The treatment of Cerebral Palsy in children has traditionally focused on enhancement of the physical impairments associated with this disability. However, now there is a more comprehensive understanding of the disabling effects that social and environmental factors can have on an individual with this condition and their ability to participate in society. There is increasing awareness of the need to consider issues beyond medical treatment of impairments, such as creating environments that enable participation by all members of society. (Vogts, Mackey, Ameratunga, Stott, 2010)
Management of children with Cerebral Palsy involves parents and professionals from a number of disciplines. This is called an interdisciplinary approach. Members of an interdisciplinary team may include parents, teachers, nurses, physicians, psychologists, counselors, occupational therapists, physical therapists, speech therapists, and others.
Interdisciplinary teams typically adopt an arena or group approach to evaluation to design meaningful services for children with Cerebral Palsy. In an arena evaluation, professionals from different disciplines observe a child being evaluated and draw information from the evaluation. This saves the child from having to participate in separate evaluations. (Griffin, Fitch, Griffin 2002)
Treatment possibilities that the interdisciplinary teams chose from generally come from the following three categories:
- Traditional Motor Therapies
- Surgical and Medical Options
- Alternative (nonstandard) Therapies
Traditional Motor Therapies can be in the form of occupational or physical therapy services. The following are roles of Physical and Occupational Therapists who provide services to infants and young children:
- Participate in identifying child/family resources, priorities, and concerns
- Participate in interdisciplinary assessment and planning
- Consult with and refer to community agencies and professionals
- Design, implement, and monitor therapeutic interventions, particularly those related to motor performance within activities of daily living.
- Recommend adaptive equipment and assistive technologies
- Recommend and fabricate orthotics (eg, splints and braces)
- Assess, recommend, and implement environmental modifications (Treatments for Cerebral Palsy, 1998).
(Some of the roles listed are shared with other disciplines including speech-language pathology, early childhood special education, nursing, and social work).
Are motor therapies effective?
The current body of literature regarding effectiveness is far from conclusive. While moderate evidence was found for some effectiveness of upper extremity training, intervention and outcome measures vary extensively due to the large disparities between individual cases of Cerebral Palsy (Reading, 2009). However, in a review of 20 efficacy studies that focused on therapeutic outcomes in five “impairment” categories: tone, postural reactions, motor milestones, reflexes, and postural alignment and control, it was concluded that experimental evidence generally did not support the efficacy of therapy in preventing central nervous system dysfunction or reducing the effects of primitive reflexes
Table 1: Comparison of two perspectives on motor development, control, and learning (Treatments for Cerebral Palsy, 1998)
Table 2: Five component model of disablement (Treatments for Cerebral Palsy, 1998)
Surgical and Medical Options can be grouped into 6 categories:
- Orthopedic Surgery
- Selective Dorsal Rhizotomy
- Continuous Intrathecal Baclofen infusion
- Botulinum toxin, subclass A
- Other anti-spasticity modalities
- Treatments for drooling
Orthopedic Surgery remains a mainstay in the treatment of spasticity. Surgical goals are met by releasing muscles and tendons or by correcting bony deformities. Desirable outcomes of surgery (diminished muscle/joint tightness, improved sitting, and improved self-care, have been described by patients. However, if the release is “not enough” ongoing scissoring can occur. “Overrelease” in some patients results in weakening and potential loss of function. Often, the deciding factor for electing surgery is related to chronic pain.
Outcome goals of Orthopedic surgery in the child with CP
- Improved function and prevention of future deformities
- Improved comfort
- Improved self-care and activities of daily living
- Improved positioning (to facilitate each of the above)
Selective Dorsal Rhizotomy (SDR) is used to decrease spasticity in selected muscle groups. In Cerebral Palsy, brain damage can minimize the normal ability to suppress excitatory muscle firings, thus leaving a state of heightened spasticity. By identifying these afferent nerve rootlets from the muscles and selectively cutting them, spasticity in that selected muscle region can be reduced.
Eligibility for SDR
- Pure spasticity (lack of athetosis or dystonia) where the spaticity is not used to funtional benefit; some centers suggest limiting to diplegia
- Selective motor control, adequate trunk balance, and lack of profound underlying weakness
- Age generally in range of 3 to 8 years
- Spontaneous forward locomotion; no dominating primitive reflexes
- History of prematurity (predominatly periventricular leukomalacia as cause)
- Minimal joint contractures or spinal deformities
- Adequate cognitive and behavioral skills to follow through with intense physical therapy
- Supportive families and postoperative programs
Continuous Intrathecal Baclofen Infusion is the placement of a pump and catheter to deliver baclofen, an antispasticity medication, directly into the spinal fluid surrounding the cord. This is a combination of surgical and pharmacologic therapies. The baclofen pump needs to be refilled about monthly. This is an alternative to SDR and presents the option for reversability. (Approved by the FDA in 1996)
Botulinum toxin (subcalss A) is injected directly into the muslce that has been identified as a major component of the spasticity “problem.” Its purpose is to block the muscle-nerve firing by preventing the release of acetylcholine at the motor nerve terminal and to therby weaken the treated muscle. Over a period of 3 to 4 months, new nerve azons grow at the site, and firing at the junction returns. As tightness returns, repeated injections are required.
Other antispasticity modalities include the use of the oral medications diazepam, baclofen, dantrolene. Once taken, they are absorbed into the bloodstream before reaching the desired sites of action, causing potential for generalized effects in the central nervous system. While improvements have been reported in some patients, side effects are common. These include decreased handling of oral secretions, drowsiness, and dizziness, among others. If spasticity symptoms are not severe and the family is aware of expected outcomes and potential risks, these medications might be considered as first-line trials after other contributing factors are excluded.
Treatments for drooling include various medications or in extreme instances, surgery. Minimizing hand-in-mouth activity, maximizing positioning, and employing jaw control techniques are also important intervention concepts. Glycopyrrolate is a medication that has been proven to help with drooling without any adverse side effects.
Several surgical procedures for drooling have been described. These entail consist of removing the salivary gland or displacing the opening of the salivary duct to direct the saliva flow to the posterior part of the mouth. Adverse outcomes of the surgery have ranged from chronic aspiration to dysphagia or excessively dry mouth.
Alternative (nonstandard) Therapies include the use of melationin for help with sleeping, homeopathic therapy, conductive education, infant massage, brushing, and craniosacral therapy. These all have very little scientifc or empirical evidence regarding their effacicity. The effectiveness of treatments should be validated prior to being considered an acceptable and standardized treatment option. Still, multiple nonstandard treatment approaches continue to be chosen by families. (Treatments for Cerebral Palsy, 1998)
Another treatment possibility that has been undergoing research is the use of Virtual Reality to improve upper-extremity control in children with cerebral palsy. It is believed that virtual reality creates an exercise environment in which the intensity of practice and positive visual and auditory feedback can be precisely and systematically manipulated in various nearly natural environments to allow for individualized training in motor learning. While a 4-week virtual reality training program demonstrated the potential to improve reaching performance and control in children with Cerebral Palsy (especially those who had normal cognitive development), to date, only one case study has actually examined its effectiveness (Chen, Kang, Chuang, Doong, Lee, Tsai, Jeng, andSung, 2007).
Barriers to Participation Faced at Home and at School
94% of parents of children with Cerebral Palsy (out of a study of 32 families) were perceptive of the fact that their children were encountering barriers due to their disability. The barrier perceived as being encountered by the greatest number of children was attitudes at school (72%) followed by difficulty accessing personal equipment (e.g. wheelchairs, walking frames or splints) in a timely fashion (59%). In addition, many families identified a lack of funding as an important barrier to accessing personal equipment, teacher aides, adapted transportation and modification of the school or home environment. The intensity (and types) of participation by child with cerebral palsy is influenced by a number of factors, such as example age, cognitive and physical ability extrinsic barriers (i.e. family finances and functioning), and government policies on education and social supports.
Over half the parents that participated in this study believed that their child was affected by attitudes in the community, difficulties accessing personal equipment and lack of support or help at school. When further questioned, many parents expressed the belief that their child experienced discrimination from both peers and teachers because of the physical and communication impairments associated with cerebral palsy
Important educational considerations include preventing negative attitudes toward children with Cerebral Palsy at school, greater and easier accessibility to equipment and services at school, extensive support programs in schools for children with cerebral palsy, and greater awareness of the barriers to participation that these children face daily (Vogts, Mackey, Ameratunga, and Stott, 2010).
In an attempt to reduce these barriers, extensive studies have been taking place in the field of assistive devices for individuals with Cerebral Palsy. Still, most attention has been paid to adult users’ or adult carers’ perspectives and seem to overlook the opinions, and therefore the difficulties, of young users. The importance of considering the potential of assistive device intervention in terms of increasing children's independence should be highlighted, in particular within the home context (where children exhibit lower independence due to their reliance on their mother and/or father). In addition to this, more information on assistive devices for self-care, a stress of follow-up services and training programs in order to help children improve their knowledge of dealing with the difficulties of device use, as well as more opportunities to access such devices before purchasing (e.g. a trial period), should be provided to children with CP and their families (Huang, Sugden, and Beveridge, 2009).
