15/02/2016

Physiotherapy intervention in
cerebral palsy

Ann Lancaster
Physiotherapist
Cerebral Palsy Service

Outline
What is cerebral palsy? Definition, classification and
overview of management of children with cerebral palsy

What can physiotherapy offer? Current evidence for

physiotherapy intervention

What about research? Challenges of research of

management of children with cerebral palsy

Cerebral palsy definition

Cerebral palsy describes a group of permanent
disorders of the development of movement and
posture, causing activity limitation, that are
attributed to non-progressive disturbances that
occurred in the developing foetal or infant brain.
The motor disorders of CP are often accompanied
by disturbances of sensation, cognition,
communication, perception and behaviour, by
epilepsy and by secondary musculoskeletal
problems
(Rosenbaum et al 2007)

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Impact of damage to immature brain

Alteration to Central Nervous System
Deficit in Motor Function
Changes in childs development

Secondary effects
Changes in muscles
muscle atrophy and intrinsic stiffness
paresis associated with soft tissue shortening + stretch
sensitive overactivity

Joint contractures
associated with muscle imbalance or persistent
positioning

Bony deformities
associated with abnormal forces on developing bones
e.g. femoral or tibial torsion,
high riding patella, scoliosis, hip dysplasia

Cerebral palsy definition

Cerebral palsy describes a group of permanent
disorders of the development of movement and
posture, causing activity limitation, that are
attributed to non-progressive disturbances that
occurred in the developing foetal or infant brain.
The motor disorders of CP are often accompanied
by disturbances of sensation, cognition,
communication, perception and behaviour, by
epilepsy and by secondary musculoskeletal
problems
(Rosenbaum et al 2007)

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Outcome dependent on
Timing and aetiology of CNS injury
Impact on further development and
reorganisation of CNS
Environment

The functional deficits reflect not only the

neural lesion but also what has been practised
and become habitual and the changing state
of the system due to growth, disuse and
misuse.
Shepherd 1995

Features of Cerebral Palsy

clinical picture of abnormal
patterns of posture and movement
developing contracture in muscle
and increased stiffness
general poverty of movement,
muscular atrophy, disuse and
weakness
negative effects on skeletal system
inactivity and abnormal muscle
physiology

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Classification
Area of body affected
hemiplegia(38%), diplegia (36%), quadriplegia(22%)
(Now use unilateral or bilateral)
Type of movement disorder
spasticity (75%), dyskinesia (choreoathetosis ,
dystonia), ataxia, hypotonia, mixed

Dystonia
Dystonia is a movement disorder in which
involuntary sustained or intermittent muscle
contractions cause twisting and repetitive
movements, abnormal postures , or both
Sanger 2003

Dyskinetic cerebral palsy

Has features of dystonia plus choreoathetosis
Choreoathetoisis is defined as constantly
changing fragmented movements

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Classification
Area of body affected
hemiplegia(38%), diplegia (36%), quadriplegia(22%)
(Now use unilateral or bilateral)
Type of movement disorder
spasticity (75%), dyskinesia (choreoathetosis ,
dystonia), ataxia, hypotonia, mixed
Severity of disability in terms of gross motor function
GMFCS scales (Levels I-V) (Palisano et al 1997)

Criteria vary for

under 2years
2-4 years
4-6 years
6-12 years
12-18 years
Performance rather
than capacity
www.canchild.ca
Palisano, Rosenbaum,
Bartlett & Livingstone
2007

Classification
Now we would classify a person with
cerebral palsy as:
Unilateral or bilateral
Type of movement disorder
GMFCS

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Physiotherapy intervention
Current Practise:
Maximise motor skills
Minimise development of deformity
Minimise learned disuse
Maximise regular physical activity
Maximise participation
Inspire them to enjoy movement
and use it!

Physiotherapy in Infancy and Early

Childhood
Aimed at
Maximising development of motor skills
With emphasis on
Self initiated activity driving exploration
By providing an encouraging and challenging
environment that allows for intensive practice
Physiotherapist as teacher for parent
Commencing as young as possible

Physiotherapy emphasis varies with level

of disability and age
GMFCS 1 & 2
Walking & running skills, involvement in sport

GMFCS 3
Maintaining use of walking as means of mobility and
independence in transfers while allowing
participation with peers which my require use of
wheeled mobility

GMFCS 4&5
Utilising & maintaining any movement
skills, balance in sitting ,
hip dyplasia and scoliosis

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4 year old boy

Classification
Area of body affected?
Type of movement disorder?
GMFCS Level?

Physical measures
Right

Left

Thomas Test

-ve

-ve

Hip abduction knees flexed (R2)

65

65

Hip abduction knees flexed (R1)

50

55

Hip abduction knees extended (R2)

25

25

Hip abduction knees extended (R1)

10

10

Hip internal rotation

50

50

Hip external rotation

40

40

Popliteal Angle (R2)

-40

-35

Popliteal Angle (R1)

-70

-65

Knee extension

-3

Dorsiflexion with knee extension (R2)

10

12

Dorsiflexion with knee extension (R1)

-35

-35

Dorsiflexion with knee flexion (R2)

15

18

Dorsiflexion with knee flexion (R1)

-25

-27

GMFCS - Between 4th and 6th birthdays

LEVEL I: Children get into and out of, and sit in, a chair without the need for hand
support. Children move from the floor and from chair sitting to standing without
the need for objects for support. Children walk indoors and outdoors, and climb
stairs. Emerging ability to run and jump.
LEVEL II: Children sit in a chair with both hands free to manipulate objects.
Children move from the floor to standing and from chair sitting to standing but
often require a stable surface to push or pull up on with their arms. Children walk
without the need for a handheld mobility device indoors and for short distances
on level surfaces outdoors. Children climb stairs holding onto a railing but are
unable to run or jump.
LEVEL III: Children sit on a regular chair but may require pelvic or trunk support to
maximize hand function. Children move in and out of chair sitting using a stable
surface to push on or pull up with their arms. Children walk with a hand-held
mobility device on level surfaces and climb stairs with assistance from an adult.
Children frequently are transported when travelling for long distances or outdoors
on uneven terrain.
www.canchild.ca
Palisano, Rosenbaum, Bartlett & Livingstone 2007

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4 year old boy

Classification
Bilateral (diplegia)
Spastic
GMFCS 2

4 year old boy

Physiotherapy intervention

Maximise motor skills

Minimise development of deformity
Minimise learned disuse
Maximise regular physical activity
Maximise participation

4 year old boy

Physiotherapy intervention
Maximise motor skills
walking with more control, change direction, stop
moving from floor to stand, climbing, stand still
Stairs, ball skills

Minimise development of deformity

Stretching, splinting, serial casting

Maximise regular physical activity

Maximise participation going to school

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Medical intervention
- Management of spasticity
General
Oral therapy
Intrathecal
baclofen

Selective Dorsal
Rhizotomy

Permanent

Reversible
Clostridium Botulinum
(Botox, Dysport)

Orthopaedic
Surgery

Focal
Graham et al 2000

4 year old girl

Classification
Bilateral (quadriplegia)
Dyskinesia with dystonia and choreoathetosis
GMFCS V

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4 year old girl

Physiotherapy intervention

Maximise motor skills

Minimise development of deformity
Minimise learned disuse
Maximise regular physical activity
Maximise participation

4 year old girl

Physiotherapy intervention
Maximise motor skills
Head and trunk control in supported sitting and standing
Any floor mobility, walking in a supportive frame

Minimise development of deformity

At risk of hip dislocation and scoliosis

Minimise learned disuse

Provide situations where she use her abilities

Maximise regular physical activity

Maximise participation

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4 year old girl

Medical intervention
Medications for dyskinesia
Orthopaedic surgery for hips or scoliosis

5yr old boy about to start school

GMFCS 2
Bilaterally involved with dyskinesia (dystonia)
Physio intervention aimed towards functional
activities he will use at school
Standing still
Playing soccer and handball

What can physiotherapy offer?

Unfortunately we cant offer a cure
We can assist a child to reach their potential
(minimise misuse and disuse)
Educate child and family in understanding &
management of their movement disorder
We are part of the supportive community
around a child
What can research show us?

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Research in physiotherapy interventions

for children with cerebral palsy
There is a lot of research
In PEDro there are
> 130 systematic reviews
> 300 clinical trials
A lot more is needed.

Morgan C et al Enriched Environments and Motor

Outcomes in Cerebral Palsy: Systematic Review and
Meta-analysis Pediatrics Vol 132 No 3 Sept 2013

SRs have failed to confirm +ve motor

outcomes more than expectation with
maturation
Neuroplasticity evidence from animals favours
an early enriched environment for promoting
optimal brain injury recovery.

Early enriched environments

Current research is looking impact of EE on
motor outcomes
EE includes:
Creation of movement environments to elicit new
motor behaviours
Parent training and support in in motor learning
principles and task analysis
Individualised, variable and frequent functional
motor task practice which emphasises
self initiated movement

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Physiotherapy for infants and young

children with cerebral palsy
Often diagnosis of cerebral palsy is not
made until over 12 months
Physiotherapy intervention can offer much
earlier than this!
We believe physiotherapy intervention can
impact development of brain and muscle

Franki I et al Evidence-Base for basic physical

techniques targeting lower limb function in
children with cerebral palsy: a systematic
review using ICF framework 2012 J of Rehabil
Med; 44: 385-395
Interventions targeting body function and
structure generally influenced this level
without significant overflow to activity level
and vice versa

Other conclusions
Strength training effective in improving muscle
strength and to a lesser extent in improving
gait and motor function
Some treadmill training is beneficial in
improving gait and endurance
Weight bearing is useful to improve bone
mineral density
Lower level studies included in the SR

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Dewar R, Love S, Johnston LM Exercise

Interventions improve postural control in
children with cerebral palsy: a systematic
review 2015 Dev Med & Child Neurology
Jun;57(6):504-520
Moderate evidence to support gross motor task
training, hippotherapy, treadmill training with
no body weight support, trunk-targetted
training & reactive balance training
Limited outcome measures used
Some related to function and to activity
but none to participation

Further research needed

For children with different types & severities of
CP to establish
Responsive & reliable postural control
outcome measures
Effective treatment and dose guidelines
Possible efficacy of mainstream exercise such
as pilates, yoga & tai chi

Law M et al Focus on function: a RCT comparing

child- vs context-focussed intervention for young
children with CP Dev Med & Child Neuro 2011, 53
Child focussed therapists identified impairments
underlying functional limitation to guide intervention
Context focussed a motor based task was identified
as goal and treatment focused on changing identified
constraints within task or environment
No significant difference in outcomes

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Novak, I et al A systematic review of

interventions for children with cerebral
palsy:the state of evidence 2013
Uses traffic light system to guide the use of
interventions according to evidence available
Most interventions aimed at body structure
and function
No interventions were shown to be effective
on more than 1 level of ICF

Novak, I et al A systematic review of

interventions for children with cerebral
palsy:the state of evidence 2013
Green light for bimanual training, constraint
induced movement, context focussed therapy,
goal directed/functional therapy, home
programmes, serial casting, fitness training.
Yellow light for stretching, orthotics and
strength training
Some caution required

Scianni AA, Butler JM, Ada LM, Teixeira-Salmela LF (2009)

Muscle strengthening is not effective in children with
cerebral palsy: A systematic review. Aust J Physio

Muscle weakness common impairment

Several uncontrolled trials reported in strength
after training and that strength can translate into
improved activity
2 RCTs strength with training
-no clear carryover to activity.
Conclusion:
Current evidence suggests that
strengthening interventions are neither
effective or worthwhile but probably
not harmful

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Verschuren O, Ada LM, Desiree B, Gorter JW, Scianni AA, Ketelaar

K (2011)
Muscle strengthening in children and adolescents with spastic
cerebral palsy:: Considerations for future resistance training
protocols Physical Therapy Vol 91 Number 7

Questioned the reasons for meta-analysis of RCTs

not shown resistance training to be effective
Highlighted the variations in method of resistance
training in previous trials
Recommended protocols consistent with training
guidelines for typically developing children and
appropriate for children with CP

Park EY , Kim WH Meta-Analysis of the effect

of strengthening interventions in individuals
with cerebral palsy 2014
13 RCTs included
Conclusions
Strengthening interventions are useful in increasing
mm strength in youth and children with cerebral
palsy
Optimal exercise consisted of 40-50 min sessions
performed 3X per week
Some impact on gait but more research needed to
determine contribution to gross motor
function and activities

The challenge of research

Uniformity of subjects
Age, sex, GMFCS level, aetiology, comorbidities

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The challenge of research

Uniformity of subjects
Outcome measures
Reliable, relevant

Outcome Measures
What is a good relevant outcome?
short term vs long term?
body structure vs function?
Quality of life?
Participation?

The challenge of research

Uniformity of subjects
Outcome measures
Natural History of Cerebral Palsy

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Rosenbaum et al 2002

Palisano 1997

Palisano 1997

Process of hip dislocation

Children requiring hip surgery to prevent hip dislocation
90
80

Incidence (%)

70
60
50
40
30
20
10
0

II

III

IV

GMFCS Level

Soo et al., JBJS 2006

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http://www.ausacpdm.org.au/
professionals/hip-surveillance

Natural History of cerebral palsy

Development of contractures

While anyone involved in managing children

with cerebral palsy will be certain these
children develop contractures, there is little
documented evidence that quantifies this.

The challenge of research

Uniformity of subjects
Outcome measures
Natural History of Cerebral Palsy
Variability of Physiotherapy Interventions

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Physiotherapy intervention
Approaches:
Neurodevelopmental therapy (NDT)
Applications:
Bobath approach
Casting
Conductive education
Orthoses
Vojta method
Dynamical systems
Electrical stimulation
Motor learning
Strength training
Task specific training
Treadmill training
Constraint induced movement
Whole body vibration
Motivational interventions
Intensive model of therapy

Future directions ?

Very early physiotherapy interventions

Use of technology in exercise programs
Supported treadmill training
Intensive exercise programs
Use of NMES
Robotics?
Virtual reality?

Mitii: move to Improve it

A Web based training program

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More research is needed !

We need to continue to evaluate our
clinical practice while providing best
practice physiotherapy intervention

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