palsy:

Some trial studies suggest efficacy with yellow light complementary and alternative medicine interventions:

• acupuncture, and animal-assisted therapy (weak positive)
• conductive education, massage, reflexology, Vojta and Yoga (weak negative)
• physical activity like exercise, activity training, strength training, and behavioural change strategies do not improve gross motor skills (yellow light, weak negative)

**even though conductive education may not improve motor skills, it could have benefits for quality of life and social skills.

Yellow light interventions to reduce constipation: cranial sacral osteopathy and reflexology appear to help (weak positive).

Yellow light interventions for reducing pain:

• massage can assist in reducing pain (weak positive)
• yoga does not appear to help with pain in children with cerebral palsy (weak negative) but does appear to improve flexibility, balance and attention span (weak positive)

Yellow light interventions for contracture management:

• isolated passive stretching is a "yellow light"
• there is low-quality evidence for the following, but further research is needed: ankle robotics, biofeedback, botulinum toxin in combination with electrical stimulation and whole-body vibration

Yellow light for physical activity:

• to enhance fitness levels, physical activity, walking ability, movement, participation, and overall quality of life: exercise, activity training, strength training, and behavioural change strategies (yellow light, weak positive)

Red Light Interventions - i.e. "probably do not do it"

Red light for motor inventions for improving function and performance of tasks in children with cerebral palsy:

The following interventions are purely passive experiences of movement through a hands-on therapeutic approach. From a neuroplasticity perspective, they do not require any initiation from the child to problem solve or to activate their motor circuity:

• cranial osteopathy
• hyperbaric oxygen
• neurodevelopmental therapy (NDT) - in its original passive form
• sensory integration(further discussion on sensory integration considerations in cerebral palsy on this page)

Red light when working on motor skills:

• cranial sacral osteopathy
• hyperbaric oxygen.

Red light for contracture management:

• Neurodevelopmental therapy (NDT)

Resources

• Cerebral Palsy Aetiology and Pathology
• CanChild
• Cerebral Palsy General Assessment