CP paper october

The Role of Physical Therapy in the Treatment of Cerebral Palsy

Jill Reiner & Sabiha Syed

Presented to Dr. Victor A. Obajuluwa

Fall 2010

Introduction

Cerebral Palsy is a nonprogressive systemic neurodevelopmental disorder that affects every system in the body. CP occurs in about every 2 per 1000 live births. About 10,000 infants and babies in the United States are diagnosed each year. While 1200 -1500 are diagnosed around preschool age. The exact cause of Cerebral Palsy is difficult to determine. It may be from many different factors that occur before, during or within three years of birth. Cerebral Palsy is characterized by damage to the developing brain. Since cerebral palsy covers such a broad category of disorders it is often classified by the type of muscle tone, distribution of limb involvement, or functional skills. The extent of trauma to the brain seen in CP is diagnosed with the help of physical exams, screening tests and questionnaires, MRI’s, CT scans, ultrasounds, intelligence testing, and electro encephalopathy. The most common types of CP are spastic, ataxic, and mixed. 

Common comorbidities include visual and hearing deficits, seizure disorders, hydroencephalus, microcephaly, scoliosis, hip dislocation, and mental retardation. CP is not curable but with proper treatment many of the symptoms may be adequately managed in order for a patient to continue with activities of daily living and function.

Some of the key treatments are physical therapy, occupational therapy, speech therapy, antispasmatics, anticonvulsants, selective dorsal rhizotomy, baclofen pump, and biofeedback. In this paper we discuss the role of aquatherapy, hippotherapy, neurodevelopmental technique, stretching, and dance movement therapy in the treatment of Cerebral Palsy. Research continues to address the causes and resulting chemotaxis that occurs in the brain injuries leading to CP. There is also research citing a possibility of gene abnormality leaving a patient more susceptible to brain insult. Continued research into the cause of brain injury is necessary. However, with the use of an aggressive multidisciplinary approach to treatment, cerebral palsy can be effectively managed thus allowing the individual to lead a full term life expectancy.

Cerebral Palsy

Cerebral palsy is an umbrella term used for a group of disabilities caused by brain damage before, during birth or in the first few years. Cerebral palsy is a result of damage to the motor control centers of a developing brain. 

Cerebral refers to the cerebrum, which is the affected area of the brain (although the disorder most likely involves connections between the cortex and other parts of the brain such as the cerebellum), Palsy refers to disorder of movement, it is important to note cerebral palsy is not a form of paralysis nor is any type of it in any way scientifically known as a "paralytic disorder". As some of the symptoms of cerebral palsy may appear to be paralysis, they are joint contractures caused by prolonged rigidity from the lesions on the brain.  Paralysis has many causes and is usually marked by nerve damage that impairs the corresponding muscle unit.

History

In 1861 an English surgeon, named Dr.

William John Little, wrote the first medical

description of a crippling disorder that made

children’s muscles stiff, weak, and prone to twitch.

He termed their condition, “Little’s Disease” for

spastic diplegia. He suggested that their condition

was caused by a lack of oxygen during labor resulting in brain damage.

In 1897 Sigmund Freud, a neurologist, suggested a difficult birth was not the cause but only a symptom of other effects on fetal development. Research conducted

during the 1980s by the National Institute of Neurological Disorders and Stroke (NINDS)

suggested that only a small number of cases of CP are caused by lack of oxygen during birth.

Epidemiology

In the industrialized world, the incidence of cerebral palsy is about 2 per 1000 live births. The incidence is higher in males than in females; the Surveillance of Cerebral Palsy in Europe (SCPE) reports a M:F ratio of 1.33:1. In the United States, approximately 10,000 infants and babies are diagnosed with CP each year, and 1200–1500 are diagnosed at

preschool age.

Causes

Prenatal:                                                Neonatal                                    Postnatal

Abdominal trauma                                    trauma                                     trauma

Multiple births                                                intercranial hemorrhage            i.c. hemorrhage           

Intrauterine infections                                    infections                                    infection

Maternal illness                                    premature (<32 wks)                        coagulopathies

Congenital malformations                        low birth weight(<6lbs)            hypoxia

Exposure to radiation                                    hyperbilirubinemia

hypoxia                                                seizures

bradycardia                                                hypoxia

         

                       

Types

v Spastic

Spastic cerebral palsy (70% of all CP patients) is characterized by the increased tone, or tension, in a muscle. Normal muscles work in pairs. When one group contracts (agonist) the other group relaxes (antagonist) this creates free movement in the desired direction. Due to complications in brain-to-nerve-to-muscle communication, the normal ebb and flow of muscle tension is disrupted. Muscles affected by spastic cerebral palsy become active together and block effective movement. This causes the muscles in spastic cerebral palsy patients to be constantly tense, spastic, with marked rigidity. Spastic cerebral palsy patients may have mild cases affecting a few movements or severe cases affecting the whole body. Although spastic cerebral palsy is not a progressive disorder the spasticity in muscles may increase over time. This increased muscle tone and stiffness in spastic cerebral palsy limits the range of movement in the joints. The effects of spastic cerebral palsy may increase with anxiety or exerted effort, leading to excessive fatigue. Spastic cerebral palsy negatively affects the patient’s muscles and joints of the extremities, causing abnormal movements, and can disrupt normal growth in children. Spastic cerebral palsy can inhibit several things such as normal motions in body movement, longitudinal muscle growth, and protein synthesis in muscle cells. Spastic cerebral palsy also limits stretching of muscles in daily activities and causes the development of muscle and joint deformities. In order for bones to develop they require the stress of normal musculature, therefore bones may become brittle, cartilage may atrophy and lead to narrowed joint spaces. Depending on the degree of spasticity, a person with cerebral palsy may exhibit a variety of angular joint deformities. Because vertebral bodies need vertical gravitational loading forces to develop properly, the spasticity and an abnormal gait may hinder proper and/or full bone and skeletal development preventing the bones to grow to their full potential. The unbalanced force on the various bones may cause the bones to grow to different lengths, so the person may have one leg longer than the other.

There are five common conditions:

Quadriplegia - affecting four limbs equally. May have hemiparetic tumors (uncontrollable shaking) affecting one side of the body.

Triplegia – affecting three limbs

Diplegia – affecting legs appearing as a scissor-like gait, with flexed knees and hips.

Monoplegia – affecting one limb. 

Hemiplegia - affects one side of the body; injury to left hemisphere affects right side of the body. Appearing as dynamic equines, and generally prescribed ankle-foot orthosis.

v Ataxic

Ataxic cerebral palsy (15% of all CP patients) is caused by damage to the cerebellum. Since the cerebellum is the control center for balance and coordination, ataxic cerebral palsy therefore affects coordination of movement. This type usually affects all four limbs and the trunk. It is characterized by poor or low muscle tone (hypotonia).

Ataxic cerebral palsy may appear as unsteady, shaky, or “drunk”. The ataxic gait will appear as wide-based with their feet unusually far apart. The increased base of support compensates for a poor sense of balance and asymmetrical hypotonia.

They may have intention tremors activated when attempting quick, precise voluntary movements. When reaching for an object the hand and arm will begin to shake. As the hand gets closer to the object the trembling gets more severe, increasing the completion time for the task and frustration for the patient.

v Athetoid (dyskinetic)

Athetoid cerebral palsy (10% of all CP patients)is a result of damage to the basal ganglia. Athetonia is characterized by mixed muscle tone appearing as slow, writhing involuntary muscle movements. The muscles alternate between floppy and tense involuntarily. The movement may be small or big, random and jerky. The writhing movements usually affect the hands, feet, arms, or legs. It may affect the muscles of the face and tongue to cause grimacing and drooling. The involuntary and uncontrollable muscle tone fluctuations may affect the whole body. This writhing often increases during times of heightened emotional stress and usually disappears during sleep. The involuntary fluctuations limit the ability to hold posture and further hinder independent mobility. These fluctuations may affect facial expressions, breathing, vocal chords, and tongue movements as well.

v Mixed

Mixed Cerebral Palsy (5% of all CP patients) is a combination of two of more types of Cerebral Palsy. The most common mixed have both the tightness of spastic and the involuntary movements of athetoid. This is caused by injury to multiple areas of the brain. 

Possible complications/comorbidities of CP

Bone thinning/osteoporosis                                                Bowel obstruction

Hip dislocation/arthritis in the hip joint                                    Injuries from falls

Joint contractures                                                                        Pneumonia

Reduced communication skills                                                Poor nutrition

Reduced intellect                                                                         Scoliosis

Signs and symptoms

The signs of CP are usually not noticed until a child is at least a year old. As the child grows, he is also developing; thus the signs are only pronounced when the child is older.  However if CP is severe, it may be noticed shortly after birth appearing as some of the following:

•            Unusual positions including being in a very relaxed, or stiff posture.

•            Seizures.

•            Weak or shrill cry

•            Trouble sucking, or swallowing.

Symptoms appearing as the child grows older may include:

•            Accidents; seizures and lack of muscle control can cause falls.

•    Skin irritation; excessive drooling irritating facial and throat muscles.

•            Dental problems; increase risk of cavities / gum disease

•            Under-developed (hypotonic) muscles in arms

Diagnosis

Medical history- details about the pregnancy, or developmental delays

Physical examinations- determine new-born reflexes, posture and muscle functions.

Screening tests and questionnaires- determine extent of developmental delays.

MRI & CT scan - Detects brain abnormalities. Preferred MRI over CT due to its high yield.

Ultra sound- identifies pathologies or threats in the brain.

Intelligence testing- identify mental retardation.

EEG (electroencephalography) - identify abnormal activity such as seizures.

Despite all these diagnostic methods, CP may show up later due to the continual development of the child.

Treatment

Since Cerebral Palsy is a nonprogressive permanent disorder, the treatment is focused on alleviating current and future symptoms, comorbidities, and discomfort.

• Occupational therapy- helps in living as independently as possible, adapt and maximize their capability.

• Speech therapy- helps in controlling the mouth and jaw muscles, so that the person can talk, bite, chew, swallow breath, and move their head effectively.

• Antispasmodics injections- helps relax muscles, and improve ROM.

• Anticonvulsant- used to treat seizure.

• Selective dorsal rhizotomy (cutting nerves of affected limbs) - reduces spasms, increases flexibility, and improves control of the affected joints or limbs

• Baclofen pump- inserted into abdomen while young, pump releases Baclofen (muscle relaxant) into the spinal cord

• Bio feedback – muscular reeducation and awareness

• Massage therapy- helps a person to relax, and strengthen, muscles and joints

• Neuro-cognitive therapy- stressing neuroplasticity, the ability of brain to adapt to demands, and social learning and interaction

• Hyperbaric oxygen therapy- pressurized oxygen is inhaled by the patient in hopes of reviving damaged brain cells

• Cord blood therapy- patients own cord blood is used to re-grow dead cells in hopes of curing CP

Physical Therapy Treatments

While there are many courses of treatment available, this paper focuses on the role of physical therapy in the treatment of cerebral palsy exclusively. Just as there are a countless number of combinations of mixed type cerebral palsy, there are also a countless number of physical therapy combinations. In the interest of narrowing the scope of this paper, we focus on the most common treatment categories used for treatment in cerebral palsy by the physical therapy field. We will be discussing neurodevelopmental technique, hippotherapy, aquatherapy, and stretching.

v Neurodevelopment Technique (NDT)

NDT is a problem-solving approach focusing on the analysis and treatment of sensory and motor impairments and functional limitations. A thorough examination and evaluation is the basis for treatment. The NDT approach considers the individual as a whole and recognizes that every expression of the person—psychological, emotional, cognitive, perceptual, and physical—has value and contributes to the overall level of function. After exam, evaluation, goals, and strategies are developed, the therapist coordinates treatment in partnership with the client and meaningful persons in the patient’s life. Implementation of treatment depends on the examination and evaluation outcomes, the client’s competencies and integrity, and the limitations of the multiple internal systems and external resources. With the NDT approach, the therapist constantly guides and modifies treatment according to the individual’s response to the selected strategies. Therapeutic handling is integral to the NDT approach. Therapeutic handling allows the therapist to (a) feel the client’s response to changes in posture or movement, (b) facilitate postural control and movement synergies that broaden the client’s options for selecting successful actions, (c) provide boundaries for movements that distract from the goal, and (d) inhibit or constrain those motor patterns that lead to secondary deformities, further disability, or decreased participation in society. The daily repetition of the designed intervention strengthens the patient’s motor learning abilities. These interventions may be independent or practiced with caregivers. As a result of NDT intervention, the individual will use the new or regained posture or movement strategies to carry out life skills more efficiently. These strategies will minimize secondary impairments that can create additional functional limitations or disability. 

 NDT being used in the form of kinesiotaping. This intervention uses kinesiotape for postural alignment and muscular development specifically challenged during this stage of growth. The daily repetition will strengthen the infant’s motor learning ability and facilitate completion of his appropriate growth phase.

v Hippotherapy

Hippotherapy is the use of horses during therapy. The horse (equine)’s walk

provides a multidimensional, variable, rhythmic and repetitive movement. The horse provides a dynamic base of support making it a useful tool for increasing trunk strength and control, balance, building overall postural strength and endurance, addressing weight bearing, and motor planning. Equine movement offers continuous organic sensory input to vestibular, proprioceptive, tactile and visual channels. During gait transitions, the patient must perform subtle adjustments in the trunk to maintain a stable position. When a patient is sitting forward astride the horse, the horse's walking gait imparts movement responses similar to normal human gait. The effects of equine movement on postural control, sensory systems, and motor planning to facilitate coordination and timing, grading of responses, respiratory control, sensory integration skills and attention skills. During a hippotherapy session, the therapist will observe the patients response to the equine movement. The patient’s resultant movement responses are similar to human movement patterns of the pelvis while walking. The variability of the horse's gait enables the therapist to grade the degree of sensory input to the patient, and then utilize this movement in combination with other treatment strategies to achieve desired results.

The physical therapist can overlay a variety of motor tasks on the horse's movement to address the motor needs of each patient and to promote functional outcomes in skill areas related to gross motor ability such as sitting, standing, and walking.

v Aquatherapy

Aquatic therapy is any program performed in the water. Aquatic therapy uses the physical properties of water to assist in the patient to perform correctly aligned movements and patterns that may not be able to be performed on land.

While submerged in water, buoyancy assists in supporting the weight of the patient. This decreases the amount of weight bearing on joints, which reduces the force of stress placed on the joints. Thereby allowing the patient to increase range of motion, decrease pain, and further stimulate the sensory-motor responses. The viscosity of water provides the source of resistance during an aquatic therapy session. This resistance allows for muscle strengthening without the need of weights.

Using resistance coupled with the water’s buoyancy allows the patient to improve skeletomuscular and postural awareness and control, increasing muscle symmetry in dynamic and static positions. Aquatic therapy also uses hydrostatic pressure to decrease swelling and improve joint position awareness. The hydrostatic pressure produces forces perpendicular to the body’s surface. This pressure provides joint positional awareness to the patient. As a result, patient proprioception is improved. The hydrostatic pressure also assists in decreasing joint and soft tissue swelling that may accompany a variety of comorbidities associated with cerebral palsy. The warmth of the water assists in relaxing muscles and vasodilators’ vessels, increasing blood flow. The warmth of the water may aid in relaxing the rigidity, spasticity, and spasms experienced in several types of cerebral palsy.

Stretching

Stretching (mobilization) is used in CP to increase the extensibility of restricted tissue, thereby elongating (lengthening) the structures that have become hypomobile over time. As CP progresses, the original rigidity may develop into contractures requiring extensive and varied types of stretching. Passive, active, active assisted, self, static, ballistic, cyclic, mechanical, and manual stretching are when a sustained end range stretch force, applied with overpressure elongates a shortened muscle-tendon unit and periarticular connective tissues by moving a restricted joint just past the available range of motion. Proprioceptive neuromuscular facilitation (PNF) uses the muscles internal biochemical reactions to integrate active muscle contractions into stretching maneuvers to either facilitate or inhibit muscle activation and to increase the likelihood that the muscle to be lengthened remains as relaxed as possible during treatment. While PNF is an effective treatment for some types of CP, it is important to note that it requires normal innervation and voluntary control of either the shortened muscle or muscle on the opposite side of the joint. Along with the various techniques, there are several determinants that can effect the usefulness of stretching in the treatment of CP. The determinants are alignment, stabilization, intensity of stretch, duration of stretch, speed of stretch, frequency of stretch, and mode of stretch. By varying these determinants, and types of stretch, the therapist has the ability to control amount of desired plasticity. The amount of plasticity is also determined by how long the muscle has been immobilized. Lengthy periods of immobilization lead to decay of contractile protein, decrease in muscle fiber diameter, decrease in the number of myofibrils, and a decrease in intramuscular capillary density; leading to sarcomere absorption; these factors then lead to muscle atrophy and weakness and an increase in fibrous and fatty tissue in the muscle. The proposed stretching technique must be of adequate determinates to stimulate the muscle – tendon unit and affects a muscle’s response to stretch. The stretch must develop enough tension to fire the golgi tendon organs to produce autogenic inhibition thus enabling a muscle to be elongated against less muscle tension. 

Dance/ Movement Therapy

Dance/ movement therapy is based upon the idea that the brain has pre-existing structures that are receptive to music, rhythm, and moving to music. While one area of the brain has been damaged, the brains neuroplasticity and innate response to music will allow for motor movement Dance therapy helps the patient gain self- esteem, coordination, reduce tension in the body, chronic pain, improve body image, and reduce the fear factor. While most traditional physical therapy treatments use passive range of motion, dance therapy incorporates active range of motion. Most dance therapies begin with a release of muscular tension to find the patients true physical limits. After the tension is released, the patient becomes fully aware of muscles and joints that he has not felt recently. While this therapy may be very uncomfortable and lengthy, it allows the patient to increase his range of motion independently with verbal cueing and little therapeutic handling. After full body muscular awareness is achieved, the patient will be able to quickly identify inefficient physical patterns. The therapist then gives instructions on how to overcome previous dysfunctional patterns. This therapy focuses on continuous active participation of the patient. This therapy allows improved balance, strength, gait, flexibility, and decreased fall risk.

Prevention

You can help prevent CP before and during pregnancy by having healthy habits: eat nutritious foods, do not smoke, and avoid exposure to harmful substances. Also, help prevent CP in children by minimizing risk for sustaining a brain injury, and know how to prevent lead poisoning, keep your child away from people who have serious contagious illnesses, such as meningitis, make sure your child's immunizations are up-to-date. Prenatal MRI is more precise of evaluation of intracranial abnormalities and lesions than traditional ultrasound.

Prognosis

The ability to live independently with CP varies widely depending on the severity of each case. Some individuals with CP will require personal assistant services for all activities of daily living. Others can lead semi-independent lives, needing support only for certain activities. However, in most cases persons with CP can expect to have a normal life expectancy.

v Research

Hippotherapy

Hippotherapy was tested on 15 children ranging in age from 4 to 12 with spastic cerebral palsy for 8 min. The end results show that it can be a benefit for the patient because, as explained earlier, hippotherapy uses the movement of the horse to achieve the results, rather than the patient. The horse’s gait evokes a natural walking response in the rider, and the rider responds by adjusting his position, and moving his muscles, much like as if the rider himself is walking. Compared to sitting on a moving barrel, sitting on a moving horse had very encouraging results for the patient.

Aquatic therapy

In water, a submerged body loses the weight of the water equal to that is displaces. This results in less stress and pressure on bone, muscle, and connective tissue. While standing in water, the depth of the water will determine the percentage of weight bearing. It also has the properties to assist, resist, and support an individual. The buoyancy will help the person with the downward pull of gravity. The study consisting of 46 children ranging in age from 5 to 7 showed that that aquatic therapy produced 56% better results than the 23% improvement of the control group (respiratory exercises alone). As stated in the study, the use of aquatic therapy will lessen the effect of gravity and improve control.

Summary

            Cerebral Palsy affects 2 in every 100 individual each year in the developed areas of the world, and it might not seem like a lot, but affecting a child is a lot no matter how few! Thankfully, the disease is not terminal and there are lots of ways to cope with it. Therapies such as hippotherapy, speech therapy, occupational therapy, aqua-therapy, stretching, and massage therapy, are few examples of treatments. In addition, surgeries such as rhizotomy and antispasmodics injections help the person to live as independently as possible. One option mentioned is cord blood therapy and although, there is no randomized control trial, but the one case that they tried it on was very successful and the doctors announced that if his “progress continues until he is seven, than he will be pronounced cured”. The best way to prevent CP is to be pro-active during pregnancy and avoid smoking, drugs, injuries and accidents that might harm the fetus. In addition, the mom to be should have good pre-natal care, nutritional meals, and exercises, to be in good health.

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