Cerebral Palsy Interventions (PDF)

Cerebral palsy interventions Evidenced- Based Practice PTY 224 Lec 3.1 Dragana Djuric  Cerebral Palsy Management OUTLINE Focus on interventions provided by physiotherapist To be familiar with different conservative management options for spastic CP Evidenced- Based...

Cerebral palsy interventions Evidenced- Based Practice PTY 224 Lec 3.1 Dragana Djuric  Cerebral Palsy Management OUTLINE Focus on interventions provided by physiotherapist To be familiar with different conservative management options for spastic CP Evidenced- Based (SDS- Revision of CP lecture from last semester)  Impairments based assessment (review) Abnormal muscle tone Decrease ROM, decrease muscle flexibility Decrease muscle strength Impaired Selective motor control Decreased proprioception, kinesthesia and body awareness Impaired balance and postural reactions Impaired endurance and CV fitness  Management of CP Physiotherapy Pharmacological Splints, AFO Surgical Assistive devices and technology  Common PT activity and role of PT Coordination with health care team Focus on: Assessment Age Treatment Level of functioning Recommendation of equipment’s ( or OT) Comorbidities Home exercises program prescription Care setting ( early intervention, inpatient, outpatient, school, community ) Community program recommendations Prevention of secondary impairments Patient/family goals  Popular approaches and interventions **Pediatric Rehabilitation requires a Multidisciplinary Approach Neurodevelopmental treatment (NDT) (Bobath approach) Proprioceptive neuromuscular facilitations (PNF) Sensory Integration ( Jean Ayres) Reflex creeping and other reflex reaction ( dr. Vaclav Vojta) Conductive education  Popular interventions Robotic-assisted gait training Virtual reality- (Computer Game-Based Rehabilitation) Context therapy Cardiovascular fitness or aerobic program Balance training Strength trening Body-weight support treadmill training Thera suit Horse riding Aquatic Intervention Constraint-Induced Movement Therapy (CIMT)  Research on treatment approaches Systematic reviews of research of CP conclude that there have been too few high- quality studies for reliable conclusion so- ‘Further research is needed’ PEDRO list more than 150 SR PEDRO more than 15 meta-analysis American Academy for CP and Developmental Medicine (AACPDM). NDT EBP The systematic review gave unclear results neither with or against Bobath. 13 papers most were unavailable, poor quality or not RCT (Zanon, 2019) Bobath concept is effective for premature babies Expert opinion and research findings is contraversal Suit therapy  Suit therapy Suit therapies involve the use of garments, made of Lycra are highly elastic- dynamic stabilization by support of the trunk and proximal joints These suits are assumed to create tension, which helps strengthen the muscles. The suit also applies deep pressure to the joints: Increase proprioceptive information, enhances body awareness Resulting in improved postural control Penguin suit, Adeli suit, Therasuit etc Use in UAE- CMRC, ZHO, NMC Royal hospital  Suit Therapy EBP Children with impaired proximal stability and require trunk control to perform ADL may benefit from a vest type of orthotic garment Children with Diplegic CP may benefit from a full body suit to improve score on GMFM  Hippotherapy " treatment with help of the horse". It's a treatment strategy that utilizes equine movement in a therapeutic way for patients with movement dysfunction. Precise, rhythmic pattern of movement Touching various part of the horse – Rhythmical pattern + combined warmth of sensory information horse hypothesized to reduce hypertonicity Normalizing hip adductor muscle activity Improves muscle strength and ROM Maintaining balance and posture Presents patients with a range of stimuli for the brain to process.  Hyppotherapy Clinical Practice It is important to screen the riders Conclusion before recommending hyppotherapy Influence the child’s posture, or therapeutic ridding balance, coordination, strength, and Benefits vs Risks should be discussed sensorimotor systems while the with the patients and parents prior to the intervention child interacts with and responds to Initial evaluation should be performed the movement of the horse. to develop treatment goals regarding desired outcome.  Hyppotherapy EBP Children with CP, aged 4 years and above, are likely to have significant improvements on GMFM (especially spastic CP). Evidence indicates that 45-min sessions of hippotherapy and therapeutic horse riding (THR) once per week for at least 8–10 weeks result in significant effects. ( THR plays an active role in controlling the horse). Children with CP who participated have shown improvements primarily in walking, running, and jumping. Other benefits may include posture, head and trunk stability, functional reaching, self care and mobility. Individual approach for hippotherapy and THR is needed (by age, level and type of disability). Botulinum Toxin Type A in the Treatment of Spasticity Botulinum toxin A (BoNT-A) or simply Botox injections are given focally in targeted muscles and work on reducing muscle activity by blocking the release of acetylcholine at the synaptic junction. Acetylcholine causes muscles to contract and activates pain responses among other functions. The toxin is naturally produced by the bacterium Clostridium Botulinum Botulinum Toxin Type A EBP No scientific agreement regarding how often and how many times BoNT-A should be repeated. Short-term effect 3- 6 month In the UAE, regular Botulinum toxin therapy is mainly for three groups of patients: 1) Patients with severe adductor muscle spasticity considered at high risk of hip dislocation. 2) Patients with lower limb spasticity who are ambulant. 3) Children with troublesome spasticity that causes discomfort and hinders their daily care Robotic assisted gate training (RAGT)  RAGT EBP Improvements in gait speed, gait endurance, and gross motor function ( 10 met WT, 6min WT, GMFM –D & E) These benefits were observed in studies with a weekly frequency of training 4 days per week and with a duration of 30 minutes training. ( intensive training minimum 4 weeks) It is possible to identify significant positive results with intensive training in CP Controversial results- better improvement for level I- II, other studies significant improvement for level III-IV ( Klobuska, 2021) FES  Functional electrical stimulation Most commonly use for foot drop or foot in equines to improve walking pattern GMFCS I- II UL- wrist-hand function Children tolerated FES well. FES cycling for severe affected CP children  Virtual Reality Games Use of technology in rehabilitation of UL  Virtual reality games VR for LL and standing balance The ability of virtual reality to create opportunities for active repetitive motor/sensory practice adds to their potential for neuroplasticity and learning in CP Greater fun and enjoyment were expressed during the VR exercises  Constraint-induced movement therapy for unilateral CP Type of constraint: glove, sling, splint  Constraint-induced movement therapy While restrained, only the affected upper limb can be used to carry out activities, forcing children to find solutions to their movement problems CIMT is an effective way to improve upper limb function at the activity level and this can be expected to carry over into participation in real life for mild effected CP CIMT was not used as much as bimanual therapy Bimanual training Hydrotherapy ( Aquatic therapy)  Aquatic therapy In a heated pool, water provides a soothing, buoyant environment for cerebral palsy patients, decreasing a patient's effective weight by 90 percent. AD- ZHO, CMRC, Amana for pediatric & adult patient Screening Contraindication: Serious epilepsy, open wounds Precautions: Fear of water (Stay close and use floatation devices) Safety management  Aquatic therapy The main benefits of aquatic therapy are: Water provides resistance in all planes and directions Encourages a wider range of movement and opposition Alleviates stress and tension Reduces pain and tension in muscles and joints Improves cardiovascular conditioning since the heart pumps more blood per beat when body is submerged in water Decreases post exercise discomfort  EQUIPMENT Vest Collar Ring  Hydrotherapy Advantages for CP: Strengthening LL Pain relief Relaxing Strengthening, stretching Improve fitness A fun and engaging environment  Aquatic therapy New research shows that Physiological effect on hydrotherapy when applied along cardiovascular, musculoskeletal, with other conventional methods nervous system of rehabilitation, exerts positive effects on impairment, activity and participation of CP patient ( Khalaji , 2017).  Halliwick Concept Developing the teaching of AD- ZHO trained PT swimming to disabled people Without eqipment To participate in water activities, to move independently in water, and to swim 10- point program The International Halliwick Association (IHA)  Stretching Prevention of contracture and deformity Elongation of muscle and connective tissue around the joint No effectiveness in research but clinician believe in positive aspect of passive stretching. Stretching Manual stretching is defined as a passive stretch provided by a physical therapist and hold for 30 to 60 seconds. Positional stretching is accomplished by placing the child in a position for longer periods of time, greater than 15 minutes ( Prone position- stretch of iliopsoas) Serial casting, without the adjunct of botulinum toxin, can be used as an additional means to provide a sustained stretch, which can be applied and monitored by physical therapists. Its very effective. (Groppe et al., 2012)  Stretching EBP A randomized controlled trial lasting five months found a statistically significant reduction of spasticity, as measured by sensitivity of the tonic stretch reflex, in eight participants with CP ages six to 19 years who received passive positional stretching of 30 minutes for three sessions each week with video feedback. Serial casting: In a randomized crossover study, in which nine children with CP ages six to 10 years received below knee casts either before or after a three month control period, significant increases in dorsiflexion were found after five weeks of serial casting but not after twelve weeks.  Strengthening EBP Strengthening training with resistance increase muscle strength without increase of spasticity Isolated strengthening only when muscle strength is below grade 2 Functional strengthening (sit to stand)- improve activity and participation – GMFCS I- II ( Martin, 2010). Improve strength- improve motor function ( Collado- Garrido, 2019) but its important to analyze No of weekly session.  Strengthening American College of Sport medicine- recommendation for people with CP Exercise program would include Aerobic Endurance Strength Flexibility exercises ( Laskin, 2003). 3 sets, 8-12 repetitions, 2 -3 days per week Standing Balance  Balance Play important role for ambulatory children Improve GMFM ( Dimension D)  A systematic review of interventions for children with cerebral palsy: state of the evidence (Novak, 2013) Green interventions Yellow light interventions should be accompanied by a sensitive outcome included anticonvulsants, bimanual measure to monitor progress. training, botulinum toxin, bisphosphonates, casting, constraint- induced movement therapy, context- focused therapy, diazepam, fitness Red light interventions should be training, goal-directed training, hip discontinued since alternatives exist. surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy.  Evidenced- Based Practice 14 New Bobath Concept  References Zanon, M. A., Pacheco, R. L., Latorraca, C. D. O. C., Martimbianco, A. L. C., Pachito, D. V., & Riera, R. (2019). Neurodevelopmental Treatment (Bobath) for Children With Cerebral Palsy: A Systematic Review. Journal of child neurology, 34(11), 679-686. Karadağ-Saygı, E., & Giray, E. (2019). The clinical aspects and effectiveness of suit therapies for cerebral palsy: A systematic review. Turkish journal of physical medicine and rehabilitation, 65(1), 93–110. https://doi.org/10.5606/tftrd.2019.3431 Tseng, S. H., Chen, H. C., & Tam, K. W. (2013). Systematic review and meta-analysis of the effect of equine assisted activities and therapies on gross motor outcome in children with cerebral palsy. Disability and rehabilitation, 35(2), 89-99. DOI: 10.3109/09638288.2012.687033  References Blumetti, F. C., Belloti, J. C., Tamaoki, M. J., & Pinto, J. A. (2019). Botulinum toxin type A in the treatment of lower limb spasticity in children with cerebral palsy. Cochrane Database of Systematic Reviews, (10). DOI: 10.1002/14651858.CD001408.pub2. Wu, J., Loprinzi, P. D., & Ren, Z. (2019). The Rehabilitative Effects of Virtual Reality Games on Balance Performance among Children with Cerebral Palsy: A Meta-Analysis of Randomized Controlled Trials. International journal of environmental research and public health, 16(21), 4161. Groppe, M., Baxter, K., & Davenport, T. E. (2012). Passive stretching and its effect on spasticity and range of motion in children with cerebral palsy: a systematic review. Journal of Student Physical Therapy Research, 5(1), 11.  References Novak, I., Morgan, C., Fahey, M., Finch-Edmondson, M., Galea, C., Hines, A., Langdon, K., Namara, M. M., Paton, M. C., Popat, H., Shore, B., Khamis, A., Stanton, E., Finemore, O. P., Tricks, A., Te Velde, A., Dark, L., Morton, N., & Badawi, N. (2020). State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Current neurology and neuroscience reports, 20(2), 3. Collado-Garrido, L., Parás-Bravo, P., Calvo-Martín, P., & Santibáñez-Margüello, M. (2019). Impact of Resistance Therapy on Motor Function in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis. International journal of environmental research and public health, 16(22), 4513 Martin, L., Baker, R., & Harvey, A. (2010). A systematic review of common physiotherapy interventions in school-aged children with cerebral palsy, Physical & Оccupational therapy in Pediatrics, 30(4), 294–312.