Cerebral palsy is a disorder with multisystem impairments, which may affect the visual, vestibular, and/or somatosensory systems. Nasher et al.
found inappropriate sequencing of muscle activity, poor anticipatory regu- lation of muscle sequencing during postural control, and postural stability that was frequently interrupted by destabilizing synergistic or antagonistic muscle activity in individuals with CP.20It is evident that physical therapists working with individuals with CP need to assess as well as address these bal- ance issues, keeping in mind the action that is required and the environment in which it is being performed.
Balance is a component of most, if not all, developmental assessments including the Gross Motor Function Measure, the Bruininks–Osterestky Test of Motor Proficiency, the Peabody Developmental Motor Scales, and the WeeFIM. These tests can be useful in helping the therapist ascertain whether the balance issue is visual (eyes open or closed), vestibular, or somatosensory (is the surface moving or not). It is also important to evaluate the child’s bal- ance needs and deficits relative to their task demands (sitting independently for dressing versus going to school and navigating the busy hallways), as well as the child’s and parents’ concerns and goals. This information can then be utilized to customize a treatment program.
Interventions should include various handling and treatment techniques mentioned elsewhere in this volume to help the child achieve success. Envi- ronments must be structured and tasks created in both open and closed sit- uations to allow the greatest carryover to functional life skills. Closed tasks21 are those whose characteristics do not change from one trial to the next;
these require less information processing with practice. Open tasks21require more information processing. In closed environments21in which surround- ings are fixed, children do not need to fit their balance into external timing, but can manage the situation at their own speed. Open environments require more attention and information processing.
Clinicians should keep in mind the action requiring balance, as well as the environment in which the child needs to function,17to appropriately assess and plan interactions to maximize a child’s function in their environment.
4. Electrical Stimulation Techniques Adam J. Rush, MD
An area that has received a great deal of press and a great deal of anecdotal experience is the role of electrical stimulation in CP. A review of the litera- ture is very confusing, and there is great inconsistency from one medical cen- ter to the next as to what they are referring. Dr. L.J. Michaud probably has the most lucid discussion of electrical stimulation in CP.22
Making recommendations regarding which children should receive neu- romuscular electrical stimulation (NMES) or transcutaneous electrical stim- ulation (TES) is a problem. Although there is no literature indicating that any particular group of children were likely to be harmed by it, or less likely to benefit, most children studied were mild to moderately affected by CP and seemed to have fairly good cognition. Furthermore, the worst side effect re- ported was a local skin reaction from the stimulating pads. Therefore, one could say that this is a harmless intervention that might be attempted in any child with CP. However, studies have not been performed comparing vari- ous regimens with each other.
We appear to have a recurring theme of therapists applying NMES and choosing their stimulation parameters based on personal experience, rather than based on good science. Dr. Michaud’s article suggests the following,
Rehabilitation Techniques 809
which strikes one as a reasonable place to begin: stimulus frequency, 45 to 50 Hz; stimulus intensity, maximum tolerated; on/off times, 10/50 seconds, or triggered; ramps, 1 to 5 seconds, or to comfort; treatment duration, 10 to 15 repetitions; frequency, 3 to 5 days per week.22
There are a number of studies regarding the relative utility of resistance exercise, NMES, or both.23Results vary, but they could be summarized to say that NMES is better than nothing, and not quite as good as resistance exercise alone, but that doing both is redundant.
5. Hippotherapy Stacey Travis, MPT
Children benefit from movement and novelty. There have been some im- provements in limb placement and balance and equilibrium seen in children who worked on the Bobath balls during neurodevelopment therapy. Hippo- therapy gives them, if you will, a hairy, olfactory-stimulating, warm, four- legged Bobath ball platform on which a trained therapist can capitalize on motor control, stretching, and equilibrium as the therapist works with the child.24–33 The North American Riding for the Handicapped Association (NARHA) has defined hippotherapy as “The use of the movement of a horse as a tool by physical therapists, occupational therapists, and speech-language pathologists to address impairments, functional limitations and disabilities in patients with neuromusculoskeletal dysfunction. This tool is used as part of an integrated treatment program to achieve functional outcomes.”33
Years of traditional, clinic-based therapy can become tedious and ineffec- tive for both the therapist and the child. Hippotherapy provides therapists and their patients with a novel and effective treatment modality that can spark new interest and enthusiasm. Hippotherapy is used for rehabilitation and is not to be confused with therapeutic riding. Therapeutic riding is not a for- mal treatment and focuses on recreation or riding skills for disabled riders.27 Hippotherapy subjects must have an initial evaluation, progress notes, and a discharge note, just as any therapy patients.25It is important to note that this treatment may not be suitable or safe for children with spinal instability, severe osteoporosis, hip dislocation, uncontrolled seizures, spinal fusion, poor static sitting balance (in children >70 pounds), or increased tone after rid- ing.33Individuals with CP have little experience with rhythmic movements because of impairments that limit their ability to reverse the direction of move- ment.26Researchers postulate that a walking horse simulates the triplanar movement of the human pelvis during gait, while the warmth and rhythm of the horse decrease tone and promote relaxation.24,29Theoretically, hippo- therapy enables a child with CP to experience rhythmic movement by de- creasing impairments and allowing for the self-organization of the move- ment patterns into functional movement strategies.29 Researchers have supported this theory by reporting a number of observable benefits of hippotherapy24–31,33(Table R3).
The majority of the existing research on hippotherapy consists of subjec- tive studies.24,27,28Results of hippotherapy are difficult to measure objec- tively due to a lack of valid and reliable instruments. Poor methodology and small sample sizes in the current research cause the results to be insignificant or inconclusive. Fortunately, despite this lack of objectivity, third-party re- imbursement has been commonly received for hippotherapy sessions from a wide variety of insurance companies since 1982.30
A typical hippotherapy session lasts from 45 minutes to an hour. Current research is lacking a consensus on a definitive frequency or duration for this
810 Rehabilitation Techniques
