Rehabilitation and Cerebral Palsy

Cerebral palsy is the leading cause of childhood disability affecting function and development. ^[1] This disorder affects the development of movement and posture that is believed to arise from nonprogressive disturbances in the developing fetal or infant brain. In addition to the motor disorders that characterize cerebral palsy, which may limit a patient's activities, individuals with cerebral palsy often display epilepsy, secondary musculoskeletal problems, and disturbances of sensation, perception, cognition, communication, and behavior. ^[2]

A rehabilitation specialist has an important role in helping to coordinate the care of these often very involved patients as well as assisting with many aspects of care, including, but not limited to, those relating to spasticity management, therapies, modalities, bracing, sialorrhea, and insomnia.

Inpatient rehabilitation may be especially useful after orthopedic surgery or placement of a baclofen pump for children with cerebral palsy for intensive physical, occupational, and/or speech therapy. These patients receive therapy in at least 2 disciplines for 3 hours daily. A change in functional status following orthopedic surgery or baclofen pump placement may necessitate the need for inpatient rehabilitation, even if needed for family training for transfers. Go to Cerebral Palsy for complete information on this topic.

A retrospective study by Bailes et al found that among pediatric hospital patients with cerebral palsy who underwent lower extremity orthopedic surgery, there was less likelihood that those from the southern or western United States or who were dependent on technology would receive physical therapy while hospitalized for the operation. Inpatient physical therapy was more likely to be used in the following patients ^[3] :

• Individuals being treated at a large hospital - 82% of these received inpatient physical therapy, compared with 75% and 72% at small and medium-sized hospitals, respectively
• Individuals aged 11-14 or 15-17 years - 79% of patients in each group received inpatient physical therapy
• Patients a high surgical burden - 84% received inpatient physical therapy, compared with 68% of those with a low burden

Overall, 75% of individuals in the study received inpatient physical therapy. ^[3]

The early introduction of independent mobility is important in children with cerebral palsy, because the ability to explore one's environment has been demonstrated to improve self-esteem. ^[4] Orthoses are frequently required to maintain functional joint position in the upper and lower extremities, especially in nonambulatory or hemiplegic patients. These devices may also help to control limb position during gait such as an ankle-foot orthosis (AFO) in foot drop to prevent tripping over the toes in a patient with inadequate dorsiflexion. ^{[5, 6]}

If a patient has impaired mobility, a wheelchair and/or mobility aids such as a cane or walker may help. Seating adaptations should be included with a manual wheelchair to keep the back straight and protect the hips from excessive adduction or abduction. A power wheelchair may be needed for children with severe spasticity or athetosis; this device can be introduced to children who have the ability to understand cause and effect for safe and appropriate use.

Serial casting and splinting can improve the range of motion (ROM) of a joint and decrease tone. This is often used at the ankles to help with plantar flexion contractures, but it also can be done on any contracted joint to provide a slow, progressive stretch. Splints should be worn as much as is possible without causing skin breakdown (at least 6 hours to provide a good stretch or sometimes a schedule of 2 hours on, 1 hour off throughout the day).

Orthoses can become especially important in ambulatory cerebral palsy to improve gait, decrease contracture, and increase endurance. Patients with cerebral palsy usually have a very inefficient gait pattern, and there can be an energy expenditure gain of as much as 350%. Devices such as an AFO help to maintain foot position and prevent worsening contractures; thus, orthoses can be of great benefit, and while wearing them, patients can potentially have fewer trips and falls.

Walkers also may be prescribed to enhance mobility. Any child with the ability and/or desire to ambulate should be given every opportunity to do so. A posterior walker promotes a more upright posture than do traditional walkers.

Frequent reevaluation of orthotic devices is important because children quickly outgrow them and can undergo skin breakdown from improper use of this equipment.

Treatment associated with cerebral palsy is aimed at improving infant-caregiver interaction, giving family support, supplying resources, and providing parental education, as well as promoting motor and developmental skills. The parent or caregiver should be taught the exercises or activities that are necessary to help the child reach his or her full potential and improve function. ^{[7, 8]}

Daily range-of-motion (ROM) exercises are important to prevent or delay contractures that are secondary to spasticity and to maintain the mobility of joints and soft tissues. Stretching exercises are performed to increase range of motion. Progressive resistance exercises should be taught in order to increase strength. ^[9] The use of age-appropriate play and of adaptive toys and games based on the desired exercises are important to elicit the child's full cooperation. Strengthening knee extensor muscles helps to improve crouching and stride length. Postural and motor control training is important and should follow the developmental sequence of normal children (that is, head and neck control should be achieved, if possible, before advancing to trunk control).

Patients and their parents often like hippotherapy (horseback-riding therapy) to help improve the child's tone, ROM, strength, coordination, and balance. Hippotherapy offers many potential cognitive, physical, and emotional benefits.

The use of Kinesio Taping can help in reeducating muscles for stretching and strengthening, and aquatic therapy can also be beneficial for strengthening, as can electrical stimulation. ^[10] Short-term use of heat and cold over the tendon may help to decrease spasticity; vibration over the tendon also reduces spasticity. However, these treatments only decrease spasticity briefly and should be used in conjunction with ROM and stretching exercises.

Electrical stimulation of weakened muscles is usually tolerated well in the older child and can help strengthen muscle and maintain bulk. In a child with weak dorsiflexors that is causing foot drop or tripping for example, electrical stimulation to the anterior tibialis could be beneficial.

The child's developmental age should always be kept in mind, and adaptive equipment should be used as needed to help the child achieve his or her milestones. For example, if a child is developmentally ready to stand and explore the environment but is limited by a lack of motor control, the use of a stander should be encouraged to facilitate the achievement of the milestones. Performance should be encouraged at a level of success to maintain the child's interest and cooperation, and assistive devices and durable medical equipment should be ordered to attain function that may not otherwise be possible.

Occupational therapy for children with cerebral palsy should focus on activities of daily living, such as feeding, dressing, toileting, grooming, and transfers. Occupational therapy also focuses on the upper extremity. The goal should be for the child to function as independently as possible with or without the use of adaptive equipment. (See also Physical Therapy.)

Children with congenital hemiplegia who can follow directions and have spasticity of wrist flexors, forearm pronators, or thumb adductors may benefit from intensive therapy. Activity-based interventions such as modified constraint-induced movement therapy (mCIMT) and bimanual intensive rehabilitation training (IRP) can improve the capability to use the impaired upper limb and improve performance in personal care. ^{[11, 12, 13]} In a 10-week study by Facchin et al, more benefits were seen from intensive treatment than in the standard treatment; in mCIMT, grasp improved, and, in IRP, spontaneous use in bimanual play and activities of daily living in younger children increased. ^[14]

Many children with dyskinetic cerebral palsy and some with spastic cerebral palsy have involvement of the face and oropharynx, causing dysphagia, drooling, and dysarthria. Speech therapy can be implemented to help improve swallowing and communication. Some children benefit from augmentative communication devices if they have some motor control and adequate cognitive skills.

Patients with athetoid cerebral palsy may benefit the most from speech therapy, because most of these individuals have normal intelligence, and communication is an obstacle that is secondary to the effect of athetosis on speech. Adequate communication is probably the most important goal for enhancing function in a patient with athetoid cerebral palsy. Many children with cerebral palsy have feeding difficulties that also would benefit from speech therapy.

Incorporation of play into all of a child's therapies is important. The child with cerebral palsy should view physical and occupational therapy as fun, not work. Caregivers should seek fun and creative ways to stimulate children, especially those who have a decreased ability to explore their own environment.