Cerebral Palsy, Treatment & Rehabilitation

Cerebral palsy (CP) is an umbrella term for a group of disorders affecting physical ability that is a result of brain injury during pregnancy, at birth or shortly after birth (less than 2 years). The injury associated CP is permanent but does not worsen over time generally.

Physical difficulties include impaired postural control, balance, coordination, strength, sensation and proprioception (movement awareness).

Non-physical difficulties include impaired speech, hearing, learning, vision and intellect. Epilepsy is also common in people with CP.

Cerebral palsy can affect both legs (diplegia), an arm and a leg on the same side (hemiplegia) or all 4 limbs (quadriplegia).

Types of Cerebral Palsy

#1 Spastic

The most common type of CP, this is characterised by stiffness and jerky movements because of a disrupted balance between muscle groups. In normal human movement, every muscular action is supported and balanced by a certain degree of background activity. People with cerebral palsy often have too many muscles with high background activity and have difficulty turning them down on command. As a result, the movement can seem stiffer and more difficult.

The presence of spasticity, a form of increased muscle tone, is a common sign to suggest that altered neural drive from the brain is present. With spasticity, the faster the limb is moved, the stiffer it seems to be. This is not just seen in cerebral palsy, but also in spinal cord injury, traumatic brain injury, stroke and multiple sclerosis.

Spasticity can affect not just the muscles used to walk and move, but also muscles that control facial expressions, swallowing and moving the arms and trunk.

How does spasticity affect the arms?

Commonly, spasticity affects the flexor components of the upper limb. This refers to the muscle groups that help to bring the shoulder inward, bend the elbows, wrists, thumbs and fingers. When these muscles have spasticity, it can result in difficultly extending (straightening) the joints to allow the arm to sit, to relax and engage in arm swing. It can also develop into pain as there is persistent compression of the joints, skin and soft tissue, sometimes resulting in subluxation and development of contracture. It can also become difficult to maintain skin hygiene.

How does spasticity affect the legs?

Spasticity in the legs tends to affect the extensor and adductor components of the lower limb. These muscle groups are responsible for keeping the legs together and stable, and also for power in order to push off the ground to walk or jump. This can present as:

  • hyperextending big toe (pointing upwards)
  • excessive toe clawing (pointing downwards)
  • toe walking or walking without heels on the ground
  • crouched gait (increased hip and knee bending while walking)
  • scissoring gait (legs are crossing the midline or over each other with each step)

How can neurological physiotherapy help?

Neurological physiotherapy can help reduce the effect of spasticity by firstly assessing the severity of the spasticity, and this is done through clinical testing and feeling for muscle tone in certain positions, at different speeds, and then comparing that to what is considered normal.

Next it is then important to consider that information in the context of the person with CP. This is because there needs to be a clinical decision made, best done in consult with a paediatrician, paediatric surgeon, neurologist or rehabilitation physician, as to whether reducing or removing this spasticity is going to negatively affect another body part or the person’s ability to move or their overall development.

If the decision is made that spasticity should be reduced, this can be done in consult with a medical professional as to whether Botulinum toxin A (Botox) would be suitable. An locally injected dose of Botox temporarily “paralyses” a single muscle, which reduces spasticity. This means that the abnormal movement can be reduced and can be effectively trained, in some instances, to develop a more normal one. Often, another effect is that more range of movement becomes available because the muscle is no longer pulling as hard as before.

However, Botox does not have a permanent effect. But when it is in effect, customised casting and splinting can be done by either a trained physiotherapist, occupational therapist or orthotist, to apply a sustained stretch through the range of movement gained. Casting can also be done in series, whereby with increased range further stretching can occur and another cast is made to replace the old one and keep up with changes in muscle and joint range.

#2 Dyskinetic

Dyskinesia means movement is abnormally variable and outside a person’s control. It is primarily a result of a lesion to the basal ganglia, hippocampus, corpus striatum or thalamus, which are intimately tied in with motivation and movement quality.

Forms of involuntary movement can present as repetitive and rhythmic (dystonia), slow and writhing (athetosis) or dance-like (chorea). These forms of involuntary movement can affect a person in one body part (focal), such as the neck or hand, or affect multiple body parts in a general way. The also tend to affect people at rest but are worsened when they attempt to move.

How can neurological physiotherapy help?

Neurological physiotherapy can assist with movement strategies to help overcome this limitation, and look at ways that may reduce the dystonia, such as sensory tricks (geste antagoniste). Botox can also be discussed and may be of some benefit to people with a more dystonic presentation.

#3 Ataxic

Ataxia refers to voluntary movement that is incoordinated, clumsy and poorly controlled. Movement can also under or overshoot targets (dysmetria). This is commonly due to a lesion to the cerebellum, a highly organised and densely myelinated part of the brain that sits above the brainstem, that controls postural muscles and connects information from the eyes, the vestibular system and the motor learning systems. It is responsible for ultimately providing feedback both ways for movement and sensing, to create smooth movement that gets better with practise.

What does ataxia do to the arms and trunk?

Because of dysmetria, the hand can fail to grasp or manipulate an object easily as there is constant interference from shaking (tremors). It can make writing, eating and dressing oneself extremely challenging. This can be worse if there is ataxia in the trunk because there is a lack of postural stability on which to base arm movement.

What does ataxia do to the legs?

When someone has ataxia, it makes their walking look unstable and they risk falling. Steps can be misjudged and misplaced, sometimes with stomping actions. In more severe cases, even walking frames is not enough and it can in itself become a tripping risk.

How can neurological physiotherapy help?

Cerebellar ataxia is, by root, a sensory processing problem. Neurological physiotherapy can help improve the processing of sensory information through other forms of sensory awareness, including attentional and non-attentional touch, and by creating a better postural alignment that would allow more accurate representation of what the body feels internally. This is an important part of helping people with CP regain their postural control.

With this in mind, specific activities, tasks and postures could be adopted to improve the underlying instability so the effect of tremor and ataxia is reduced, and appropriate muscles can be strengthened. Dynamic visual retraining can also be used to help improve the sense of balance offered by the visual system, in order to make standing and walking safer.

#4 Mixed

The last type is a mixture of neurological presentations and is consequently, the most difficult to treat.

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