Cerebral Palsy Interventions

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

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]

In 2020, Novak et al.[9] published an updated systematic review of available interventions for children with cerebral palsy. This was an update on the original article published in 2013.[10] Novak et al.[9] 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.[9]

Green light allied health interventions - i.e. "go"[edit | edit source]

  • acceptance and commitment therapy
  • action observations
  • casting
  • constraint-induced movement therapy
  • environmental enrichment
  • 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)[9]

NB green light medical, surgical, pharmacological, and regenerative therapy interventions include, but are not limited to:[9]

  • 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. "probably do it"[edit | edit source]

Include, but are not limited to:[9]

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

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

  • cranial osteopathy
  • hyperbaric oxygen
  • neurodevelopmental therapy (in its original passive form)
  • sensory integration[10]

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 9.4 9.5 Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, et al. State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy. Curr Neurol Neurosci Rep. 2020 Feb 21;20(2):3.
  10. 10.0 10.1 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