The rehabilitation of the child with cerebral palsy is aimed not only at improving his physical condition but maximizing potential for achieving independence in all areas of function - movement and mobility, fine motor and self-care and communication. Hands on therapy, while of obvious importance, is only a small part of the overall approach, which encompasses meeting not only the educational and equipment needs of the child, but the psychosocial needs of the family as well. To that end has evolved the concept of the rehabilitation team consisting of a primary physician, physician specialists (physiatry, orthopedics, neurology, urology, etc.), therapists (physical, occupational, speech and recreational), orthotist, ADL nurse, teachers, social workers and a biomedical engineer, all called in at different times in the child's life. The physician-leader of the team must be willing to maintain frequent contact with all other members of the team as well as periodically reassess the child, since needs change as the child grows. Appropriate timing of intervention strategies is most important.
What follows is an overview of the many facets of rehabilitation programming for the child with cerebral palsy. For additional detail, the reader is referred to the available literature.117
SYSTEMS OF THERAPY
Many systems of therapy have been developed over the years and have been given the names of their various inventors.5 Physiologic evidence of the advantages of one particular therapy system over another has not been presented to any conclusive degree. The key to success of any therapy program is the consistency of its deliverance and the fact that the parents need to be involved from the very beginning in supplementing the treatments given by the therapists in the home. 3 Priority should be given to maintaining normal joint range of motion, variously referred to by the different systems as passive range of motion, stretching or elongation exercises. Useful movement patterns can then be encouraged.
Currently, the system most used is that originally developed by the Bobaths in the early 1960s.6 This "neurodevelopmental" therapy (NDT) approach emphasizes positioning and handling the child in such a way as to promote as near as normal movement patterns. A most important aspect of that therapy involves inhibition of abnormal primitive reflex patterns - those reflexes that are subcortically controlled. Examples include the symmetric and asymmetric tonic neck responses, whereby head position dominates body posture - palmar and plantar grasp reflexes, abnormal oral reflexes such as rooting and tongue thrusting, and abnormal reactions to tactile stimulation such as placing and stepping reflexes. It is felt that before normal movement can occur, inhibition of these reflexes is necessary.
Neurodevelopmental therapy also emphasizes the development of isolated extremity and trunk movement rather than mass patterns, and encourages more normal movements by manually improving reciprocal and rotational movements through both the pelvic and shoulder girdles. An equally important part of therapy involves appropriate positioning when carrying the child so as to avoid mass reflex patterns.
The treatment of the hypotonic child is somewhat different as joint compression plays an important role in increasing joint proprioceptive feedback, giving the child a better sense of body position in space.
More recently, NDT therapy has also made use of bracing and casting techniques in "reflex inhibiting" positions as adjuncts to therapy.7
Occupational therapy is aimed at improving both trunk control and fine motor function. Work is often done early on improving trunk and proximal shoulder girdle muscle control by developing as near as normal muscle contraction patterns to give proximal stability as a foundation for improving controlled distal motor movement patterns.
Similarly, by inhibiting abnormal oral reflexes and encouraging more normal suck/swallow mechanisms in the young infants, speech therapists will first work on improving needing patterns. Appropriate positioning of the head and manual facilitation of jaw control are important. As the child grows, auditory stimulation is emphasized as a model for language, while muscle control developed by "normalizing" feeding patterns can provide the foundation for the development of functional articulation.
Alternative systems of therapy are still in use. For example, the system developed by Brunnstrom8 in the early 1960s actually makes use of the primitive reflexes to facilitate initiation of movement. Nevertheless, these reflex patterns are not allowed to become the dominant movement patterns and, once the initial movement is established, reflex inhibition will be attempted to allow establishment of cortical control.
Suffice it to say, the success of any treatment system depends on constant re-evaluation of the child and on not perseverating on therapeutic systems or strategies that are not achieving desired goals. The need for intensively delivering the program, both by consistent attendance and by home programming is re-emphasized. Finally, one must never lose sight of the fact that therapy alone will not improve upon the child's inherent neurologic potential.
EARLY INTERVENTION PROGRAMS
Infant stimulation programs can be seen as complementing therapy given individually and are begun as soon as the child is diagnosed as being at risk. The model most commonly used is considered an interdisciplinary approach. In these small groups of four to eight children under the guidance of an early intervention learning specialist, with additional input from physical, occupational and speech therapists, parents are taught to handle and position their infants and preschoolers in a manner which will encourage the children to develop movement and play skills appropriate for their age. Intervention is designed to minimize the deleterious effects of spastic synergistic posturing and diminish the influence of retained primitive reflexes on movement. Activities designed to promote development of gross motor skills (head control, rolling, sitting, prone mobility, ie, both abdominal and four point quadruped crawling, pulling to stand and finally ambulation), fine motor skills (swatting, attaining an object, working toward an object, and various graduations of coordinated reaching, including radial grasp, pincer grasp and graded release), and feeding and language skills (suck/swallow, decreasing tongue thrust, rotary chewing, breath support for vocalizing, etc.) are taught. In addition, the supportive counseling of a social worker is utilized both in the program and in separate group sessions with the parents alone.
Most published series to date have questioned the abilities of such early intervention programs to improve the motor skills of these children, but do admit that there is improvement in the child's sociability as well as the parent's ability to manage the child in the home and accept the child's handicap.9'13 Most of these studies have been flawed by too short a period of study or follow-up as well as by the fact that many of these children were first enrolled at ages when many workers in the field would consider the child already too old to realize maximum gains from truly early intervention.
MEDICAL MANAGEMENT OF SPASTICITY
For a significant percentage of children, modification of spasticity by therapeutic handling and positioning is insufficient, leading to a search for additional methods of diminishing tone. Medications used include Dantrium, Valium, and Lioresal as well as Cogentin and Clonipin occasionally. The former three drugs are used primarily for treating generalized spasticity. Valium acts primarily centrally, while Dantrium's major site of action is at the muscle sarcoplasm. Lioresal's site of action is less well defined and may include both spinal and brain centers. All three can result in quantitative relaxation of muscle tension, but most studies to date have shown poor effect for functional improvement in spite of relaxation achieved14 due to sedative effects at the necessary dose. Cogentin and Clonipin have been used more recently to provide relaxation in children who show primarily rigidity and have been found to be quite effective, although dosages need to be titrated to avoid oversedation.
Quite often, we are concerned with the deforming characteristics of spasticity in specific muscle groups. For example, spasticity in the hip adductors can cause both a scissoring gait as well as place the hips at greater risk for subluxation. Similarly, gastrocnemius spasticity can cause toe walking as well as difficulty tolerating braces. Spastic hamstrings contribute significantly to the crouched, internally rotated gait seen in diplegics. Common offending muscle groups in the upper extremities include the wrist and finger flexors as well as the elbow flexors. Furthermore, most children will not show the same degree of spasticity in all the above groups, so that techniques for the selective relief of spasticity do have a role in the management of these children. Such techniques include motor point blocks and peripheral nerve blocks. Agents vary, with phenol in a 2% to 3% solution being most commonly described in the literature. We have used a 50% solution of ethyl alcohol because of its ease of handling and lesser risk of systemic toxicity.
Controlled intensity electrical stimulation allows isolation of the peripheral nerves, following aliquots of solution slowly injected until a desired effect is achieved. This technique has been very successful for the adductors, blocking the obturator nerve at the groin and for the gasttocs, blocking the tibial nerve at the knee. We have just started using this technique for the hamstrings, blocking the sciatic nerve at the level of the ischial tuberosity.
The effects of peripheral nerve blocks are temporary, lasting from 4 to 6 months, occasionally longer. The procedure is therefore useful in "buying time," allowing therapy to be delivered more effectively. For very young children, there is also delay in the performance of initial invasive surgical procedures until the child has gotten past his first pre-school growth spurt. Not uncommonly, even once the block has worn off, the fact that therapy has been given more effectively for a prolonged period prevents the problem of spasticity from being quite as manifest as was previously, and repeat blocks are rarely necessary.
Peripheral nerve blocks have also been used to demonstrate the effect that could be expected with a more permanent surgical procedure and is also found to be helpful by the orthopedic surgeons in facilitating the effect of stretching with serial casts. The only untoward effect we have encountered is the temporary development of painful paresthesias in 10% to 15% of children undergoing tibial nerve block. This generally lasts at most 3 to 4 weeks and can almost always be managed with mild analgesics and the soothing effects of hydrotherapy.
Braces (orthoses) can function dynamically to increase the energy efficiency of gait, or statically to control joint alignment. The optimal brace for the child with cerebral palsy does both.
Some of the older systems oí therapy, notably that of Phelps,5 advocated initially bracing children at all joints to control position (Figure 1). Thereafter, as volitional control developed, components were gradually removed. Current thinking goes against such massive early bracing with the most common brace used being the custom molded ankle foot orthosis (AFO) made from a plaster mold of the child's foot after obtaining optimal position. The most desired position is that of slight dorsiflexion at the ankle with the heel held in either neutral or slight varus. This is the most functional position for heel-toe gait, and also lessens the tendency for knee recurvatum in midstance as the moment of force at heel strike is behind the knee, forcing it toward flexion. For children whose toes have a tendency to curl, the foot plate can be extended to the toes but should be set into slight toe extension to allow roll-off through the metatarsal heads. We tend to first use this brace as the child is just starting to ambulate, since the dorsiflexed position of the ankle is not desired if the child is spending most of his time crawling.
For many children with spastic diplegia there is also a tendency for the legs to internally rotate at the hip and flex at the knee, the so-called "crouch" gait. Rather than using extensive rigid metal bracing or metal cable twisters, less bulky bracing of elastic webbing attached to the tops of AFO's is used.15 These wrap around the leg and attach to a plastic pelvic belt in such a way that the pull is in external rotation at the hip and extension at the knee. This accomplishes the same purpose as traditional bracing without the weight, bulk or expense.
More rigid bracing of conventional metal uprights and leather pads is still used primarily for passive positioning allowing the severely involved child to assume the upright stance and gain the physiologic benefits of vertically, ie, a lessening of the tendency for osteoporosis and beneficial gravitational effects on respiratory and bowel and bladder function.
Upper extremity bracing can likewise take the form of bulky plastic bracing to maintain as near normal position of the wrists and fingers which tend to become deformed in a flexion synergy pattern (Figure 2). Fine motor function is rarely enhanced by such bracing, whose bulk precludes free finger movements. Occasionally, less extensive bracing, ie, wrist cock-up splints, correct wrist flexion yet allow finger manipulations. All such bracing, however, is poorly tolerated by young children, especially hémiplégies who are able to use their good hand to remove the brace. Many children have the cortical thumb (thumb in palm) deformity as their major abnormality. A simple fabric thumb loop orthosis, better tolerated than plastic braces, can sometimes lead to dramatic improvement in oppositional skills.
Given the physical limitations imposed by the severe tonal abnormalities in some cerebral palsy children, the use of adaptive equipment to enhance mobility, hand function and communication skills becomes a vital adjunct to therapy and can be viewed as an extension of bracing. With today's technology, the use of computer-assisted and electronically powered devices has become possible. However, even at a very young age, the use of simple assistive devices to enhance all areas of development can be introduced at the age when most children would normally be crawling, reaching or uttering first sounds, often as young as 6 or 7 months.
Mobility devices16 can take the form of wheeled scooter boards, providing as little as abdominal support to as much as total body support in which the child can be positioned with legs abducted to prevent scissoring and wedged at the chest to allow some prone head and back extension (Figure 3 and 4). These children can then push with their arms, thereby achieving early independent mobility. Wheeled gocarts for children with good sitting balance can provide early "wheelchair" experience and can be begun as early as 12 to 18 months.
For those children with poor control of the trunk, adaptive seat inserts are constructed, providing as much support as necessary by utilizing lateral head, trunk and hip supports, abduction pommel, foot straps or stirrups, seat belt and trunk harness where needed. Such inserts can be constructed of a variety of materials from wood to triwall to various firm plastic foams (Adaptafoam) and can fit into most strollers. As the child grows, travel chairs can be prescribed with all the above modifications.
For the older child with adequate upper extremity and trunk control there are many lightweight and "sporty" appearing wheelchairs available which are cosmetically more acceptable. Formal wheelchair prescription, however, is often deferred even past the age at which the child can actually manipulate a chair (2Vi to 3 years) as this is often viewed by the parents as "throwing in the towel" on walking. Careful preparation emphasizing the needs and benefits of functional mobility provided by a chair as well as truthful assurances that limited ambulation will be continued as long as possible will smooth the transition.
Figure 1. Molded ankle foot orthosis (AFO); AFO with elastic twisters and pelvic belt; standard metal long leg braces with pelvic and spinal supports.
Figure 2. (from left) Functional hand splint; fabric cortical thumb loop orthosis.
Figure 3. Mobility devices (clockwise from lower right): scooter board for abdominal support; scooter with total body support; custom seat insert (in stroller).
Figure 4. Mobility devices (from left): travel chair, electric wheelchair, "sporty" manual wheelchair.
Figure 5. Universal cuff with fork inserted.
Figure 6. Adapted toys (switch activations not shown).
Finally, for children with profound physical involvement but enough preservation of cognitive and visual perceptual skills, provision of an electric wheelchair, using adaptive seating as described above and appropriate switch activations can provide independent mobility.
In the area of fine motor activities and activities of daily living simple devices such as holders and cuffs strapped onto the child's hand into which utensils, crayons, etc. can be inserted, can substitute for deficient grasping (Figure 5). Long-handled extensions allow greater range of reaching. Liberal use of velcro closures substitutes for buttons, zippers and shoelaces. For the older child, technology has led to the development of Environmental Control Units which can be used to operate television, telephone, page turners, feeders, etc., in a specially equipped room, so that even profoundly physically involved children can have some measure of functional independence.
For the non-verbal child, augmentative communication devices provide a means of interacting with others. The first and most crucial step for the infant involves learning that he can impact upon his environment. This is accomplished through the use of adapted toys activated by any of several simple electronic switches, so that even the more physically involved child can "make the toy go" (Figure 6). Once this cause/effect relationship is learned, it can be utilized for a variety of simple electronic "scanners" such as a clock scanner, in which the pictures of significant people, objects, actions, etc. are placed at different "time" positions (Figure 7). Such simple devices can be introduced at a cognitive age of about 18 months, by which time the concept of symbolic representations of the child's environment is established.
The complexity and sophistication of computerdriven devices with voice output17 is now available to those children whose cognitive potential allows their use (Figure 8). Selection of appropriate means of activation, ie, the right switch, is crucial. Drawbacks to current systems include bulk (poor portability), slow speed and cost. Undoubtedly, future technological advances will reduce or eliminate those problems.
For children with cerebral palsy, the goal of rehabilitation is to maximize functional independence in the face of often profound physical involvement. It is hoped that the reader has been given some insights into the complexities of that task, so that, faced with such a patient, the pediatrician is aware of what should be done, and to whom he/she can turn for assistance in carrying out the rehabilitation program.
Figure 7. Clock scanner (switch activation not shown).
Figure 8. Augmentative communication device with voice output.
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