Introduction
Although cerebral palsy is a non-progressive disease, it is often accompanied by comorbidities and secondary complications. [1] Improving functional competence and independence affected by these secondary issues is the goal of CP management. [2] Interventions for children with cerebral palsy (CP) should be positive. They should be task-oriented, goal-oriented (focusing on the goals of the child and the family), and concerned with the environment in which the child will actively play and work. [3]
The most common challenges when managing CP include spasticity, pain, difficulty swallowing nutrients, and dystonia. It is also important to ensure hip monitoring due to the increased risk of hip displacement. [1] Patients with CP can work with a multidisciplinary team Includes: [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 need to use assistive technology. [2]
Spasticity
Spasticity and dystonia, which cause difficulty in coordinating strength and selective motor control, are the most common movement disorders in CP. Spasticity leads to joint and skeletal deformity, loss of function, and pain, and is a major challenge in the management of CP. [2] Multi-factor approach Used to fight spasticity, including drug therapy, physical therapy, or surgical intervention. [4]
Pharmacology
Commonly used drugs for spasticity include baclofen, diazepam, clonazepam, dantrolene, and tizanidine. [2] These drugs target general cramping. [4]
Botulinum Toxin
To combat focal spasticity, botulinum toxin (botox) is one of the basic therapies used intramuscularly. Reduced cramping lasts 3-8 months. Rehabilitation is required during this time to take full advantage of the reduced spasticity. Botox effects include increased passive and active movement Reduces discomfort and pain associated with muscle tension. It also helps with posture correction. [4] Lower extremity spasticity from 1-6 years and spastic hemiplegia from 5-15 years have shown the best results. [5]
Surgeries
Selective dorsal rhizotomy is a surgical procedure aimed at reducing spasticity that impairs gait. The procedure improves the range of motion and walking ability of patients with CP. [2] It is most effective in children ages 3-8, usually with GMFCS levels between three and four.
Other surgical options for children with CP include:[2]
- Lengthens soft tissues, such as adductors and hamstrings
- Multilevel surgery of the ankle and foot
- Nerve blocks
- Tendon transfer
- Joint stabilisations
Management of Hand Dysfunction
An individual’s hand function can be affected bilaterally or unilaterally. Two common techniques to help hand function are restraint-induced exercise therapy and arm-strengthening bimanual therapy. [2]
Constraint-Induced Movement Therapy
Constraint-Induced Movement Therapy (CIMT) is based on the idea that intensive use of the affected hand over the unaffected hand will improve hand function in the affected hand. Protocols vary, but children’s less affected arms are restrained in some way (eg mitten sling and gloves) hours each day, they undergo intensive structured training. [6] Studies have shown that CIMT is an effective method for improving hand function, but its effect on muscle tone has not been determined. [2]
Hand-Arm Intensive Bimanual Therapy
Arm-strengthening bimanual therapy is another technique that improves hand function by using the hands. It refers to repetitive task practice that uses two hands instead of one to perform functional activities. [7] It is a child-friendly technology that is not limited by the child’s body The less affected hand. Arm intensive bimanual therapy is better tolerated than CIMT. [2]
Management of Hip and Ankle Deformities
Hip
Hip dislocations, subluxations, and other related problems are common in children with CP. Screening for cases of hip deformity using the Hip Surveillance Program is recommended. [2] Surgical treatment of hip disease includes reconstructive procedures such as osteotomy and arthroplasty.
Ankle
Orthotics help improve ankle range of motion, which in turn improves gait. Ankle-foot orthoses (AFOs) can help children with spastic cerebral palsy reduce energy expenditure. [2]
Physiotherapy
Research shows that children with CP can benefit from physical therapy in the following ways:[5]
- Improve local muscle endurance: low-resistance and high-repetition exercises for major muscle groups
- Prevention of joint contractures: Passive gentle range-of-motion exercises and stretches of major joints; stretches need to be sustained for 6 hours to be effective[3][8]
- Increased Muscle Strength: Progressively Increased Resistance Exercises Through All Major Muscle Groups
Additionally, physical therapy can help improve balance posture control gait and assist with movement and transfer. [5]
Occupational Therapy
Occupational therapy (OT) is an important part of CP rehabilitation and helps children improve fine motor function in the upper extremities. In addition, occupational therapists can provide adaptive equipment for learning and self-care, and can help change a child’s learning environment to Improve information processing and attention. [5]
** Initiating physical and occupational therapy in children with CP aged 4-5 years was more effective than in older children. [5]
Summary of Cerebral Palsy Interventions
Nowak et al. (2013)[9] reviewed available interventions for children with CP. They organized these interventions into a traffic light system based on a systematic review of the evidence. Green light interventions were shown to be effective Yellow light interventions had lower levels Evidence supporting their effectiveness or inconclusive evidence and red-light interventions were shown to be ineffective.
Green Light Interventions – i.e. “go”
- Botulinum toxin (BoNT) diazepam and selective dorsal rhizotomy to reduce muscle spasticity
- A plaster cast to improve and maintain ankle range of motion
- Hip monitoring to maintain hip integrity
- Restraint-Inducing Movement Therapy Hand Training Situation-Focused Therapy Goal-Directed/Functional Training Occupational Therapy Follow BoNT and Family Programs to Improve Athletic Performance and/or Self-Care
- Fitness training for improving fitness
- Bisphosphonates to Improve Bone Density
- Pressure Care to Reduce Risk of Pressure Ulcers
- Anticonvulsants for managing seizures[9]
Yellow Light Intervention – That Might Do It
- Acupuncture
- Alcohol (injected intramuscularly to reduce spasms)
- AAC; Animal Assisted Therapy; Assistive Technology
- Baclofen (oral)
- Hippotherapy
- Cognitive behaviour therapy
- Communication training
- Conductive education
- Dysphagia management
- Early intervention (for motor outcomes)
- Electrical stimulation[9]
Intervention by running a red light—that is, possibly not doing it
- Craniosacral therapy
- Hip bracing
- Hyperbaric oxygen
- Neurodevelopmental therapy
- Sensory integration[9]
References
- ↑ Jump up to: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.
- ↑ Jump up to: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.
- ↑ Jump up to:3.0 3.1 Eskay, K. Cerebral Palsy General Assessment and Interventions. Plus. 2022
- ↑ Jump up to: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.
- ↑ Jump up to: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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ Jump up to: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