The rehabilitation of children with cerebral palsy

The rehabilitation of children with cerebral movement disorder
(syndroma dystoni, high neurological risk (neuro-risk) children)

THE REHABILITATION OF CHILDREN WITH CEREBRAL PALSY

There are many controversies regarding the treatment and rehabilitation of cerebral palsy. There is no prevailing attitude towards cerebral palsy (CP) therapies; however, the common point of view is that CP cannot be treated; CP is a life-long condition. There is a widespread point of view in the professional and scientific literature that various therapeutic interventions (different forms of physiotherapy, orthopaedic procedures, drugs, and so on) cannot significantly change the course of the disease. In practice this means that the condition slowly gets worse over time and as the child grows.

We must stress here that this is not the attitude of the Polyclinic’s rehabilitation team. Our point of view is that with proper and intensive rehabilitation we can improve the condition and quality of life of children with CP by a significant percentage. For that reason alone, we believe that we can change the course of the disease (see Stojčević Polovina rehabilitation method).

THE NATURAL COURSE OF CEREBRAL PALSY

How is the course of the disease explained in the professional and scientific literature and what does “significantly change” mean?

We can explain the course of the disease most easily by using the GMFCS (Gross Motor Function Classification System), a classification system that assesses the severity of the clinical picture of children with CP, (today by far the most widespread classification system for CP in the world). According to the GMFCS classification system, there are five levels of severity of the clinical picture; Level I represents the least severe form of CP and Level V represents the most severe. Each level of the GMFCS is associated with specific motor capabilities (usually the result of GMFM testing, expressed as a percentage, is taken). So, for example, a child with CP, classified at GMFCS Level V, is expected to reach about 15% of the motor growth values tested with GMFM-88 (about 20% of those tested with GMFM-66). When he reaches his motor growth value limit, which for a child with CP GMFCS V is sometime during the second year of life, it is not likely that he will make any further progress, and even less likely that he will cross over into Level IV (a less severe form). The condition will most likely remain the same, and over time will slightly worsen. This scenario represents the natural course of CP. That is the opinion and attitude of the majority of researchers and doctors who deal with cerebral palsy.

What does “significantly change the course of disease” mean? This means that through rehabilitation a child with cerebral palsy improves his GMFCS level for the better. Changing the course of disease means reaching a state where a child with cerebral palsy becomes as similar as possible to a healthy child. 

WHICH DIFFERENT APPROACHES AND IDEAS EXIST REGARDING THE REHABILITATION OF CEREBRAL PALSY?

Rehabilitation is often complex and it can include: physiotherapy, various operative orthopaedic measures, occupational therapy, speech therapy and special needs education treatment. When muscle tone is increased, botulinum toxin (Botox, Dysport) or baclofen (administered orally or by the insertion of a baclofen pump) are sometimes used, or selective dorsal rhizotomy is performed. It is also essential that the child be monitored by a neuropaediatrician, and often by other specialists, primarily ophthalmologists and ENT (ear-nose-throat) specialists.

The best-known therapeutic approaches for the treatment of cerebral palsy are as follows: Neurodevelopmental therapy – the Bobath method, Vojta, Peto – Conductive education, Sensory integration and other less well known and less represented therapeutic approaches. Research to date hasn’t shown or clearly confirmed the advantage of one type of therapy over the others.

Neurodevelopmental therapy (NDT) – The Bobath Method

Neurodevelopmental therapy (NDT) – The Bobath Method is probably the most widespread method in Western Europe, the USA and Australia. Initially, NDT was based on the inhibition of abnormal muscle tone and persistent primitive reflexes accompanied by the facilitation of normal movement (1). In this method, the therapist tries to give a child with cerebral palsy the feeling and experience of normal movement, whereas in earlier phases the child used reflex inhibiting postures (RIP) that were mainly static postures.

Over time NDT has shifted towards facilitating postural reactions and postural control, functions that are more or less insufficiently developed in children with cerebral palsy. Key points of control, mainly proximal (closer to the centre of the body) but also distal (farther from the centre of the body) are used to try to inhibit abnormal patterns of movement and facilitate postural reactions and postural control. Passive movements are avoided. An important aspect of this approach includes the proper handling of children in everyday activities (e.g. dressing, undressing and carrying).

The therapy was initially performed following normal development, but over time the NDT concept has undergone numerous changes. According to the new approach, it is often suggested that during NDT therapy individual developmental components are not essential; (for example, it is frequently pointed out that many children can walk without ever having crawled).

Despite the fact that NDT, that is, the Bobath concept, is the most widespread approach, a review of the literature suggests that NDT cannot significantly influence the natural course of cerebral palsy. This was shown in a study by the American Academy for Cerebral Palsy and Developmental Medicine. The study didn’t show any advantage of NDT over other therapies. With the exception of improvement in dynamic range of motion, it was not proved that NDT changed abnormal motoric responses, slowed or prevented contractures, or that it facilitated more normal motor development or functional motor activities. There was also no clear evidence that NDT was beneficial for social-emotional, language or cognitive development, improved parent-child interactions, or led to greater parent satisfaction (2). In the same way, a systematic review of the research on the effectiveness of NDT in high-risk (neuro-risk) children (3) didn’t show the effectiveness of NDT.

The Vojta method

The founder of this therapy was a neurologist, Professor Vaclav Vojta. The method began to be developed in 1954, first in Prague and then in Munich. Vojta therapy is based on reflexive locomotion. Reflexive locomotion is defined as reciprocal motor activity of a global character. According to Prof. Vojta, reflexive locomotion is present in all healthy newborns; these are inborn mechanisms of movement, that is, neonatal automatisms. Reflexive locomotion consists of reflexive crawling and reflexive rolling. We do not see reflexive locomotion in full in normal development, but certain elements are present in particular phases of normal development.

Children who later develop cerebral palsy do not possess all of the elements that are normally present in particular phases of development. If reflexive locomotion is stimulated during therapy individual elements can be stored in the central nervous system and as such can be used later to develop particular functions.

Reflexive locomotion is induced through two positions and nine stimulus zones.

Trained parents have the primary responsibility of carrying out the therapy. It is recommended that therapy be carried out two to four times per day, every day.

As we have already mentioned, the medical literature does not demonstrate a clear advantage of one therapeutic approach over another. In a systematic review of the effects of early intervention on motor development (3) from 2005, eight studies examined the effect of NDT – the Bobath method and in seven of those studies there was no recorded positive effect on motor outcome in children treated according to the principles of NDT – the Bobath approach in comparison with a control group. One study that did show some improvement was in fact comparing two groups of children treated by the principles of NDT, but with different intensities. In the same study, the authors describe a study in which children who underwent regular Vojta therapy achieved better results than children who didn’t get enough Vojta therapy.

Peto Method – Conductive education

Prof. Andreas Peto (Budapest, Hungary) developed conductive education, a method that combines education and treatment. Conductive education is carried out in a group setting and the group is led by conductors. A conductor is a combination of physiotherapist, occupational therapist, speech therapist and educator; training includes a four-year university education. The conductive education programme is intensive and repetitious; it lasts virtually all day and it includes many aspects of everyday life, including the following: mobility, self-care, and preparation for school. Basic mobility is systematically practised by following verbal instructions; children are encouraged to verbalise a given task (e.g. “I am getting up off the chair!”). Songs and rhymes are often used to make it easier to learn and to increase motivation. An important characteristic of conductive education is that children are encouraged to complete specific tasks in the best possible way; however, the quality of the motion or movement itself is not the most important thing.

The literature has not confirmed the efficacy of conductive education (see the report of the AACPDM, American Academy for Cerebral Palsy and Developmental Medicine) (4).

Sensory integration

In 1960, Jean Ayres started developing sensory integration. It was originally designed to help children with learning difficulties, and then later was adapted for children with neurological problems, including those with cerebral palsy. A significant number of children with cerebral palsy have various sensory disorders and sensory integration therapy is supposed to enable the children to process sensory information better, which, as a result, leads to better function.

Sensory integration is often combined with other methods; the limited experience of combining this method with the Stojčević Polovina method in our Polyclinic has been positive.

Baclofen therapy

Baclofen is an agonist of the inhibitory neurotransmitter GABA, and it is used for the treatment of generalised spasticity. It is applied orally or intrathecally, where the effect is greater. The therapeutic effect should be to make care easier, reduce pain, improve sleep and slow the development of contractures.

Botulinum toxin therapy (Botox, Dysport)

Botulinum toxin has become a standard treatment for hypertonicity (spasticity) in specific muscles in children with cerebral palsy, as an alternative to orally- or intrathecally-applied baclofen. Botulin toxin temporarily reduces rigidity in muscles by blocking neuromuscular junctions, causing muscle weakness at the same time. The effect lasts about 3-4 months. It is important that there are no fixed contractures at the planned site of treatment. Botulinum toxin is most frequently used in the lower leg (m. gastrocnemius). Since it is an injection that is given, a mild sedative is sometimes given prior to botulinum application. Botulinum toxin is not recommended for children under two years of age. It is often combined with orthoses, immobilisation or physiotherapy.

Numerous studies have shown a statistically significant, although small, improvement in GMFM results (5). The medical literature cites an average improvement of 3% in measured GMFM scores (6), which definitely means an (admittedly temporary) improvement for a child with cerebral palsy, but not a substantial enough improvement to significantly change the GMFCS level, that is, for the child to cross over into a milder form of cerebral palsy.

It is important to select the use of botulinum toxin carefully both because of the possible harmful side effects (rare, if therapeutic doses are adhered to), and because of the fact that the clinical picture in some children may worsen if the muscles are weakened too much.

After careful assessment and when there are clear indications, botulinum toxin therapy is administered in our Polyclinic, with intensive physiotherapy always being recommended after application.

Alternative therapies
Adeli suit

This treatment includes the use of space suits, designed for Russian astronauts. The philosophy of the therapy is that the suit functions as an orthosis that acts as a support for joints and helps with movement. The use of these suits is supposed to lead to increased brain activity and bone density in the children using them. Clinical research has not confirmed the results of this treatment (7, 8).

Treshold electrical stimulation
Low intensity stimulation does not lead to muscle contractions. The electrical stimulation is typically applied for five hours per night, six nights a week, for two-four years. In theory it causes an electromagnetic field that increases blood flow through the treated area, causing the secretion of hormones that in turn provide sensory input without cortical inhibition. It is used to treat various conditions, including cerebral palsy.
The literature cites that the therapy may have positive effects, especially if it is applied in combination with other therapies (8); however, clinical research to date has not confirmed the efficacy of the therapy.

Hyperbaric oxygen chamber
At one time it was extremely popular to treat cerebral palsy using a hyperbaric oxygen chamber. There are many conditions where the use of a hyperbaric oxygen chamber is indicated and justified; however, cerebral palsy is not among them. Studies have not shown any benefit of the use of the hyperbaric oxygen chamber in children with cerebral palsy, in fact the opposite has been shown, the use of the chamber has sometimes been linked to various harmful effects in children (8).


The Institute for the Achievement of Human Potential (IAHP) – Glenn Doman and Carl Delacato
The approach itself originated in Philadelphia (USA) and was proposed by Doman and Delacato in 1960. One of the main elements of the therapy is so-called “patterning” in which the child’s entire body moves rhythmically in such a way that it imitates amphibian locomotor patterns. The patterning itself requires the assistance of several people; however, the main objections to the method concern the passivity and the lack of independent activity in the treatment
Many professional organisations within the USA have openly criticised this method (including the American Academy of Paediatrics, American Academy of Neurology 1967, American Academy of Physical Medicine and Rehabilitation 1968). According to a 1999 report of the American Academy of Paediatrics the treatment is based on outdated theories and there is no evidence that it is beneficial.

Hippotherapy
Hippotherapy is frequently used in the rehabilitation of children with cerebral palsy, often in addition to other methods. Data from the literature suggest that hippotherapy may improve motor control in children with cerebral palsy (9). The experience of the Polyclinic coincides with the findings in the literature and we often recommend that hippotherapy be combined with the Stojčević Polovina rehabilitation principle, when this is feasible.


Stojčević Polovina Rehabilitation Method

The Stojčević Polovina therapeutic approach began to be developed in the early 1970s in the department for the rehabilitation of children of the "Sestre milosrdnice" University Hospital in Zagreb (then the Dr Mladen Stojanović Clinical Hospital).

The basis of the approach was presented in Prof. Stojčević Polovina’s doctoral dissertation, published in 1979, and entitled „Early and super-early rehabilitation of children with deviations from motor development“. During the last ten years the method has been developed intensively at the Polyclinic. The Neuronal group selection theory, developed by Prof. Edelman, (winner of the 1972 Nobel Prize in medicine) presents a theoretical foundation upon which the therapeutic approach can be explained.

The therapeutic approach itself consists of techniques developed at the Polyclinic and selected elements of Vojta and NDT approaches. It is very intensive and it is tailor-made to each child, depending on the extent of damage to the child’s brain and the child’s developmental level.

The Stojčević Polovina rehabilitation approach depends, to a great extent, on parents who are responsible for carrying out the therapy, which has its positive and negative sides.

The negative side of the approach (if it is indeed negative?) is the incomparably larger commitment required of parents in comparison with other methods, which is very often linked to a change in the entire family’s way of life. (However, the fact that a child with special needs is in the family itself almost always influences the way of life of the family, regardless of the type of therapy).

What we consider the greatest advantage of this method is the fact that parents are given a chance to fight for their child.

The Stojčević Polovina rehabilitation approach is different from the majority of other methods.

It is different in the intensity of therapy.

It is different in that rehabilitation techniques developed at the clinic are used. Similarities to other approaches also exist because in addition to our own techniques we have tried to incorporate into a single approach everything that we considered to be the best from other therapeutic approaches, primarily NDT and Vojta.

It is also different because of our attitude; we believe the natural course of cerebral palsy can be changed. That in no way means that cerebral palsy can be cured, however, we believe that a child, regardless of the extent of brain damage, can reach his full potential with the Stojčević Polovina therapeutic approach more often than with other approaches. Sometimes “full potential” means a healthy child.

The basic elements of the Stojčević Polovina approach were presented at the Third International Cerebral Palsy Conference held in Sydney, Australia in 2009 (10). The results of intensive rehabilitation using the Stojčević Polovina rehabilitation approach in children with cerebral palsy were presented at the conference; GMFCS levels and GMFM scores before and after rehabilitation were presented.

GMFM usually corresponds well with the GMFCS level. GMFCS is used more and more often to assess the severity of the clinical picture in children with cerebral palsy; a child with minimal problems is classified in Level I, while a child with the greatest deviation from normal development is classified in Level V. The main reason why use of the GMFCS has become so widespread in the last ten years is because of its stability. The literature cites that 73% of children with cerebral palsy that were classified in one of the levels of the GMFCS remain in them permanently, regardless of the type of therapy given, whereas the clinical picture of 27% of children changes, for the majority, unfortunately, for the worse (11). The information cited says much about the natural course of cerebral palsy.

During a five-year study using the Stojčević Polovina method 50% of the children studied changed their GMFCS Level, all for the better. At the end of the study, the GMFM score for 95% of the children increased statistically significantly (however, the increase in GMFM scores in only 50% of the children was great enough to reclassify them into lower GMFCS levels). Naturally, these results require further confirmation and preparations for a new study are currently in progress; (a few-fold greater number of children are expected to be included in the study, a Class I study, with an expected duration of 5 years).

Literatura
1) Bobath K, Bobath B, 1984 The neuro-developmental treatment. In: Scrutton D, editor. Management of Motor Disorders in Children with Cerebral Palsy. London: Spastics International Medical Publications
2) Butler C, Darrah J, 2002 , AACPDM Evidence Report: Effects of NeurodevelopmentalTreatment (NDT) for Cerebral Palsy, Developmental Medicine and Child Neurology, 2001,4778-790
3) Blauw-Hospers C.H., Hadders-Algra M : A Systematic review of the effects of early intervention on motor development, Developmental medicine Child Neurology 2005, 47: 421-432
4) Darrah J, Watkins B, Chen L, Bonin C, Effects of Conductive Education Intervention for Children with a Diagnosis of Cerebral Palsy: An AACPDM Evidence Report, 2003, Approved by AACPDM Treatment Outcomes Commitee Review Panel: American Academy for Cerebral Palsy and Developmental Medicine
5) Scholtes VA et all, The combined effect of lower lomb multilevel botulinum toxin type a and comprehensive rehabilitation on mobility in children with cerebral palsy: a randomized clinical trial. Arch Phys Med Rehab 87: 1551-1558, 2006
6) Rosenbaum PL et all, Prognosis for Gross Motor Function in Cerebral Palsy, JAMA, 18, vol 288, 2002
7) Rosenbaum PL, Cerebral palsy: what parents and doctors want to know. BMJ 2003; 326:970-974
8) Gage JR, In: Gage JR editor The Treatment of Gait Problems in Cerebral Palsy, 2004 Mac Keith Press, Cambridge
9) Sterba JA ( 2007) Does horseback riding therapy or therapist-directed hippo-therapy rehabilitate children with cerebral palsy? Dev. Med. Child Neurol 1: 68-73 Review
10) Polovina S, Škorić T., Polovina T., Polovina A.: Effects of Long Term Intensive Rehabilitation in Children with Cerebral Palsy: Our View on the Neuronal Group Selection Theory, International Cerebral Palsy Conference, Conference Proceedings, Sydney, Australia 2009
11) Palisano JR, Cameron D, Rosenbaum LP, Walter DS, Russel D, Stabilitiy of Gros Motor Function Classification System, Developmental Medicine and Child Neurology, 2006, 48: 424-428



THE REHABILITATION OF CHILDREN WITH CEREBRAL MOVEMENT DISORDER
(SYNDROMA DYSTONI, HIGH NEUROLOGICAL RISK (NEURO-RISK) CHILDREN)

A diagnosis of cerebral movement disorder, syndroma dystoni, or a high-risk (neuro-risk) child is usually the same diagnosis. In reality it is a working diagnosis that describes the current condition of a child; it describes a particular deviation from normal development, whereby it is usually a case of deviation from normal motor development.

The causes are usually changes in the central nervous system (CNS) resulting from a lack of oxygen (various levels of hypoxia) or haemorrhaging.

The diagnosis itself cannot for certain answer the question of what the final outcome will be. The final outcome of cerebral movement disorder can be a completely healthy child, a child with minor deviations from normal development that do not necessarily have to be visible (see development coordination disorder), or a child with a clear neurological disorder, which usually means one of the forms of cerebral palsy (see cerebral palsy).

What the final outcome will be depends on many factors, whereby one of the most important ones is the extent of damage to the central nervous system. Luckily, the majority of high-risk (neuro-risk) children have minor deviations from normal development and therefore have relatively good chances for a favourable outcome.

It is possible to get to a favourable outcome in two ways. One way is that a child, who has at one point in his development deviated from normal, not be given any form of therapy; however, thanks to the neuroplasticity of the brain, that is, the ability of the brain to bridge the problem itself, the child becomes totally healthy. This is possible regardless of the fact that at one point the child had developmental problems (which can usually be diagnosed by clinical examination or by a diagnostic tool such as cranial ultrasound). Naturally, the chances for such an outcome are higher the lesser the deviation is from normal.

The problem is in the fact that we can never say for certain which child will spontaneously reach ideal development, and which won’t. If a particular developmental problem persists, it is very often permanent, that is, it is very difficult to “cure” it.

It is for this reason that the Polyclinic team’s attitude and recommendation is to include children in a rehabilitation programme as soon as a diagnosis of cerebral movement disorder (syndroma dystoni, high-risk/neuro-risk child) is made, even when there are only minor deviations from normal development. Just as the diagnosis of a high-risk/neuro-risk child in itself indicates a certain risk or danger, so rehabilitation can be considered a method by which we can help to significantly increase a child’s chances of ultimately being healthy.

There is a correlation between the extent of damage and the time when rehabilitation is initiated. In general we can say that the results are better, the earlier that rehabilitation is begun.

It is important to know that permanent disability (here we usually mean CP in its various forms) is not present at birth. It is a process in which damage to the central nervous system interferes with normal development. The symptoms are often not visible to parents while the baby is small. By the time the problems become clearly visible then the potential of rehabilitation for the majority of children is slight. For that reason, early and timely rehabilitation is extremely important. Sometimes a child with greater damage to the central nervous system (for example damage visible on cranial ultrasound or MRI) who begins therapy earlier has a greater chance for a favourable outcome than a child with less damage who begins rehabilitation later.

By ideal and early rehabilitation we mean rehabilitation that is initiated before the child is three months old; by timely rehabilitation we mean rehabilitation that is initiated up until the child turns nine months old (however, there is a difference between rehabilitation initiated at four months and rehabilitation initiated at nine months); we consider rehabilitation initiated after nine months of age to be late rehabilitation.

There are many therapeutic approaches; often they are very different, sometimes the approaches are completely opposed. For this reason, parents are often placed in a difficult situation when they hear two opposing opinions from two specialists because then they can rely only on their parental instincts to choose what they think is the best therapy for their child. In the same way, there are numerous controversies about how intense the therapy should be.

The most commonly applied approaches are NDT – the Bobath approach and Vojta therapy.

In NDT-the Bobath approach, very often, the physiotherapist carries out therapy on an out-patient basis (once, twice, or more frequently per week; sometimes in blocks of ten days, depending on the therapist’s assessment and the particular institution’s capabilities), while parents are responsible for the correct care and handling of the child and specific smaller therapeutic tasks.

In Vojta therapy, trained parents carry out therapy every day, a few times per day.

Very rarely are the approaches combined, if only because it is rare for licensed Vojta and Bobath therapists to work in the same institution (NDT and Vojta therapies are described in more detail in the section on cerebral palsy therapies).

At the Polyclinic we have developed our own therapeutic approach which in itself comprises clinic-based techniques, and specific elements of Bobath and Vojta approaches. We usually recommend an intensive rehabilitation programme initiated as early as possible. The essential attitude and philosophy of the Stojčević Polovina rehabilitation approach is to give every child a chance to reach normal development regardless of the extent of brain damage. We believe that this is possible even with very severe damage, if rehabilitation is begun on time (for children with the greatest deviation from normal development rehabilitation should be begun before the third month of life, corrected age). The aim is a healthy child. In cases where the damage is severe and when the chances are extremely small, say 1%, according to our rehabilitation approach, we try everything to achieve that 1%. The opposite is also true, mild deviation from normal development often corrects itself spontaneously; however, early and careful rehabilitation is required so that children who can be completely healthy do not end up in the small percentage of those who do not have a happy outcome.