Pediatric Annals

Controversial Therapies in the Management of Cerebral Palsy

Dennis J Matthews, MD

Abstract

Rehabilitation management of the child with cerebral palsy is complex and challenging. The child with cerebral palsy often has multisystem involvement, which requires a thorough understanding of the interaction of the biological, environmental, and developmental factors affecting each child. Designing a treatment program requires a thorough assessment of the gross and tine motor function; cognitive, language, and personal social function; and projected functional potential. Periodic reassessment and program updating are essential. The rehabilitation goal is to foster an optimal developmental course so the function or potential allowed by the organic déficits can be fully realized.1

The purpose of this article is to describe some of the general principles of therapeutic intervention for motor dysfunction along with specific controversial approaches. It is important to understand that most of these methods have developed empirically from clinical observation, and a theoretical framework was devised later to explain the possible neurological physiological principles. To date, there are very few, if any, controlled studies on the outcomes of various treatments despite the vigorous proclamations from various proponents. The reports are generally anecdotal and self-validating. Controlling the extensive number of variables is most difficult and perplexing.

The most widely used method is that of neurodevelopmental therapy as developed by the Bobaths.2-4 This system of treatment is based on the premise that the chief obstacle to normal motor movement is postural mechanism impairment. The goal is to alter abnormal postures, reduce or increase tone, improve balance and antigravity postures, and develop fundamental movement patternings following the normal developmental sequence. Movement is controlled through the proximal joints, head, shoulders, and pelvis. Righting and equilibrium reactions are elicited through movements and a variety of training aids. The parents are advised to try to handle and treat the child in daily activities at home.

Sensory integrative therapy advocated by Ayres,5 originally designed for learning disabled children, is now being applied to a variety of neuromuscular disorders. Through her studies, Ayres has postulated a neurological sequence of sensory input, followed by an integration and sorting-out process that occurs at various levels of the nervous system. She feels a motor response and subsequent input that provides feedback contribute to the integration process, and that motor learning is on the unconscious level, rather than on the higher conscious cortical level. Remediation is aimed at enhancing sensory motor function and automatic postural responses with emphasis on tactile and vestibular stimulation.

Doman and Delacato,6 expanding on the ideas of Fay,7 recommend a program following the successive states ot locomotion adopted by animals ascending the phylogenetic scale. This highly controversial method8 uses a series of set patterns repeated many times during the day, attempting to train cerebral dominance and normalization ot function. Unlocking reflexes and position are used to establish movements that are gradually brought under voluntary control. Continued performance is believed to result in improved function and strength of spastic muscles and diminution ot tone and postural disturbances. The progressive patterned movements are initially practiced passively several times during the day. The Doman-Delacato system also recommends periods ot carbon dioxide rebreathing and occasional fluid restriction. Auditory and visual stimulation is provided tor some children. Patterns beyond the child's stage ot development are not encouraged. Neurological organization is considered possible if each developmental level is established before going on to the nexr.

Various forms ot relaxation and biofeedback training to reduce muscle tone have been used with variable success in a wide range of clinical problems.9 Ortega10 demonstrated significant improvement in tone after progressive relaxation training. Finley11 and others use biofeedback training to reduce the muscle tone in four children with spastic cerebral palsy. All four…

Rehabilitation management of the child with cerebral palsy is complex and challenging. The child with cerebral palsy often has multisystem involvement, which requires a thorough understanding of the interaction of the biological, environmental, and developmental factors affecting each child. Designing a treatment program requires a thorough assessment of the gross and tine motor function; cognitive, language, and personal social function; and projected functional potential. Periodic reassessment and program updating are essential. The rehabilitation goal is to foster an optimal developmental course so the function or potential allowed by the organic déficits can be fully realized.1

The purpose of this article is to describe some of the general principles of therapeutic intervention for motor dysfunction along with specific controversial approaches. It is important to understand that most of these methods have developed empirically from clinical observation, and a theoretical framework was devised later to explain the possible neurological physiological principles. To date, there are very few, if any, controlled studies on the outcomes of various treatments despite the vigorous proclamations from various proponents. The reports are generally anecdotal and self-validating. Controlling the extensive number of variables is most difficult and perplexing.

The most widely used method is that of neurodevelopmental therapy as developed by the Bobaths.2-4 This system of treatment is based on the premise that the chief obstacle to normal motor movement is postural mechanism impairment. The goal is to alter abnormal postures, reduce or increase tone, improve balance and antigravity postures, and develop fundamental movement patternings following the normal developmental sequence. Movement is controlled through the proximal joints, head, shoulders, and pelvis. Righting and equilibrium reactions are elicited through movements and a variety of training aids. The parents are advised to try to handle and treat the child in daily activities at home.

Sensory integrative therapy advocated by Ayres,5 originally designed for learning disabled children, is now being applied to a variety of neuromuscular disorders. Through her studies, Ayres has postulated a neurological sequence of sensory input, followed by an integration and sorting-out process that occurs at various levels of the nervous system. She feels a motor response and subsequent input that provides feedback contribute to the integration process, and that motor learning is on the unconscious level, rather than on the higher conscious cortical level. Remediation is aimed at enhancing sensory motor function and automatic postural responses with emphasis on tactile and vestibular stimulation.

Doman and Delacato,6 expanding on the ideas of Fay,7 recommend a program following the successive states ot locomotion adopted by animals ascending the phylogenetic scale. This highly controversial method8 uses a series of set patterns repeated many times during the day, attempting to train cerebral dominance and normalization ot function. Unlocking reflexes and position are used to establish movements that are gradually brought under voluntary control. Continued performance is believed to result in improved function and strength of spastic muscles and diminution ot tone and postural disturbances. The progressive patterned movements are initially practiced passively several times during the day. The Doman-Delacato system also recommends periods ot carbon dioxide rebreathing and occasional fluid restriction. Auditory and visual stimulation is provided tor some children. Patterns beyond the child's stage ot development are not encouraged. Neurological organization is considered possible if each developmental level is established before going on to the nexr.

Various forms ot relaxation and biofeedback training to reduce muscle tone have been used with variable success in a wide range of clinical problems.9 Ortega10 demonstrated significant improvement in tone after progressive relaxation training. Finley11 and others use biofeedback training to reduce the muscle tone in four children with spastic cerebral palsy. All four of these children improved. Theeffectsof their relaxation were confounded by the concomitant use ot behavior modification techniques. Further studies need to be done to examine whether the ability to relax and gain more efficient control of motor function can be generalized to situations in which training does not take place.

Functional electrical stimulation has been used for a variety of purposes in patients with cerebral palsy. Orthotic and therapeutic use ot this modality has been reported and measured by a number of investigators12,13 who examined its effect on muscle force, electromyogram patterns, basographic and goniometrie patterns, spasticity, and reflexes. Clinical evaluations in relatively large patient populations have been carried out by a tew investigators.12 Most clinical reports have been rather general and somewhat superficial, mainly because of the intrinsic difficulties ot describing in quantitative terms the patient's response to the stimulation. This often observed discrepancy between objective measurement and clinical judgment has been one of the factors limiting the widespread use of this technique.

Inhibition has been demonstrated repeatedly following functional electrical stimulation.14,15 The stimulation of peripheral nerves produces an inhibition of spasticity in the antagonist muscles. This inhibition has also been noted following transcutaneous electrical stimulation in children with cerebral palsy.16,17 Although promising initially, the lack of long term carry-over and the requirements for frequent application quickly lead to poor patient compliance.17 Further research involving different designs, instrumentation, and longitudinal following are continuing, which may produce a clinically relevant treatment.

Neurosurgical treatment is controversial and not widely accepted. Interest in selective dorsal rhizotomy for spasticity and cerebral palsy has been frequently raised following reports of Peacock. ,8 Stimulation of some rootlets has been demonstrated to produce sustained muscle contraction or spread of that contraction to muscle groups from other segments, and selectively dividing those overactive rootlets has reduced spasticity. The other rootlets, which produce shorter and combined contraction, are left alone. Using Peacock s technique, the posterior rootlets from L2 to Sl are isolated bilaterally and each rootlet is stimulated with a single and titanic stimulus between 10 and 50 volts using unipolar probes. He also relies heavily on direct observations of sustained muscular contraction and the spread of this contraction to other muscle groups.

Peacock and his colleagues reported on 60 children, most of whom had spastic diplegia, with follow-up between one and five years. These children have been identified as purely spastic with no clear signs of dystonia or orthopedic contractures. Preoperatively, the tone in 35 of the 40 children was high or very high; postoperatively, it was normal or near normal in 22 and hypotonic in the rest. Immediately postoperatively the children were weaker but they rapidly recovered, and in only one case was there persisting weakness. Twelve of 14 children had improved walking pattern with an increased range of new movement and stride length. They reported one child whose walking and running appeared to become normal. Five of eight children who had used walking aids before were able to walk without them. Of the 13 children who walked with support before surgery, one became independent, eight could walk with aids, and four still needed support.

A case is being made for the procedure having few short and medium term hazards. It does seem clear that the procedure reduces spasticity and that some children have significant gains. It is impossible to know at this stage if there are any long term hazards from the rhizotomy surgery. Much more thorough evaluations of any potential long term secondary problems are needed. A more objective analysis of the outcome including gait analysis and serial electromyography would be appropriate. The major concern is the fear of widespread applications of the technique without satisfactory safeguards and selection criteria.

Epidural electrical stimulation over the dorsal columns has been reported to decrease spasticity in patients with spastic hemiplegia with a carry-over of hours to days.19 Cerebellar stimulation has been shown to reduce spasticity and hypertonia in some patients with cerebral palsy.20,21 Functional gains are not universal and most reports of dramatic change are anecdotal. Steroactic thalamic and dentate lesions are also performed to control dystonia of cerebral origin.

Rigid adherence to any one system of treatment is unjustified. A mode of intervention should be selected as most appropriate for each child at a particular time. Well selected components of each method can be used to produce the best individualized therapeutic approach. One will quickly realize that similar techniques are often used, but the rationale and terminology may be different. There are, however, common fundamental aspects to various systems as each emphasize postural mechanisms, voluntary motion, and perceptual motor function. Only a reasonable and well timed application of different nonoperative and operative therapeutic methods used in a framework of normal development can lead to the accomplishment of optimum functional skills and quality of life.

REFERENCES

1. MolnarGE: Pediatric RchaMitation. Baltimore. Williams and Wilkins. 1985. ? 143.

2. Bobath B: Abdominal Postural Reflexes Caused rrv Brain Lesions. London, Heinemann, 1971.

3. Bobath B. Bobath K: Mute«· Development in the Different Types of Cerebral ftdsy. London, Hcinemann. 1975.

4. NetmAogical Basis for the Treatment of Cerebral R&y. Philadelphia, JB Lippincott. 1980.

5. Ayres AJ : Sensory Integration and Learning Disorders. Los Angeles, Western Psychological Services. 1972.

6. Doman RJ. Spit: EB. Zucman E, et al: Children with severe brain injuries. JAMA 1960; 174:257.

7. Fay T: Use of pathological and unlocking reflexes with the rehabilitation of spastici. Am J Phys Med 1954: 33:347.

8. American Academy of Pediatrics: The Doman-Delacato treatment of neurologically handicapped children- Pedtairics 1982; 70:810-812.

9. Basmajian JV: Introduction: Principles and Background in Biofeedback- Principles and Practice for Clinicians. Baltimore. Williamsand Wilkins, 1979.

10. Ot tega DF: Relaxation exercise with cerebral-palsied adults showing spasticity. ) Appi BehavAnal 1978: 11:447.

11. Finley WW, NimanCA. StandleyJ. et al: Electrophysiologic behavior modification of frontal EMG in cetebral-palsied children. Bici/eedhuck and Self Regulation 1977; 2:59.

12. Merletti R, Andina A. Galante M. et al: Clinical experience of electronic peroneal stimulations in 50 hemiparetic patients. Scand) ftehabit Med 1979: 11:111.

13. Vodovnik L. Bajdir. Krai) A. et al: Functional electrical stimulation (at control of locomotive systems. CRC Cntical Rettete of Bioengineermg, 1981.

14. Liherson WT: Experiment concerning reciprocal inhibitions of antagonist elicited by electrical stimulation of agonist in a normal individual. Am ) Phys Med 1965; 44:6.

15. Chase JL. Pollack SF. Morris L: Inhibition of human muscle by stimulation of cutaneous nerves, in Functional Neuromuscular Stimulation. Washington, DC, National Academy of Sciences, 1972.

16. Maiden JW, Charash LI: Transcranial stimulation lor the inhibition of primitive reflexes in children with cerebral palsy. Neurology Reports 1985: 9:33-38.

17. Matthews DJ. Gringau: R: Effects of transcranial stimulation fot reducing spasticity in children with cerebral palsy. Arch Phys Med RehoM 1987.

18. Peacock WJ. Areas LJ. Berman B: Cerebral palsy spasticity. Selected posterior rhinotomy. Rrdiotr Neuroso 1987; 13:61.

19. Siegfreid J. Krainick JU. Hoas H: Electrical spinal cord stimulation for spastic movement disorders. Appi Neumphysioi 1978; 41:134.

20. Cooper IS, Riklan M. Amin I: Chronic cerebellar stimulation in cerebral palsy. Nemolug? 1976; 25:744.

21. Penn RD, Gottlieb GL, Agarwal GC-. Cerebellar stimulation in man: Quantitative changes in spasticity. J Neurosurg Psychiat 1986; 49:273.

10.3928/0090-4481-19881201-08

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