Many interventions have been applied to treat cerebral palsy, but when all is said and done we are still dealing with a nervous system that is impaired in many different ways. Some of the interventions that we are applying to children with cerebral palsy (CP) are really attempts at remediation of the consequences of weakness or abnormal tone. The interventions we apply have their own side effects and limitations. As a consequence, we can fall into a trap and apply these interventions with an intensity that sends an un- fair signal to the child and family. That signal is that we can make the child normal. We do not make damaged nervous systems normal. In many cases, we simply teach and/or trick the child’s nervous system to cope and provide strategies that alter some of the side effects and, in some cases, simply de- lude ourselves.
1. Neurodevelopmental Therapy Elizabeth Jeanson, PT
In the 1960s and early 1970s, pediatric therapists for CP appeared distinct from therapists who trained on poliomyelitis cases and from there quickly developed a cadre of therapists who practiced neurodevelopmental therapy (NDT). Neurodevelopmental treatment has gone through a long evolution over the years. Time has forced it to become more eclectic and become one of the most commonly used intervention strategies for children from infancy through adulthood with CP.1Since the conception of NDT by Dr. Karl and Mrs. Berta Bobath in the 1940s, the scientific community’s understanding of the brain and the conceptual framework of NDT has evolved. As our under- standing of how the brain inspires and controls movement evolves, so does the theory of NDT into what is currently accepted as the Dynamic Systems Theory. In this way NDT is a “living concept.”2It adapts and grows as knowledge of the brain’s function is revealed.
Using the Dynamic Systems Theory, NDT-trained therapists are able to use a variety of handling techniques. These specialized techniques encour- age active use of appropriate muscles and diminish involvement of muscles not necessary for the completion of a task. Child-directed and -initiated movement tasks are critical to the success of neurodevelopmental treatment.2 Therapists practicing NDT set functional individual session goals, which build upon each other to facilitate new motor skills or improve the efficiency of learned motor tasks. Improvements in efficiency can include decreased en- ergy used during a task, decreased work required of the muscles during a task, and habituation of new patterns of movement. These tasks are specific to and driven by the functional needs of the child. In NDT the child takes an active role in treatment design. The therapist must be constantly evaluating their input into the child’s movement with the goal of active, habituated, in- dependent movement.
NDT is a problem-solving approach focusing on the individual’s current needs while aiming for the long-term goal of function across the lifespan.2 Occupational, speech, and physical therapists as well as educators can use NDT. The benefits of utilizing NDT include improved ability to perform functional activities appropriate to the needs of the individual, active partici- pation of the child, improved strength, flexibility, and alignment, and im- proved function over a lifespan. NDT is not an exclusive treatment for indi- viduals with CP.
NDT-trained therapists have completed an 8-week pediatric or a 3-week adult course, and some, an additional 3-week infant postgraduate course.
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Practicing therapists can be found in every community. Therapists can learn about the theory and techniques at a variety of continuing education courses offered throughout the year and over the course of many years.
2. Strengthening Exercises Diane Damiano, PhD
In past years, several clinical myths existed about what one should never pro- vide to patients with CP, such as “no plastic for spastics” when prescribing orthoses or “never strengthen spasticity.” Recent research has provided evi- dence to dispel these myths and bring a new level of awareness of how chil- dren with CP can be helped. It has always been known that increased tone is not the only or even the most significant impairment of CP, but that there is poor recruitment of muscle unit activity and inconsistent maintenance of maximum efforts. Research that investigates muscle strengthening has con- tributed to this understanding.
More than 50 years ago, Phelps proposed that resisted exercise “to develop strength or skill in a weakened muscle or an impaired muscle group” was an integral part of treatment in CP.3Shortly thereafter, physical therapists de- nounced strengthening for their patients with upper motor neuron syndromes based primarily on the clinical concern that such strong physical effort would exacerbate spasticity. However, scientific evidence has been accumulating in recent years that dispels this contention and supports the effectiveness of strength training for improving motor function in CP as well as in other neuromotor disorders. Muscle strength is related to motor performance and should be an integral part of a rehabilitation program that addresses other impairments which inhibit motor performance in this population, such as muscle–tendon shortening, spasticity, and coordination deficits.
It has been shown that even highly functional children with spastic CP are likely to have considerable weakness in their involved extremities com- pared to age-related peers, with the degree of weakness increasing with the level of neurologic involvement.4,5If a child has at least some voluntary control in a muscle group, the capacity for strengthening exists. In the ab- sence of voluntary control, strength training is more problematic, but may be facilitated by the use of electrical stimulation or by strengthening within synergistic movement patterns. However, strengthening is only justifiable if the ultimate goal is to improve a specific motor skill or function. Therefore, a child with little or no capacity for voluntary muscle control is unlikely to experience substantial functional benefits from a strength-training program.
Most ambulatory children with CP have the capacity to strengthen their muscles, although poor isolated control or inadequate length in the ankle dorsiflexor or the hamstring muscles may limit progress in some patients.
Nonambulatory children may also experience improvements in their ability to use their upper extremities, transfer more effectively, or engage more actively in recreational and fitness activities. Invasive procedures such as muscle–tendon lengthening, selective dorsal rhizotomy, intrathecal baclofen pump implantation, or botulinum toxin injections may improve muscle length and/or control so that muscles can then be strengthened more effectively.
In turn, strength training may serve to augment or prolong the outcomes of these procedures.
To participate in a strength-training program, the child must be able to comprehend and to consistently produce a maximal or near-maximal effort.
Children as young as 3 years of age may be capable of this, but waiting to augment the program until the child is age 4 or 5 years is more realistic.
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