Treatment of Cerebral Palsy: Physical Therapy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy
Cerebral Palsy

Physical Therapy

Physical therapy is one of the most important aspects of cerebral palsy therapy. The referral to the physical therapist is often the first referral made in a cerebral palsied child’s treatment and is usually started soon after a diagnosis of cerebral palsy is made. Physical therapy consists of activities and education to improve flexibility, strength, mobility, and function. A physical therapist also designs, modifies, and orders adaptive equipment. Physical therapy may be carried out in clinics, hospitals, and schools -- and through a home exercise program. Physical therapy will not be successful without an ongoing daily home program.

Cerebral Palsy

Cerebral Palsy

The job of the physical therapist is to help a child’s mobility to develop and to carry out and teach exercises designed to avoid contractures, bone deformity and unwanted movement. In general, they are trained to work with your child to enable him or her to obtain maximum physical function.

Therapy -- whether for movement, speech, or practical tasks -- is a cornerstone of cerebral palsy treatment. The skills a 2-year-old needs to explore the world are very different from those that a child needs in the classroom or a young adult needs to become independent. Cerebral palsy therapy should be tailored to reflect these changing demands.

Physical therapy is usually just one element of an infant development program that also includes efforts to provide a varied and stimulating environment. Like all children, the child with cerebral palsy needs new experiences and interactions with the world around him in order to learn. Stimulation programs can bring this valuable experience to the child who is physically unable to explore.

A physical therapy program may consist of one or more of the following:

Stretching: Stretching of muscles is done by moving the arms or legs in a way that produces a slow, steady pull on the muscles to keep them loose. Children with cerebral palsy have increased tone and tend to get very tight muscles. Therefore it is extremely important to perform daily stretches to keep arms and legs limber so the child can continue to move and function.

Strengthening: Strengthening exercises work specific muscle groups to enable them to support the body better and increase function.

Positioning: The body is placed in a specific position to attain long stretches. Some positions help to minimize unwanted tone. Positioning can be done in a variety of ways, including: bracing, abduction pillows, knee immobilizers, wheelchair inserts, sitting recommendations, and handling techniques.

Physical therapists tend to focus mainly on activities involving the legs, such as walking, braces, using crutches and rehabilitation after a surgery. A patient’s physical therapy treatment program will likely change quite a bit over the years, as one will probably not have the same physical limitations one had as an infant, although they are all a result of the neurological disorder (CP). Physical therapy can also help a child’s family through reducing stress caused by caring for the child. Much of what the physical therapist will do in their treatment program will be exercises that the parents are able to perform at home, making it a less daunting task to help the child’s development. Many parents attend their child’s physical therapy sessions with them. Parental attendance is helpful in physical therapy for a number of reasons. Many children perform better in comfortable settings. For instance, it has been noted that children can often complete exercises and tasks much more easily at home than in the office of the physical therapist. For this reason, having his or her parent(s) present can give the child much-needed positive reinforcement and a feeling of security, without which the child may perform less impressively in their physical therapy program.

Physical therapy is used to prevent contracture complications by stretching the affected muscles, and is also used in certain situations to improve motor development. Specific physical exercises help to keep the muscles from becoming weakened and from deteriorating due to lack of use. Patients can experience muscle contractures when muscles become fixed in a rigid and abnormal position. Treatment may include behavior therapy involving psychological techniques to complement physical, speech or occupational therapy and can also help to improve quality of life.

The fields of physical therapy and occupational therapy can overlap quite a bit in the treatment of a child with cerebral palsy. They are both responsible for motor skill development, but the occupational therapist is focused on fine motor skills involving the hands, face and feet, while the physical therapist’s concentration on motor skills will be the development of gross motor skills, involving movement on a grander scale. Providing a patient with adaptive equipment (mechanical aids), helping the child with positioning and seating, sensory integration and range of motion are other examples of the over lap between physical therapy and occupational therapy. Another is orthotics, however the occupational therapist will focus on upper extremities, while the physical therapist will focus on lower extremity orthotics. In addition to the aforementioned over lapping areas of specialization, a physical therapist will also be responsible for oromotor skills, functional skills, pain management, gait analysis and training, balance, fitness, posture and biomechanical alignment.

Another goal of some physical therapy programs is to improve the child's motor development. A widespread program of physical therapy that works toward this goal is the Bobath technique, named for a husband and wife team who pioneered this approach in England. This program is based on the idea that the primitive reflexes retained by many children with cerebral palsy present major roadblocks to learning voluntary control. A therapist using the Bobath technique tries to counteract these reflexes by positioning the child in an opposing movement. So, for example, if a child with cerebral palsy normally keeps his arm flexed, the therapist would repeatedly extend it.

A second such approach to physical therapy is "patterning," which is based on the principle that motor skills should be taught in more or less the same sequence that they develop normally. In this controversial approach, the therapist guides the child with movement problems along the path of normal motor development. For example, the child is first taught elementary movements like pulling himself to a standing position and crawling before he is taught to walk -- regardless of his age. Some experts and organizations, including the American Academy of Pediatrics, have expressed strong reservations about the patterning approach, because studies have not documented its value.

The Bobath approach to treatment

The Bobath treatment aims to improve posture and movement to enable more realistic functioning in daily life. Through specialised ways of handling, stiffness can be reduced, muscle control against gravity increased and fluctuating muscle activity stabilised.  Depending on the severity of the condition, the child may be better able to learn how to sit up, use his/her hands, to stand up, to stand, and to walk. Ideally the treatment will be an integral part of the daily routine for that child. For example, the way the child is picked up, carried, put down, or positioned when sitting, will enable parents/carers to enhance the child's ability and function.

The aims of the treatment are goal-orientated and influenced by several factors such as the age of the child, severity of their condition and their motivation. Treatment is planned for each child via assessment. Some of the areas that will be assessed are:

the patterns of movement the child presents with;
age-appropriate movements that the child may not be achieving or may find difficult;
the child's present capabilities;
examination of the child's posture in different situations and positions.

Once the child has been assessed, a prioritized 'problem-solving' list will be formulated, and then appropriate techniques used to address these areas.

Positioning is very important in Bobath treatment. Correct positioning helps improve movements. Experience of different positions is necessary to improve overall body control and reduce the risk of unnecessary poor posture.

Handling a child using key points on the body allows the therapist to manipulate the child to correct their movements. Help may be given with movements like chewing, handling objects, moving about, sitting or lying down. Even when a child is being carried, using correct positioning and handling of 'key points' on the child's body, is considered very important, as this lets the child experience, as far possible, normal movement patterns.

How parents, families and carers are involved

Like any other therapy, Bobath requires effort and practice in order to achieve benefits so input from parents and carers is essential as they spend most time handling the child. The therapist will work with the family and/or carers to teach them how to handle and position the child properly at home, so encouraging and facilitating correct movement. 

Brothers and sisters are also encouraged to join in. In fact, anyone involved with the child can participate in the therapy. Good communication by everyone involved with the child is essential; this helps to ensure the child is having appropriate goals identified, and to ensure that progress is considered satisfactory.

Many children do not like therapy so incorporating the movements into day-to-day life and leisure activities enhances outcomes and is more acceptable and practical to the whole family. 

A second such approach to physical therapy is "patterning," which is based on the principle that motor skills should be taught in more or less the same sequence that they develop normally. In this controversial approach, the therapist guides the child with movement problems along the path of normal motor development. For example, the child is first taught elementary movements like pulling himself to a standing position and crawling before he is taught to walk -- regardless of his age. Some experts and organizations, including the American Academy of Pediatrics, have expressed strong reservations about the patterning approach, because studies have not documented its value.

As the child with cerebral palsy approaches school age, the emphasis of therapy shifts away from early motor development. Efforts now focus on preparing the child for the classroom, helping the child master activities of daily living, and maximizing the child's ability to communicate.

Physical therapy can now help the child with cerebral palsy prepare for the classroom by improving his or her ability to sit, move independently or in a wheelchair, or perform precise tasks, such as writing. In occupational therapy, the therapist works with the child to develop such skills as feeding, dressing, or using the bathroom. This can help reduce demands on caregivers and boost self-reliance and self-esteem. For the many children who have difficulty communicating, speech therapy works to identify specific difficulties and overcome them through a program of exercises. For example, if a child has difficulty saying words that begin with "b," the therapist may suggest daily practice with a list of "b" words, increasing their difficulty as each list is mastered. Speech therapy can also work to help the child learn to use special communication devices, such as a computer with voice synthesizers.

As a child with cerebral palsy grows older, the need for and types of therapy and other support services will continue to change. Continuing physical therapy addresses movement problems and is supplemented by vocational training, recreation and leisure programs, and special education when necessary. Counseling for emotional and psychological challenges may be needed at any age, but is often most critical during adolescence. Depending on their physical and intellectual abilities, adults may need attendant care, living accommodations, transportation, or employment opportunities.

Regardless of the patient's age and which forms of therapy are used, treatment does not end when the patient leaves the office or treatment center. In fact, most of the work is often done at home. The therapist functions as a coach, providing parents and patients with the strategy and drills that can help improve performance at home, at school, and in the world. As research continues, doctors and parents can expect new forms of therapy and better information about which forms of therapy are most effective for individuals with cerebral palsy.

Children's social and intellectual capabilities are as significant as their movement skills. Therefore, when scheduling sessions, therapists must consider a child's need to develop social community activates. Classroom activities may take precedence over therapy.

While walking may be an appropriate goal for some children, independent powered-wheelchair mobility may be of greater overall benefit, especially if limited walking takes a lot of energy. Long-term consequences of walking with crutches (or walkers) may need consideration. Looking to adulthood, opportunities for independent living and employment also need to be considered as intervention strategies evolve.

Children approaching adolescence need enjoyable activities to keep them fit and motivated. At this stage, the PT focus shifts to a physical fitness perspective with activities such as swimming, horseback riding and working out.

Treatment for adolescents center on personal independence. teenagers are key players in developing their own goals. If self-care is not possible, learning to direct personal care attendants allows some independence. Mobility and communication skills continue to be emphasized. When a teenager moves to a larger high school setting requiring moving from classroom to classroom, walking may be inefficient and exhausting. Accordingly, a physical therapist can help an adolescent choose the best means of mobility.

For the adolescent who is not limited by significant impairment of intelligence or memory, independent community mobility is an appropriate goal. This can be accomplished by learning to drive or using public transportation.

During puberty, physical therapists may address issues regarding bodily changes, sexuality and weight gain.

In the past, children who needed it received therapy regularly, from birth to adulthood. Currently, few insurance companies cover therapy to that extent. Instead, brief, intense periods of therapy are considered desirable, especially at times of transition and growth. For example, when a child is considered ready to learn a new skill, such as getting on and off the toilet, she or he is likely to benefit from therapy two or three times each week until this skill is mastered. In addition, physical therapists can work with parents to devise home exercise programs. In this way therapy can be ongoing.

Today, therapists follow a family centered approach focusing on lifetime needs especially for communication, mobility and self-care. Improvement at the level of impairment may minimize deformity and reduce pain. Successfully reducing limitations and disabilities greatly improves quality of life.

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