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A guide to physiotherapy in cerebral palsy
Symposium: special needs
A guide to physiotherapy in cerebral palsy
on therapeutic practice during the last 50 years, including the Bobath concept, conductive education and sensory integration; to a greater or lesser extent these innovative models of treatment have been adopted as good practice and accepted as conventional approaches to treatment. The motor disorders seen in CP are frequently accompanied by disturbances of sensation, cognition, communication, perception and/or behaviour disorders1; this makes working with other therapy professions in everyday practice essential. In recent years there has been an increasing trend towards interdisciplinary working between physiotherapists, occupational therapists and speech and language therapists, with joint treatment goals set and individual expertise shared to meet the individual child’s needs. Transdisciplinary working remains less common: this is where the therapist whose professional expertise is most appropriate to meet the child’s predominant needs delivers all aspects of therapy with support from other professionals. This approach is compatible with the emerging models of a more family-based practice where the social context in which the child’s development takes place is of paramount importance, and therapy is conducted in close collaboration with parents. Transdisciplinary working from a family-centred perspective reduces the number of professionals the family have to deal with, and more realistically reflects their own situation where one person may have to meet all the child’s needs. However, both interdisciplinary and transdisciplinary working clearly put more demands on the professionals involved and require highly specialized practitioners.
Christine E Barber
Abstract This review aims to elucidate current thinking and physiotherapy practice in the treatment and management of children with cerebral palsy (CP). It discusses established approaches to treatment, such as Bobath/ NDT, conductive education and sensory integration, commonly used by therapist to address the problems seen in children with CP. The review also explores interventions that are currently advocated for the treatment of specific groups of people with CP, including constraint induced movement therapy, partial body weight-supported treadmill training and strength-training programmes.
Keywords cerebral palsy; conductive education; constraint induced movement therapy; interdisciplinary; Bobath/NDT; occupational therapy; partial body weight-supported treadmill training; physiotherapy; sensory integration; speech and language therapy; strength-training programmes; transdisciplinary
Role of physiotherapy in treatment and management In developmental conditions the aim of intervention is not only to improve current functional ability, but to undertake treatment that will provide the best basis for future health and wellbeing, and promote the individual’s participation in everyday life situations. Although most therapeutic intervention is undertaken during childhood, there is an increasing awareness that the problems associated with CP extend beyond maturity. There is a growing body of knowledge that identifies a variety of patterns of deterioration that emerge throughout adult life; these are often associated with specific classifications of CP. Intervention is required that will not only meet the child’s immediate needs but will address the long-term effects of the condition. The aims of treatment can be divided into four domains: 1. Improve the child’s repertoire of skills; 2. Maintain existing levels of activity; 3. Ameliorate or prevent secondary changes to body structure; 4. Facilitate everyday care and management. Therapeutic intervention aims to maximize the child’s potential to acquire everyday functional skills that will enable him/her to participate effectively in society. In the early stages of development or with the most severely affected children, this may include working towards improving their postural control to acquire basic activities, such as the ability to hold their head up or sit independently, which are essential for communication and basic skills such as eating. For the less affected child the aim of treatment might be to enable him/her to play with age-appropriate toys. In the older child everyday activities, such as walking at an appropriate speed in the school environment or riding a tricycle, may be the goals of treatment. It is in this domain of functional activity
Introduction Cerebral palsy (CP) can be described as a group of disorders primarily affecting the development of movement and posture and causing limitation of activity1: therefore it is not surprising that physiotherapy is one of the mainstays of treatment and management for this condition. The physiotherapist’s role encompasses many different aspects of intervention, including neonatal positioning, pre- and post- operative care associated with orthopaedic surgery and, most commonly, ongoing individual therapy programmes. Therapy services are usually community based; children being treated at home or in child development centres during the early years, and in the school setting throughout childhood and adolescence. In addition to these services, there are also specialist centres for the treatment of CP that provide intensive courses of treatment. These centres commonly involve and support parents in the treatment and management of their child’s condition, and liaise closely with community therapy services. This review will attempt to clarify the role of physiotherapy in the treatment and management of CP, and discuss the most commonly used treatment approaches and modalities. Although most physiotherapists use an eclectic approach to the treatment of CP, there have been several major influences
Christine E Barber MCSP MSc is Director of Therapy Services, The Bobath Centre for Children with Cerebral Palsy and Adults with Neurological Disability, Bradbury House, 250 East End Road, East Finchley, London N2 8AU, UK.
PAEDIATRICS AND CHILD HEALTH 18:9
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© 2008 Elsevier Ltd. All rights reserved.
Symposium: special needs
that the effectiveness of therapeutic interventions is usually measured. Maintenance of existing levels of activity is an important aim of therapeutic intervention. Loss of muscle length due to hypertonus and contractures associated with growth result in a limited range of movement and frequently prevent normal efficient alignment of the body segments. Increasing body weight coupled with muscles that are weak decrease the child’s ability to maintain posture against the force of gravity and as a consequence there is often deterioration in functional skills and the reduction of activity. Levels of fitness may already be poor and will deteriorate further if everyday activity is reduced. Prevention or amelioration of secondary changes is of primary importance, as loss of muscle length with the resultant malalignment will expose the child to different biomechanical forces causing compensatory activity and eventually fixed deformity.2 With the most severely affected children, therapists have a role to play, not only in maintenance of alignment through good positioning and seating to optimize the child’s ability to interact with his/her environment, but also to prevent the development of deformity through the institution of individual postural management programmes. Even with the most severely affected children it is vital to reduce hypertonus, and maintain muscle length and joint range in order to facilitate general health care, including hygiene and the maintenance of tissue viability.
for therapists to conceptualize and analyse the relationship between what are often quite disparate aspects of the upper motor neurone (UMN) syndrome. There is also a variety of treatment modalities that have been shown to have positive effects on specific groups of children with CP, such as constraint induced movement therapy (CIMT) for children with hemiplegia, partial body weight-supported treadmill training (PBWSTT) for children with some ambulatory ability and muscle strengthening programmes for children with diplegia.
Bobath concept The Bobath approach, also known as neurodevelopmental treatment (NDT), was pioneered by the physiotherapists Dr Karel Bobath and Berta Bobath in the 1940s. The concept was based on astute observations of how abnormal tone interfered with the child’s ability to develop functional activity. The Bobaths developed a theoretical framework for practice based on the neurophysiological knowledge of the day. Current teaching of the Bobath concept is based on contemporary scientific knowledge.5 The Bobath concept recognizes that normal or near-normal quality of tone is the necessary basis for effective movement.6 Therapists use specialized handling techniques that improve the quality of tone and facilitate the use of more efficient movement patterns in the execution of everyday tasks. The need for active participation is emphasized throughout treatment with the specific aim of the child initiating and controlling the activity for him/herself as soon as possible. The importance of the quality of tone has always been central to this concept of treatment; currently the understanding of tone encompasses both neural and non-neural aspects6 and their contribution to the motor disorder. The Bobaths emphasized the need for movement strategies learnt in treatment to be carried over into everyday life activities; therefore, there is a strong emphasis on parent and carer participation. Everyday activities such as playing and dressing are used to promote practice and provide the opportunity for the repetition needed for the acquisition of new skills. When planning the most appropriate activities to work towards, therapists draw on an in-depth knowledge of child development, recognizing the interdependence of different aspects of development, including the control of movement, perception, cognition and the development of the musculoskeletal system. Early intervention has been advocated by therapists working with this concept, with the aim of optimizing the development of the infant’s activity prior to patterns of movement associated with abnormal tone becoming strongly established.
Current thinking in physiotherapy In recent years there has been an increasing drive in the therapy professions towards evidence-based practice (EBP). However, research into the efficacy of treatment in CP is limited and hampered by the difficulties of controlling the many variables present when researching this population.3 A series of studies designed to compare intensity of treatment and the influence of working for specific goals initially showed some advantage in intensive therapy input,4 but concluded that there was no strong evidence to suggest that intensive bursts of treatment were more effective than normal delivery of service or that specific goal-directed treatment was any more effective than treatment guided by general aims. There is still no convincing evidence for one treatment method over another on grounds of effectiveness. There is therefore a pressing need for more rigorous research into therapy intervention in CP, with perhaps a refocus on what may be the expected outcomes of therapy with evidence sought at impairment, activity and participation levels. Part of the ethos of EBP is the evaluation of individual therapy interventions. There is increasing momentum for formal evaluation of regular intervention, with the use of outcome measures becoming part of standard physiotherapy practice. Usually, a variety of outcome measures are used that reflect the aims of treatment, measuring changes at impairment, activity and increasingly participation levels.
Conductive education Conductive education was pioneered by Professor Andreas Peto, and is often referred to as the Peto approach. This approach, although frequently thought of as a therapeutic approach, has its origins in learning theory; the problems of movement experienced by children with CP are thought of primarily as problems of the learning process. Training takes place in an educational setting, where activities are structured by a conductor who is trained to advance all aspects of motor and cognitive development, as well as self-care activities.
Therapy approaches There are several well known and established approaches to therapy that are commonly used in the treatment of CP; these include the Bobath concept, conductive education and sensory integration. These approaches provide a theoretical framework
PAEDIATRICS AND CHILD HEALTH 18:9
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© 2008 Elsevier Ltd. All rights reserved.
Symposium: special needs
The importance of group work as a motivating factor is stressed, and there is a strong emphasis on the importance of anticipation,7 with forward planning of activities and volitional control in acquisition of new skills. A central element of the approach is involving the children in the use of verbal reinforcement before and during the task.7 The emphasis of intervention is on independence in attaining goals rather than on quality of movement. Comparison between conductive education and traditional therapies showed little difference in functional outcomes but the presence of more contractures in the group treated with conductive education.6 In Hungary, where this approach was pioneered, children tend to be in the educational setting all day; however, there are few establishments that implement conductive education in this form. Frequently aspects of conductive education, such as group work and the use of specialized furniture, are incorporated into more eclectic treatment programmes.
CP. These include CIMT for children with hemiplegia, strengthening programmes for children with diplegia and PBWSTT for children with some ambulatory ability. These interventions frequently require intensive bursts of treatment and may or may not be used in conjunction with other modalities of treatment in an overall management plan.
Constraint-induced movement therapy This treatment is specifically used to improve upper limb function in children with hemiplegia who account for approximately 30% of all children with CP.10 CIMT is based on research conducted by Taub11 that demonstrated cortical reorganization in non-human primates in response to forced use following a neural lesion. CIMT was initially used in adults with hemiparesis. Taub postulated that during the acute phase of stroke suppressed neuroactivity renders the individual unable to use the upper limb effectively, which over time results in learned non-use of the affected upper limb. Similar loss of function seen in children with hemiplegia as a result of CP has been described as developmental disregard.12 During development the children with hemiplegia frequently find daily tasks are more effective and efficient using the non-affected hand; this may be the case even if the impairment is only mild in the affected limb. Traditionally, a CIMT programme involves restraining the use of the non-affected limb for approximately 90% of the waking hours, coupled with an intensive programme of training the affected upper limb for 6–7 days over 2–3 weeks. These techniques have led to increased functional ability in the affected upper limb with a concomitant cortical reorganization. In recent years a variety of clinical trials have been run using CIMT or modified CIMT programmes where the unaffected limb is restrained for less than 3 h a day, and forced use where restraint of the unaffected limb is used without an additional training programme. Restraint of the limb may take several forms, including bi-valved casts, a glove or a sling. Activity programmes involve selected tasks that are systematically increased in difficulty and explicit feedback on success of the task is given; this is often referred to as a shaping process. In a recent systematic review of CIMT13 only three trials met the criteria of being randomized controlled trials (RCT) or controlled clinical trials. The review found positive effects using modified CIMT and CIMT with forced use. However, although these trends were encouraging, they were inconclusive and it was concluded that CIMT should remain the subject of clinical trials. A subsequent RCT demonstrated marked improvements in upper extremity function in response to a CIMT programme.12 More work needs to be undertaken into the efficacy of CIMT but results are encouraging and it likely that this approach may help bridge the gap between what the child is capable of in ideal circumstances and what the child does in his/her everyday life.
Sensory integration Sensory integration is more frequently thought of as being in the professional domain of occupational therapists, and was in fact developed by an occupational therapist, Jean Ayres, in the 1960s; however, some aspects of this approach are frequently incorporated into treatment programmes by physiotherapists and occupational therapists working with children with CP. Initially, sensory integration was developed to address problems of function that were more subtle than those that could be attributed to overt central nervous system (CNS) disorders such as CP, and were frequently seen in children with minimal cerebral dysfunction. In this concept difficulties in planning and executing organized behaviour are attributed to problems of processing sensory inputs within the CNS, including vestibular, proprioceptive, tactile, visual and auditory.8 Children with sensory integration dysfunction frequently use different sensory combination strategies from those that are typical in the developing child.8 Treatment focuses on integrating neurological processing by facilitating the individual to register and process the type, quality and intensity of sensation provided by the environment to enable effective behaviour.8 Children with problems of sensory integration often display inappropriate responses to sensory input. They include children who show a poor ability to register sensory information and therefore seek sensory input, and those who are hypersensitive to sensory stimuli and therefore require desensitizing. The processing of sensory information is fundamental to organizing a wide variety of behaviours,8 and its disturbance may manifest in emotional and behavioural difficulties, as well as frequently impacting on the child’s ability to organize movement. A significant number of children with CP have sensory impairments. Sensory integration may help processing and integration of this sensory information, thereby enhancing the child’s acquisition of function. Sensory integration can be successfully combined with NDT (Bobath)9 in specific groups of children with CP.
Partial body weight-supported treadmill training In recent years there has been increasing interest in PBWSTT as part of treatment programmes for children with some walking ability. The child is suspended over a treadmill in a harness which supports varying degrees of their body weight, reducing some of the effort required for walking. The treadmill assists in production of steps and enables the speed to be maintained while the
Specific interventions Several specific interventions are currently under scientific scrutiny and offer treatment to clearly defined groups of children with
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© 2008 Elsevier Ltd. All rights reserved.
Symposium: special needs
child is supported in a safe environment. There is considerable variability in how PBWSTT programmes are delivered. A recent study, which looked at the effects of PBWSTT on endurance, functional gait and balance, trained children for 30 min twice daily for 2 weeks,14 showed improvements in walking speed and energy efficiency. However, there was no improvement in the ‘6 min endurance walking test’ which is frequently used by therapists as an indicator of how the child’s everyday walking may be affected. A recent systematic review15 of PBWSTT in young children with developmental disability (the majority of whom had CP) concluded that the research available provided only a relatively low level of evidence, and that there was no definitive evidence that PBWSTT alone increases ambulatory ability. Although the systematic review did not support the effectiveness of the treatment, the evidence from some of the papers reviewed suggested some positive improvements. This review highlighted the need for further, more conclusive research before PBWSTT is used more extensively in the clinical setting.
References 1 Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy. Dev Med Child Neurol 2007; 109: 8–14. 2 Graham KH. Mechanisms of deformity. In: Scrutton D, Damiano D, Mayston M, eds. Management of the motor disorders of children with cerebral palsy, 2nd edn. London: MacKieth Press, 2004, p. 105–129 No. 161. Clinics in developmental medicine. 3 Hur JJ. Review of research on therapeutic interventions for children with cerebral palsy. Acta Neurol Scand 1995; 91: 423–432. 4 Bower E, Michell D, Burnett M, Campbell MJ, McLellan DL. Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 months. Dev Med Child Neurol 2001; 43: 4–15. 5 Mayston MJ. Physiotherapy management in cerebral palsy: an update on treatment approaches. In: Scrutton D, Damiano D, Mayston M, eds. Management of the motor disorders of children with cerebral palsy. 2nd edn, London: MacKieth Press, 2004, p. 147–160 No. 161. Clinics in developmental medicine. 6 Mayston MJ. Setting the scene. In: Edwards S, ed. Neurological physiotherapy – a problem solving approach, 2nd edn. Edinburgh: Churchill Livingstone, 2002, p. 3–19. 7 Medveczky E. Conductive education as an educational method of neurorehabilitation. Budapest: International Petö Institute, 2006. 8 Spitzer S, Roley SS. Sensory integration revisited. In: Roley SS, Blanche EI, Schaaf RC, eds. Understanding the nature of sensory integration with diverse populations. Therapy Skills Builders, 2001, p. 3–27. 9 Blanche E. Cerebral palsy. In: Blanche E, Botticelli T, Holloway M, eds. Combining neuro-developmental and sensory integration principles: an approach to physical therapy. New York: Psychological Corporation, 1995, p. 67–84. 10 Hagberg B, Hagberg G, Beckung E, Uverbrant P. Changing panorama of cerebral palsy in Sweden VIII. Prevalence and origin in the birth year period 1994–1994. Acta Paediatr 2001; 90: 271–277. 11 Taub E. Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In: Ince LP, ed. Behavioural psychorehabilitation medicine; clinical applications. Philadelphia: Williams and Wilkins, 1980, p. 371–401. 12 Deluca SC, Echols K, Law CR, Ramey SL. Intensive paediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. J Child Neurol 2006; 21: 931–938. 13 Hoare B, Imms C, Carey L, Wasiak J. Constraint induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy: a cochrane systematic review. Clin Rehabil 2007; 21: 675–685. 14 Provost B, Dieruf K, Burtner PA, et al. Endurance and gait in children with cerebral palsy after intensive body weight-supported treadmill training. Pediatr Phys Ther 2007; 19: 2–10. 15 Laforme Fiss AC, Effgen SK. Outcomes for young children with disabilities associated with the use of partial, body-weightsupported, treadmill training: an evidence-based review. Phys Ther Rev 2006; 11: 179–189. 16 Dodd KJ, Taylor NF, Damiano DL. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Arch Phys Med Rehabil 2002; 83: 1157–1164.
Strength-training programmes Trials of specific muscle strengthening programmes have shown that training may strengthen muscles without adverse effects in children and adolescents with CP. In the majority of trials the participants have had spastic hypertonia with a diplegic or hemiplegic distribution. To date these trials have provided evidence that strength-training programmes may improve strength, but the relationship between improved strength and functional improvement remains unclear.16 As with other areas of therapeutic intervention, there is currently inadequate evidence to show changes in activity or improved ability to participate in everyday life. However, there are strong indications that strength training programmes should play an important role in the habilitation of individual’s with specific classifications of CP.
Summary The approaches that are used by physiotherapists when working with children with CP are many and varied. Although currently there is little evidence to support the efficacy of one approach to treatment over others, this may in part reflect the innate difficulties of research into such a heterogeneous population as CP where there are a large number of variables to control. In order to draw definitive conclusions about the efficacy of treatment more high quality and rigorous clinical trails need to be undertaken. The increasing support for research and a strong move towards EBP in the physiotherapy profession should, over time, make it possible to identify which aspects of therapeutic intervention are most appropriate for children presenting with specific clinical features. The lack of evidence for tried and tested forms of treatment does not mean that the therapy professions should abandon those treatments as they have been supported by the consensus of professional opinion but that their validity and efficacy should be continuously scrutinized. As a profession, physiotherapists are becoming increasingly proactive in evaluating all aspects of practice to ensure that good practice is carried forward and new treatment modalities are judiciously introduced and evaluated. ◆
PAEDIATRICS AND CHILD HEALTH 18:9
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© 2008 Elsevier Ltd. All rights reserved.
A guide to physiotherapy in cerebral palsy
on therapeutic practice during the last 50 years, including the Bobath concept, conductive education and sensory integration; to a greater or lesser extent these innovative models of treatment have been adopted as good practice and accepted as conventional approaches to treatment. The motor disorders seen in CP are frequently accompanied by disturbances of sensation, cognition, communication, perception and/or behaviour disorders1; this makes working with other therapy professions in everyday practice essential. In recent years there has been an increasing trend towards interdisciplinary working between physiotherapists, occupational therapists and speech and language therapists, with joint treatment goals set and individual expertise shared to meet the individual child’s needs. Transdisciplinary working remains less common: this is where the therapist whose professional expertise is most appropriate to meet the child’s predominant needs delivers all aspects of therapy with support from other professionals. This approach is compatible with the emerging models of a more family-based practice where the social context in which the child’s development takes place is of paramount importance, and therapy is conducted in close collaboration with parents. Transdisciplinary working from a family-centred perspective reduces the number of professionals the family have to deal with, and more realistically reflects their own situation where one person may have to meet all the child’s needs. However, both interdisciplinary and transdisciplinary working clearly put more demands on the professionals involved and require highly specialized practitioners.
Christine E Barber
Abstract This review aims to elucidate current thinking and physiotherapy practice in the treatment and management of children with cerebral palsy (CP). It discusses established approaches to treatment, such as Bobath/ NDT, conductive education and sensory integration, commonly used by therapist to address the problems seen in children with CP. The review also explores interventions that are currently advocated for the treatment of specific groups of people with CP, including constraint induced movement therapy, partial body weight-supported treadmill training and strength-training programmes.
Keywords cerebral palsy; conductive education; constraint induced movement therapy; interdisciplinary; Bobath/NDT; occupational therapy; partial body weight-supported treadmill training; physiotherapy; sensory integration; speech and language therapy; strength-training programmes; transdisciplinary
Role of physiotherapy in treatment and management In developmental conditions the aim of intervention is not only to improve current functional ability, but to undertake treatment that will provide the best basis for future health and wellbeing, and promote the individual’s participation in everyday life situations. Although most therapeutic intervention is undertaken during childhood, there is an increasing awareness that the problems associated with CP extend beyond maturity. There is a growing body of knowledge that identifies a variety of patterns of deterioration that emerge throughout adult life; these are often associated with specific classifications of CP. Intervention is required that will not only meet the child’s immediate needs but will address the long-term effects of the condition. The aims of treatment can be divided into four domains: 1. Improve the child’s repertoire of skills; 2. Maintain existing levels of activity; 3. Ameliorate or prevent secondary changes to body structure; 4. Facilitate everyday care and management. Therapeutic intervention aims to maximize the child’s potential to acquire everyday functional skills that will enable him/her to participate effectively in society. In the early stages of development or with the most severely affected children, this may include working towards improving their postural control to acquire basic activities, such as the ability to hold their head up or sit independently, which are essential for communication and basic skills such as eating. For the less affected child the aim of treatment might be to enable him/her to play with age-appropriate toys. In the older child everyday activities, such as walking at an appropriate speed in the school environment or riding a tricycle, may be the goals of treatment. It is in this domain of functional activity
Introduction Cerebral palsy (CP) can be described as a group of disorders primarily affecting the development of movement and posture and causing limitation of activity1: therefore it is not surprising that physiotherapy is one of the mainstays of treatment and management for this condition. The physiotherapist’s role encompasses many different aspects of intervention, including neonatal positioning, pre- and post- operative care associated with orthopaedic surgery and, most commonly, ongoing individual therapy programmes. Therapy services are usually community based; children being treated at home or in child development centres during the early years, and in the school setting throughout childhood and adolescence. In addition to these services, there are also specialist centres for the treatment of CP that provide intensive courses of treatment. These centres commonly involve and support parents in the treatment and management of their child’s condition, and liaise closely with community therapy services. This review will attempt to clarify the role of physiotherapy in the treatment and management of CP, and discuss the most commonly used treatment approaches and modalities. Although most physiotherapists use an eclectic approach to the treatment of CP, there have been several major influences
Christine E Barber MCSP MSc is Director of Therapy Services, The Bobath Centre for Children with Cerebral Palsy and Adults with Neurological Disability, Bradbury House, 250 East End Road, East Finchley, London N2 8AU, UK.
PAEDIATRICS AND CHILD HEALTH 18:9
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© 2008 Elsevier Ltd. All rights reserved.
Symposium: special needs
that the effectiveness of therapeutic interventions is usually measured. Maintenance of existing levels of activity is an important aim of therapeutic intervention. Loss of muscle length due to hypertonus and contractures associated with growth result in a limited range of movement and frequently prevent normal efficient alignment of the body segments. Increasing body weight coupled with muscles that are weak decrease the child’s ability to maintain posture against the force of gravity and as a consequence there is often deterioration in functional skills and the reduction of activity. Levels of fitness may already be poor and will deteriorate further if everyday activity is reduced. Prevention or amelioration of secondary changes is of primary importance, as loss of muscle length with the resultant malalignment will expose the child to different biomechanical forces causing compensatory activity and eventually fixed deformity.2 With the most severely affected children, therapists have a role to play, not only in maintenance of alignment through good positioning and seating to optimize the child’s ability to interact with his/her environment, but also to prevent the development of deformity through the institution of individual postural management programmes. Even with the most severely affected children it is vital to reduce hypertonus, and maintain muscle length and joint range in order to facilitate general health care, including hygiene and the maintenance of tissue viability.
for therapists to conceptualize and analyse the relationship between what are often quite disparate aspects of the upper motor neurone (UMN) syndrome. There is also a variety of treatment modalities that have been shown to have positive effects on specific groups of children with CP, such as constraint induced movement therapy (CIMT) for children with hemiplegia, partial body weight-supported treadmill training (PBWSTT) for children with some ambulatory ability and muscle strengthening programmes for children with diplegia.
Bobath concept The Bobath approach, also known as neurodevelopmental treatment (NDT), was pioneered by the physiotherapists Dr Karel Bobath and Berta Bobath in the 1940s. The concept was based on astute observations of how abnormal tone interfered with the child’s ability to develop functional activity. The Bobaths developed a theoretical framework for practice based on the neurophysiological knowledge of the day. Current teaching of the Bobath concept is based on contemporary scientific knowledge.5 The Bobath concept recognizes that normal or near-normal quality of tone is the necessary basis for effective movement.6 Therapists use specialized handling techniques that improve the quality of tone and facilitate the use of more efficient movement patterns in the execution of everyday tasks. The need for active participation is emphasized throughout treatment with the specific aim of the child initiating and controlling the activity for him/herself as soon as possible. The importance of the quality of tone has always been central to this concept of treatment; currently the understanding of tone encompasses both neural and non-neural aspects6 and their contribution to the motor disorder. The Bobaths emphasized the need for movement strategies learnt in treatment to be carried over into everyday life activities; therefore, there is a strong emphasis on parent and carer participation. Everyday activities such as playing and dressing are used to promote practice and provide the opportunity for the repetition needed for the acquisition of new skills. When planning the most appropriate activities to work towards, therapists draw on an in-depth knowledge of child development, recognizing the interdependence of different aspects of development, including the control of movement, perception, cognition and the development of the musculoskeletal system. Early intervention has been advocated by therapists working with this concept, with the aim of optimizing the development of the infant’s activity prior to patterns of movement associated with abnormal tone becoming strongly established.
Current thinking in physiotherapy In recent years there has been an increasing drive in the therapy professions towards evidence-based practice (EBP). However, research into the efficacy of treatment in CP is limited and hampered by the difficulties of controlling the many variables present when researching this population.3 A series of studies designed to compare intensity of treatment and the influence of working for specific goals initially showed some advantage in intensive therapy input,4 but concluded that there was no strong evidence to suggest that intensive bursts of treatment were more effective than normal delivery of service or that specific goal-directed treatment was any more effective than treatment guided by general aims. There is still no convincing evidence for one treatment method over another on grounds of effectiveness. There is therefore a pressing need for more rigorous research into therapy intervention in CP, with perhaps a refocus on what may be the expected outcomes of therapy with evidence sought at impairment, activity and participation levels. Part of the ethos of EBP is the evaluation of individual therapy interventions. There is increasing momentum for formal evaluation of regular intervention, with the use of outcome measures becoming part of standard physiotherapy practice. Usually, a variety of outcome measures are used that reflect the aims of treatment, measuring changes at impairment, activity and increasingly participation levels.
Conductive education Conductive education was pioneered by Professor Andreas Peto, and is often referred to as the Peto approach. This approach, although frequently thought of as a therapeutic approach, has its origins in learning theory; the problems of movement experienced by children with CP are thought of primarily as problems of the learning process. Training takes place in an educational setting, where activities are structured by a conductor who is trained to advance all aspects of motor and cognitive development, as well as self-care activities.
Therapy approaches There are several well known and established approaches to therapy that are commonly used in the treatment of CP; these include the Bobath concept, conductive education and sensory integration. These approaches provide a theoretical framework
PAEDIATRICS AND CHILD HEALTH 18:9
411
© 2008 Elsevier Ltd. All rights reserved.
Symposium: special needs
The importance of group work as a motivating factor is stressed, and there is a strong emphasis on the importance of anticipation,7 with forward planning of activities and volitional control in acquisition of new skills. A central element of the approach is involving the children in the use of verbal reinforcement before and during the task.7 The emphasis of intervention is on independence in attaining goals rather than on quality of movement. Comparison between conductive education and traditional therapies showed little difference in functional outcomes but the presence of more contractures in the group treated with conductive education.6 In Hungary, where this approach was pioneered, children tend to be in the educational setting all day; however, there are few establishments that implement conductive education in this form. Frequently aspects of conductive education, such as group work and the use of specialized furniture, are incorporated into more eclectic treatment programmes.
CP. These include CIMT for children with hemiplegia, strengthening programmes for children with diplegia and PBWSTT for children with some ambulatory ability. These interventions frequently require intensive bursts of treatment and may or may not be used in conjunction with other modalities of treatment in an overall management plan.
Constraint-induced movement therapy This treatment is specifically used to improve upper limb function in children with hemiplegia who account for approximately 30% of all children with CP.10 CIMT is based on research conducted by Taub11 that demonstrated cortical reorganization in non-human primates in response to forced use following a neural lesion. CIMT was initially used in adults with hemiparesis. Taub postulated that during the acute phase of stroke suppressed neuroactivity renders the individual unable to use the upper limb effectively, which over time results in learned non-use of the affected upper limb. Similar loss of function seen in children with hemiplegia as a result of CP has been described as developmental disregard.12 During development the children with hemiplegia frequently find daily tasks are more effective and efficient using the non-affected hand; this may be the case even if the impairment is only mild in the affected limb. Traditionally, a CIMT programme involves restraining the use of the non-affected limb for approximately 90% of the waking hours, coupled with an intensive programme of training the affected upper limb for 6–7 days over 2–3 weeks. These techniques have led to increased functional ability in the affected upper limb with a concomitant cortical reorganization. In recent years a variety of clinical trials have been run using CIMT or modified CIMT programmes where the unaffected limb is restrained for less than 3 h a day, and forced use where restraint of the unaffected limb is used without an additional training programme. Restraint of the limb may take several forms, including bi-valved casts, a glove or a sling. Activity programmes involve selected tasks that are systematically increased in difficulty and explicit feedback on success of the task is given; this is often referred to as a shaping process. In a recent systematic review of CIMT13 only three trials met the criteria of being randomized controlled trials (RCT) or controlled clinical trials. The review found positive effects using modified CIMT and CIMT with forced use. However, although these trends were encouraging, they were inconclusive and it was concluded that CIMT should remain the subject of clinical trials. A subsequent RCT demonstrated marked improvements in upper extremity function in response to a CIMT programme.12 More work needs to be undertaken into the efficacy of CIMT but results are encouraging and it likely that this approach may help bridge the gap between what the child is capable of in ideal circumstances and what the child does in his/her everyday life.
Sensory integration Sensory integration is more frequently thought of as being in the professional domain of occupational therapists, and was in fact developed by an occupational therapist, Jean Ayres, in the 1960s; however, some aspects of this approach are frequently incorporated into treatment programmes by physiotherapists and occupational therapists working with children with CP. Initially, sensory integration was developed to address problems of function that were more subtle than those that could be attributed to overt central nervous system (CNS) disorders such as CP, and were frequently seen in children with minimal cerebral dysfunction. In this concept difficulties in planning and executing organized behaviour are attributed to problems of processing sensory inputs within the CNS, including vestibular, proprioceptive, tactile, visual and auditory.8 Children with sensory integration dysfunction frequently use different sensory combination strategies from those that are typical in the developing child.8 Treatment focuses on integrating neurological processing by facilitating the individual to register and process the type, quality and intensity of sensation provided by the environment to enable effective behaviour.8 Children with problems of sensory integration often display inappropriate responses to sensory input. They include children who show a poor ability to register sensory information and therefore seek sensory input, and those who are hypersensitive to sensory stimuli and therefore require desensitizing. The processing of sensory information is fundamental to organizing a wide variety of behaviours,8 and its disturbance may manifest in emotional and behavioural difficulties, as well as frequently impacting on the child’s ability to organize movement. A significant number of children with CP have sensory impairments. Sensory integration may help processing and integration of this sensory information, thereby enhancing the child’s acquisition of function. Sensory integration can be successfully combined with NDT (Bobath)9 in specific groups of children with CP.
Partial body weight-supported treadmill training In recent years there has been increasing interest in PBWSTT as part of treatment programmes for children with some walking ability. The child is suspended over a treadmill in a harness which supports varying degrees of their body weight, reducing some of the effort required for walking. The treadmill assists in production of steps and enables the speed to be maintained while the
Specific interventions Several specific interventions are currently under scientific scrutiny and offer treatment to clearly defined groups of children with
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Symposium: special needs
child is supported in a safe environment. There is considerable variability in how PBWSTT programmes are delivered. A recent study, which looked at the effects of PBWSTT on endurance, functional gait and balance, trained children for 30 min twice daily for 2 weeks,14 showed improvements in walking speed and energy efficiency. However, there was no improvement in the ‘6 min endurance walking test’ which is frequently used by therapists as an indicator of how the child’s everyday walking may be affected. A recent systematic review15 of PBWSTT in young children with developmental disability (the majority of whom had CP) concluded that the research available provided only a relatively low level of evidence, and that there was no definitive evidence that PBWSTT alone increases ambulatory ability. Although the systematic review did not support the effectiveness of the treatment, the evidence from some of the papers reviewed suggested some positive improvements. This review highlighted the need for further, more conclusive research before PBWSTT is used more extensively in the clinical setting.
References 1 Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy. Dev Med Child Neurol 2007; 109: 8–14. 2 Graham KH. Mechanisms of deformity. In: Scrutton D, Damiano D, Mayston M, eds. Management of the motor disorders of children with cerebral palsy, 2nd edn. London: MacKieth Press, 2004, p. 105–129 No. 161. Clinics in developmental medicine. 3 Hur JJ. Review of research on therapeutic interventions for children with cerebral palsy. Acta Neurol Scand 1995; 91: 423–432. 4 Bower E, Michell D, Burnett M, Campbell MJ, McLellan DL. Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 months. Dev Med Child Neurol 2001; 43: 4–15. 5 Mayston MJ. Physiotherapy management in cerebral palsy: an update on treatment approaches. In: Scrutton D, Damiano D, Mayston M, eds. Management of the motor disorders of children with cerebral palsy. 2nd edn, London: MacKieth Press, 2004, p. 147–160 No. 161. Clinics in developmental medicine. 6 Mayston MJ. Setting the scene. In: Edwards S, ed. Neurological physiotherapy – a problem solving approach, 2nd edn. Edinburgh: Churchill Livingstone, 2002, p. 3–19. 7 Medveczky E. Conductive education as an educational method of neurorehabilitation. Budapest: International Petö Institute, 2006. 8 Spitzer S, Roley SS. Sensory integration revisited. In: Roley SS, Blanche EI, Schaaf RC, eds. Understanding the nature of sensory integration with diverse populations. Therapy Skills Builders, 2001, p. 3–27. 9 Blanche E. Cerebral palsy. In: Blanche E, Botticelli T, Holloway M, eds. Combining neuro-developmental and sensory integration principles: an approach to physical therapy. New York: Psychological Corporation, 1995, p. 67–84. 10 Hagberg B, Hagberg G, Beckung E, Uverbrant P. Changing panorama of cerebral palsy in Sweden VIII. Prevalence and origin in the birth year period 1994–1994. Acta Paediatr 2001; 90: 271–277. 11 Taub E. Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In: Ince LP, ed. Behavioural psychorehabilitation medicine; clinical applications. Philadelphia: Williams and Wilkins, 1980, p. 371–401. 12 Deluca SC, Echols K, Law CR, Ramey SL. Intensive paediatric constraint-induced therapy for children with cerebral palsy: randomized, controlled, crossover trial. J Child Neurol 2006; 21: 931–938. 13 Hoare B, Imms C, Carey L, Wasiak J. Constraint induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy: a cochrane systematic review. Clin Rehabil 2007; 21: 675–685. 14 Provost B, Dieruf K, Burtner PA, et al. Endurance and gait in children with cerebral palsy after intensive body weight-supported treadmill training. Pediatr Phys Ther 2007; 19: 2–10. 15 Laforme Fiss AC, Effgen SK. Outcomes for young children with disabilities associated with the use of partial, body-weightsupported, treadmill training: an evidence-based review. Phys Ther Rev 2006; 11: 179–189. 16 Dodd KJ, Taylor NF, Damiano DL. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Arch Phys Med Rehabil 2002; 83: 1157–1164.
Strength-training programmes Trials of specific muscle strengthening programmes have shown that training may strengthen muscles without adverse effects in children and adolescents with CP. In the majority of trials the participants have had spastic hypertonia with a diplegic or hemiplegic distribution. To date these trials have provided evidence that strength-training programmes may improve strength, but the relationship between improved strength and functional improvement remains unclear.16 As with other areas of therapeutic intervention, there is currently inadequate evidence to show changes in activity or improved ability to participate in everyday life. However, there are strong indications that strength training programmes should play an important role in the habilitation of individual’s with specific classifications of CP.
Summary The approaches that are used by physiotherapists when working with children with CP are many and varied. Although currently there is little evidence to support the efficacy of one approach to treatment over others, this may in part reflect the innate difficulties of research into such a heterogeneous population as CP where there are a large number of variables to control. In order to draw definitive conclusions about the efficacy of treatment more high quality and rigorous clinical trails need to be undertaken. The increasing support for research and a strong move towards EBP in the physiotherapy profession should, over time, make it possible to identify which aspects of therapeutic intervention are most appropriate for children presenting with specific clinical features. The lack of evidence for tried and tested forms of treatment does not mean that the therapy professions should abandon those treatments as they have been supported by the consensus of professional opinion but that their validity and efficacy should be continuously scrutinized. As a profession, physiotherapists are becoming increasingly proactive in evaluating all aspects of practice to ensure that good practice is carried forward and new treatment modalities are judiciously introduced and evaluated. ◆
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