pt for cp

What is 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. While 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), and 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 actually joint contractures caused by lesions on the brain suffered before, during birth or in the first few years, whereas paralysis has a plethora of causes and is usually marked by nerve damage that impairs the corresponding muscle.

There are four major types of cerebral palsy currently identified.

            Spastic Spastic cerebral palsy refers to the increased tone, or tension, in a muscle. Normal muscles work in pairs. When one group contracts (agonist) the other group relaxes (antagonist), allowing 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 that affect only a few movements, or severe cases that can affect the whole body. Although spastic cerebral palsy is not thought to be a progressive disorder, as brain damage does not get worse over time, spasticity in muscles can increase over time. This increased muscle tone and stiffness in spastic cerebral palsy can limit 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 joint spaces become small, articular cartilage may atrophy, leading 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.

            Ataxic Ataxic cerebral palsy is caused by damage to the cerebellum, which is in the base of the brain. The cerebellum is the control center for balance and coordination and coordinates the actions for different groups of muscles. Ataxic cerebral palsy therefore affects coordination of movement. Ataxic cerebral palsy usually affects all four limbs and the trunk. In addition, ataxic cerebral palsy is characterized by poor or low muscle tone, also known as hypotonic.

Ataxic cerebral palsy can affect an individual in several ways. A person with ataxic cerebral palsy will usually have a wide-based gait, or walk. Because of their poor sense of balance they tend to walk with their feet unusually far apart. In appearance, a person with ataxic cerebral palsy will look very unsteady and shaky. This is due to low muscle tone where the body is constantly trying to counter-balance itself.

They may also have intention tremors. Intention tremors activated when attempting quick, precise voluntary movements. For example, when reaching for an object, such as a book, 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.

            Athetoid(dyskinetic) Athetoid cerebral palsy is a result of damage to the basal ganglia. Athetonia is characterized by mixed muscle tone being seen 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 also affect the muscles of the face and tongue to cause grimacing and drooling. The involuntary and uncontrollable muscle tone fluctuations sometimes 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.

Mixed Mixed Cerebral Palsy 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.  The least common mix is athetoid and ataxic, however any mix may occur. Cerebral Palsy may occur in an individual as hemiplegia, diplegia, or quadriplegia.

A few obvious symptoms of Cerebral Palsy are:

Delayed turning over, crawling and walking

Problems with speech or babbling

Abnormal stiffness or looseness of the body

Eyes that drift to the inside or outside

Trouble moving from one position to another

Trouble sitting upright at an age where sitting up should be easily achieved.

Difficulty mastering fine motor skills such as writing, buttoning a shirt, using scissors

Difficulty mastering gross motor skills such as walking, kicking a ball, riding a tricycle, or running

Uncontrollable shaking or jerking of the legs, arms, or torso

Abnormal drooling or weakened muscles of the face

Difficulty sucking and/or swallowing

What causes Cerebral Palsy

Generally, there two ways to invoke the brain damage seen in Cerebral Palsy; either through developmental brain malformation or neurological damage to the developing brain. Since the developing brain in utero is difficult to examine, the precise cause of neonatal damage is difficult to determine.

However some known causes and risk factors include:

Rh factor incompatibility, a difference in the blood between mother and fetus that can cause brain damage in the fetus

Low birth weight (less than 2 pounds)

Severe jaundice after birth

Maternal diabetes or hyperthyroidism

Maternal high blood pressure

Poor maternal nutrition

Maternal seizures or mental retardation

Incomplete cervix (premature dilation) leading to premature delivery

Maternal bleeding from placenta previa or abruptio placenta

            Premature delivery (less than 37 weeks)

            Prolonged rupture of ambriotic membranes leading to fetal infection

            Severed depressed fetal heart rate

            Abnormal presentation (such as breech, face, or transverse)

Asphyxia from insufficient oxygen to the brain due to breathing problems or poor blood flow in the brain

Meningitis – infection over the surface of the brain

Seizures caused by abnormal electrical activity of the brain

Interventricular hemorrhage (I. V. H.)

Periventricular encephalomalacia (P.V.L.) damage to the brain tissue located around the ventricles (fluid spaces) due to the lack of oxygen or problems with blood flow

Multiple births (twins, triplets)

Hypoxia

Brain damage early in life

Miller, Freeman & Bachrach, Steven J. (1995) Cerebral Palsy: A Complete Guide for Caregiving. The John Hopkins University Press

Geralis, Elaine (ed.). (1998) Children with Cerebral Palsy. Woodbine House

Stanley, Fiona, Blair, Eve, Alberman, Eva. (2000) Cerebral Palsies: Epidemiology & Causal Pathways. Mac Keith Press

How is Cerebral Palsy treated?

Since Cerebral Palsy is a nonprogressive permanent disorder, the treatment is focused on alleviating current and future symptoms, comorbidities, and discomfort. 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 is also a countless number is physical therapy combinations. In the interest of narrowing the scope of this paper, we focus on the four 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 (in combination with strengthening).

What is NeuroDevelopmental Technique (NDT):

NDT is a problem-solving approach to the examination and treatment of the impairments and functional limitations of individuals with neuropathology. The patients who receive the greatest benefit from NDT have dysfunction in posture and movement that lead to limitations in functional activity. NDT focuses on the analysis and treatment of sensorimotor impairments and functional limitations. A thorough examination and evaluation is the basis for treatment. The examination begins with the identification of an individual’s abilities and limitations. 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. This examination focuses on identifying functions and their limitations. Evaluation analyzes and prioritizes the effectiveness of posture and movement and hypothesizes which systems affect function. Examination and evaluation lead to the establishment of treatment goals and the development of treatment strategies aligning with the individual’s current needs, while continuing to aim for the long-term outcome of achieving the best possible inclusion in society across the life span.

After exam, evaluation, goals, and strategies are developed, the therapist coordinates treatment in partnership with the client and meaningful persons in the patients 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. It is an essential tool in both examination and treatment. 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, if practiced, lead to secondary deformities, further disability, or decreased participation in society.

After the development of appropriate therapeutic handling techniques, the therapist creates a model of service and delivery of intervention that will fit the client’s lifestyle. The model of service integrates the proposed intervention into the patients activities of daily living. The daily repetition of the designed intervention strengthens the patients 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. The NDT approach is continually evolving as new information, new theories, and new models consistent with available clinical evidence emerge. In addition, as the characteristics of the populations with CNS pathophysiology change, this approach continues to evolve alongside the change.

Excerpt from "Neuro-Developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice" by Janet M Howle (in collaboration with the NDTA Theory Committee Copyright 2002.)

Supporting evidence for the use of neurodevelopmental technique as a physical therapy modality in the treatment of cerebral palsy

What is 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 can be used to facilitate coordination and timing, grading of responses, respiratory control, sensory integration skills and attention skills. Equine movement is capable of stimulating and strengthening the neurophysiological systems and connections used in most functional activities and activities of daily living.

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.

Supporting evidence for the use of hippotherapy as a physical therapy modality in the treatment of cerebral palsy (as provided from americanhippotherapyassociation.org):

The effect of hippotherapy on ten children with cerebral palsy.

Casady RL, Nichols-Larsen DS. (2004) Pediatr Phys Ther. Fall;16(3):165-72. PURPOSE: The purpose of this study was to determine whether hippotherapy has an effect on the general functional development of children with cerebral palsy. METHODS: The study employed a repeated-measures design with two pre-tests and two post-tests conducted 10 weeks apart using the Pediatric Evaluation of Disability Inventory (PEDI) and the Gross Motor Function Measure (GMFM) as outcome measures. A convenience sample of 10 children with cerebral palsy participated whose ages were 2.3 to 6.8 years at baseline (mean +/- 4.1 +/- 1.7 sd). Subjects received hippotherapy once weekly for 10 weeks between pre-test 2 and post-test 1. Test scores on the GMFM and PEDI were compared before and after hippotherapy. RESULTS: One-way analysis of variance of group mean scores with repeated measures was significant (p < 0.05) for all PEDI subscales and all GMFM dimensions except lying/rolling. Post hoc analyses with the Tukey test for honest significant differences on the PEDI and GMFM total measures as well as GMFM crawling/kneeling and PEDI social skills subtests were statistically significant between pre-test 2 and post-test 1. CONCLUSIONS: The results of this study suggest that hippotherapy has a positive effect on the functional motor performance of children with cerebral palsy. Hippotherapy appears to be a viable treatment strategy for therapists with experience and training in this form of treatment and a means of improving functional outcomes in children with cerebral palsy.

Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy).

Benda W, McGibbon NH, Grant KL. (2003) J Altern Complement Med. Dec;9(6):817-25. OBJECTIVE: To evaluate the effect of hippotherapy on muscle activity in children with spastic cerebral palsy. DESIGN: Pretest/post-test control group. SETTING/LOCATION: Therapeutic Riding of Tucson (TROT), Tucson, AZ. SUBJECTS: Fifteen (15) children ranging from 4 to 12 years of age diagnosed with spastic cerebral palsy. INTERVENTIONS: Children meeting inclusion criteria were randomized to either 8 minutes of hippotherapy or 8 minutes astride a stationary barrel. OUTCOME MEASURES: Remote surface electromyography (EMG) was used to measure muscle activity of the trunk and upper legs during sitting, standing, and walking tasks before and after each intervention. RESULTS: After hippotherapy, significant improvement in symmetry of muscle activity was noted in those muscle groups displaying the highest asymmetry prior to hippotherapy. No significant change was noted after sitting astride a barrel. CONCLUSIONS: Eight minutes of hippotherapy, but not stationary sitting astride a barrel, resulted in improved symmetry in muscle activity in children with spastic cerebral palsy. These results suggest that the movement of the horse rather than passive stretching accounts for the measured improvements.

Hippotherapy as a method for complex rehabilitation of patients with late residual stage of infantile cerebral palsy.

Sokolov PL, Dremova GV, Samsonova SV. (2002) Zh Nevrol Psikhiatr Im S S Korsakova.;102(10):42-5. Influence and therapeutic efficacy of horseback riding (hippotherapy) as a method for complex rehabilitation of patients with late residual stage of infantile cerebral palsy were studied. Significant increase of a range of active and passive movements in large joints of lower extremities, higher, indices of hand dynamometry on the left, of vital lung capacity as well as a relief of relief of reactive and personality anxiety and depression, higher motivation for rehabilitation treatment, etc., were registered. Neurophysiological study revealed significant changes of afferentation at stem and thalamus cortical levels and of spectral components of cortical rhythmics. The data obtained allow us to consider hippotherapy as an effective method of complex rehabilitation of patients with late residual stage of infantile cerebral palsy. A combination of sensory stimulation and motor rehabilitation components may be a key mechanism of positive effect.

What is Aquatherapy?

Aquatic therapy or pool 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 sensorimotor 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 utilizes 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 vasodilates vessels, increasing blood flow. The warmth of the water may aid in relaxing the rigidity, spascitity, and spasms experienced in several types of cerebral palsy

Supporting evidence for the use of aquatherapy as a physical therapy modality treatment of cerebral palsy

Insert two research abstracts

(below) typical pool used for aqua therapy (http://www.redmondpt.com)

(below)  dynamic muscle strengthening exercise performed during aquatherapy session