Perspective

Cerebral palsy (CP) is a misnomer at best. Little suggested the name in the mid-1800s, but there is still no established direct relationship between the identifiable state of the brain and the distortions in posture and movement control that we are able to observe in the individual. ^, The condition is not always evident at birth, although the work of Prechtl statistically supports the possibility of a link between the quality of spontaneous movements in the first months of life and later difficulties in coordinated movement expression. Recently in a systematic review of spontaneous infant movement as a predictor of later CP, 47 studies were scrutinized. The authors found that Prechtl’s General Movement Assessment had the strongest sensitivity for predictive validity for a later diagnosis of CP. They caution practitioners in the use of this tool in isolation due to a high level of false positive results. In only a small number of children has a specific lesion been identified that corresponds to the observed motor responses of the child, and this elite group includes children with porencephaly and other early developmental malformations of the brain. Whether there is a biochemical element in the brain of a child that distorts the actual motor learning process has not been established. There is a shocking variability in the age at which intervention is initiated for individual children with CP. The continuation of a “wait and see” philosophy in many cases postpones the delivery of services and resultant early intervention. Programs that provide early screening for infants under the Individuals with Disabilities Educational Act (IDEA) utilize a team of professionals trained in early childhood and typical development to identify children at risk. ^, These programs vary from state to state but through Federal and State funding provide services for children 0 to 3 years of age for early intervention. Understanding the process of movement and postural distortion that characterizes children who carry the label of “cerebral palsy” is a critical piece in the delivery of services to this population.

Historically, the evolution of diagnosis and treatment intervention or management is clear and relates to the recognition of the special needs of this minority of society. The British physician, Little, identified the condition on the basis of observable characteristics of movement and posture, or—in other words—the external features of the condition, so the initial efforts at remediation fell to physiatrists and orthopedists such as Deaver and Phelps. ^{, ,} In an article by Kottke and Knapp in 1988 physiatrist Dr. George Deaver was considered the “Grandfather” of physical medicine and rehabilitation, treating individuals with cerebral palsy when others would not consider it. Deaver placed importance on external bracing that was periodically reduced in the hope that the child would take over control of increasing parts of his or her own body. Phelps, an orthopedist, used bracing and surgery and was a significant force in obtaining schooling for these children in the United States. ^, He pointed out that these children did not belong in academic classes with children diagnosed as retarded or mentally handicapped, and that children with CP should be exposed to a traditional academic curriculum. In his Children’s Rehabilitation Institute in Reisterstown, Maryland, he also advocated restriction of a more functional limb to encourage the use of the one less used, particularly in work with the upper extremities, which was an early introduction of constraint-induced movement therapy (CIMT) known to us today.

In the 1950s and 1960s new theories simultaneously emerged of neuromotor behavior that redefined the clinical characteristics of CP and permitted clinicians to orient their intervention strategies to the principles of motor development and motor learning. Kabat, in conjunction with Knott, introduced proprioceptive neuromuscular facilitation (PNF), which was applied to children with movement disorders and to adults with a history of trauma. In 1952 Dorthoy Voss joined Kabat and Knott and expanded on the techniques. The use of diagonal patterns of movement in this approach changed the customary postures of the child and introduced more functional movement patterns in logical learning sequences. Physical and occupational therapist Margaret Rood added the more specific sensory components of ice and light, quick brushing of the skin surface to guide the desired motor response. She spoke of the need to focus attention on both “heavy work” and “light work” during the early development of movement skills. These terms referred to the central body moving over a limb that has been fixed or bearing weight and extremity movement with central stability. Bobath was working in London at this same time and observed the need to have a dynamic distribution between stability and mobility, after finding that inhibition of the reflexive movements was not sufficient to change the functional outcome of the child with CP. Both Rood and Bobath pointed out that the areas of the child’s body that appeared to be spastic changed when the body was placed in a different relationship to gravity. This observation held up for reexamination of the prevailing view of the time, namely, that spasticity existed in a tendon or muscle, a specific structure. CP was identified in the mid-1900s as an incident that occurred shortly before, during, or shortly after the birth of the infant. Early intervention was recommended. This timeline was extended to cover the first 2 years of life, which included early cases of meningitis, encephalitis, drowning accidents, and so forth. These factors are true today; however, multiple causes of CP have been documented. A systematic review and meta-analysis on the prevalence of CP in 2013 revealed that infants with a gestational age less than 28 weeks and birth weights of 1000 g to 1499 g were at highest risk for CP.

Interestingly, the overall prevalence of CP was found to be 2.11 per 1000 live births, which has remained consistent despite an increased survival rate and improved neonatal care. The Centers for Disease Control and Prevention report a slightly higher incidence of 1.5 to 4 per 1000 births.

Although early clinicians defined CP as a “disorder of posture and movement control,” many of the children also had learning problems and inadequate general brain development affecting cognitive skills, reasoning, and judgment. There was a general agreement on categories according to movement characteristics that included spasticity, athetosis, flaccidity, ataxia, and rigidity. Categorization according to the part of the body affected was added to identify hemiplegia, quadriplegia, diplegia, and even monoplegia (affecting one limb), and triplegia (affecting three limbs). It was noted that some children “appeared” to move from one category to another as their body changed with growth and hormonal expression. Therapists began to be aware that a child with high tone could have varying degrees of low tone and muscle weakness underneath when spasticity was inhibited. Fluctuating tone could be confused with ataxia, and the precise intervention strategy might be elusive.

The birth process is complex at many different levels. Sequential hormonal changes alert both the fetus and the mother that it is time for a separation. The infant moves into position for exiting the uterus through the birth canal while the mother’s body prepares to participate in the work (labor) of the expulsion. When all goes smoothly, the head of the infant is molded by the passage through the birth canal, and the fibrous sutures of the cranial plates return to their balanced alignment and functional motion. When the birth process is prolonged for any of many reasons, the physiological timing of these changes is interrupted. In the majority of healthy infants born at term, spontaneous movements seem to assist in the activation of the central body (trunk) and the limbs to permit a typical expression of developmental movement responses after birth. Body movement and respiration are coordinated with the infant’s physiological rhythms in this initial adaptation to the world of gravity. With complications of the pregnancy or the birth process, these spontaneous movements that are so easily made by the healthy infant become laborious and sometimes impossible, affecting motor actions, postural mechanisms, and the basic physiological rhythms. CP is a heterogeneous collection of clinical syndromes, not a disease, or pathological, or etiological entity. ^{, ,} Little described CP as “a persistent disorder of movement and posture appearing early in life and due to a developmental nonprogressive disorder of the brain.” Current definitions have reiterated that atypical execution of movement and interference with postural mechanisms are the key characteristics of this nonprogressive disorder affecting the developing brain, with wide-ranging presentations. ^{, ,}

CP affects the total development of the child. The primary disorder is of motor execution, but common associated dysfunctions include sensory deficits (hearing or vision); epilepsy; learning disabilities; cognitive deficits; emotional, social, and behavioral problems; and speech and language disorders. The degree of severity varies greatly from mild to moderate to severe, and may be combined with multiple comorbidities.

Diagnostic categorization of the characteristics of cerebral palsy

In general, a diagnosis of CP suggests that the individual has a lesion within in the brain affecting the motor control system with a residual disorder of posture and movement control. Varying degrees of associated components are seen with this disorder that further defines the category that a child may fall into: severity of motor abnormalities, anatomical and magnetic resonance imaging (MRI) findings, extent of associated impairments, and the timing of the neurological injury. Further, the severity and type of CP depend on the extent and damage to associated area(s) in the brain affecting the motor cortex. The labeling process helps to identify the parts of the body that are primarily involved. Diplegia, hemiplegia, and quadriplegia indicate that the lower extremities, one side of the body, or all four extremities, respectively, are affected. This can be misleading to the therapist who is working with infants because these children often change their clinical presentation and their respective disabilities. The disorder is not progressive, but the presentation of involvement of body segments may manifest itself differently with hormonal influences as the child grows and his or her structure and tonal distribution changes against gravity. Structure and function are closely related as the child grows and the body matures.

The clinician must be aware that the categorization of CP is based on descriptions of observable characteristics; thus it is a symptomatic description. The hypertonus of spasticity prevents a smooth exchange between mobility and stability of the body and interferes with reciprocal innervation. Constriction of respiratory adaptability occurs with poor trunk control. Incrimination of postural tone occurs with an increase in the speed of even passive movement, and clonus may occur in response to sudden passive movement. Although diagnostic terms reflect the distribution of excessive postural tone, the entire body must be considered to be involved. Spasticity, by nature, involves reduced quantity and quality of movement, which makes its distribution easier to identify. Recruitment of the corticomotor neuron pool is affected in the presence of spasticity, and therefore timing issues result in the poor grading of agonists and antagonists. There is also a risk of reduction in the range of limb movements over time when therapy does not include active adaptation in end ranges and organization of postural transitions. Category (spasticity) has the highest occurrence of cases of CP. ^, There are several spastic types of CP that require clarification. Fig. 10.1 Spastic diplegia implies that the lower extremities are more involved than the upper extremities but could manifest with varying degrees of arm and hand function, and often the involvement is asymmetrical. , Hemiplegia displays involvement of one side of the body and can manifest itself with the arm involved more than the leg or the leg involved as much as or more than the arm. ^{, ,} This group of individuals is at risk of developing seizures as they go through puberty; however, a seizure disorder can occur in any of the types of CP as a comorbidity. Quadriplegia, as the term implies, involves the entire body. ^{, ,}

Classification of Cerebral Palsy. CP , Cerebral palsy. LE’s , Lower extremities; UE’s , upper extremities.

(Developed by Claudia Senesac © 2018.)

Dyskinetic syndromes, which include athetosis and dystonic types of CP, are characterized by involuntary movements. This type of CP is a result of damage to the basal ganglia, which is responsible for regulating voluntary movements. This area of the brain also is important in regulating emotions, mood, and behavior in general. The term dyskinetic is commonly used with children who lack posture, axial, and trunk coactivation. The excessive peripheral movement of the limbs occurs without central coactivation to stabilize the trunk. Dystonic types of CP are dominated by tension and can result in repetitive, sustained movements, or awkward postures. Movement behavior is slow or fast with little control over the movements and may be associated with pain. Athetosis usually has a hypotonic base or underlying tone with slow writhing movements seen at rest, which get more pronounced with increased movement attempts. The child with athetosis can become floppy or be quite spastic within a moment’s notice. Muscle tone can fluctuate in both types of dyskinetic CP from hypotonia to hypertonia, making their movements unpredictable. These changes in tone are spontaneous and often related to varied stimuli, which are often specific to each child including—but not limited to—mood, hormones, and environmental influences. Dyskinetic syndromes may occur with greater involvement in particular extremities, although the condition most often interferes with postural stability as a whole. When pathological or primitive reflexes are used to accomplish movement, there is difficulty with midline orientation and symmetry.

Tonic neck reflexes are observed in this population with the asymmetrical tonic neck reflex (ATNR) the most common although others may also be present. Dyskinetic distribution of postural tone is changeable in force and velocity, particularly during attempted movement by the individual. Midrange control is limited—if present at all—and frequently end ranges of motion are used to accomplish a motor task. ^{, ,} For these reasons, these children have a reduced risk for contractures over time. However, as with any habitual pattern of movement, muscular and joint tightness may occur. Fine motor skills, discrete movements, and skills that require slow control are difficult for these children. Expressive language also may be affected due to changes in muscle tone distribution influencing every muscle in the body, including those that support respiration and speech.

Hypotonicity is another category of CP, but it may also mask undiagnosed degenerative conditions (see Chapter 10). Recent reports suggest that “pure hypotonia” is not an attribute of CP, and further testing to rule out other causation may be indicated. ^, Hypotonia in a young infant also may be a precursor of a dyskinetic syndrome. Often, athetoid movements or spasticity are not noticed until the infant is attempting antigravity postures, although there may be some disorganization of movement patterns apparent to the careful observer. Generalized hypotonia may disguise some specific areas of deep muscle tightness with accompanying local immobility in an effort to gain stability for function. Careful examination will assist the therapist in the interpretation of the child’s movement strategies.

True ataxia is a cerebellar disorder that is seen more frequently as a sequela of tumor removal (see Chapters 20 and 22 ) than as a problem occurring from birth. Ataxic syndromes are more commonly found in term infants. This type of CP is a diagnosis of exclusion. In a small number of patients there is congenital hypoplasia of the cerebellum. Most of these children are hypotonic at birth and display delays in motor acquisition and language skills. Recruitment and timing issues remain problems in this population. Trajectory of the limbs, speed, distance, power, and precision are frequently documented as problems in this category. Midline is often achieved, but control of midrange movements of the extremities and control of trunk postural reactions are affected. These classifications, even when accurately applied, give the therapist only a general idea of the treatment problem and must be supplemented by a specific analysis of posture and movement control during task performance, an interview for home care information, and assessment of treatment responses (see Chapters 6 and 7 ). The therapist is then ready to establish treatment priorities for the individual child. Refer to Fig. 10.1 for an overview of the classification for types of CP.

Many of the characteristics described in the preceding paragraphs also apply to children who have had closed head traumas or brain infections. Further information can be obtained in Chapters 22 and 26 . Some of the treatment suggestions that follow may also be applied in such cases. As with CP, early positioning and handling after trauma may deter later problems.

Initial observations and assessment

Examination of the individual child begins with careful observation of the interaction between parents and the child, including parental handling of the child that occurs spontaneously. Some additional insight can be gained about the relationship between parent and child by observing how the child is handled both physically and emotionally. Does the child receive and respond to verbal reassurance from the parent in the therapy situation? Are immediate bribes offered to the child? Does parent eye contact increase the child’s confidence in responding? Does family communication convey the idea of negativity in the therapy situation or a difficult experience that will soon come to an end? The family orientation will affect the response of the child while working with the therapist. Making connections with the child and family is a critical component to a successful relationship that forms with ongoing treatment.

The therapist working as part of a team may have the advantage of a social worker or psychologist who will relate to the problems and motivations of the parents. Parental responses toward the disabled child arise from the parents’ uncertainty, fear, concern for the future, disappointment, distress, and other typical reactions to this unforeseeable life experience. A period of grief is to be expected as their child is often unable to accomplish the milestones and dreams the parents had envisioned for them. Providing clear information for the family in the form of education and interpretation of medical information will assist parents discover how to help their child move forward in all domains. They may be further assisted by opportunities to interact with well-adjusted parents of older children with a diagnosis of CP. Assisting families to make connections with other families and children in the community provides them a supportive network of people who share similar experiences.

A problem-based approach to the assessment and management of the child with CP includes the family as key members of the team. While observing the child, the experienced therapist will want to periodically elicit from the parents their view of the problem and their goals for their child. By listening carefully, the therapist also will be able to discern the emotional impressions that have surrounded previous experiences with professionals. Sometimes what is not said is more important than what is verbally offered immediately. Listening carefully and clarifying facts are more important than overwhelming the parents with excessive information and suppositions during early contacts. Observation of the family response to information will keep the therapist on track in developing a positive relationship with parents that deepens over time. The therapist’s role is often as interpreter of medical information as parents attempt to make some sense of their child’s diagnosis.

The next general step is to observe, in as much detail as possible, the spontaneous movement of the child when separated from the parent ( Fig. 10.2 ). Is the child very passive? How does he or she react to the supporting surface ( Fig. 10.3 )? Are there atypical patterns of movement to reach a toy? Are clearly typical responses occurring with specific interference by pathological synergies or total patterns of movement? Does the child rely heavily on visual communication? Do the eyes focus on a presented object, or does the postural abnormality increase with an effort to focus the eyes? Does the child lead or follow hand activity? Does an effort to move result only in an increase of postural tone with abnormal distribution? Does respiration adapt to new postural adaptations ( Fig. 10.4 )? Is the child able to speak as well while standing as while sitting? Fig. 10.5 provides key questions to keep in mind during the assessment.

Typical infants accumulate a multitude of experiences as they move smoothly and spontaneously in their environments.

Lack of support surface contact demonstrates difficulty conforming to and activating off of the supporting surface.

Emotional reactions are also translated into stronger spastic reactions influencing respiratory adaptation.

Questions to guide the therapist during the collection of data while assessing the child with cerebral palsy.

(Developed by Claudia Senesac © 2018.)

This type of observation is valuable because movement patterns directly reflect the state of the central nervous system (CNS) and can generally be seen while the parent is still handling the child. Once the child is on the mat or treatment table, outer clothing can be removed to observe interactions of limbs and trunk. Observation of the musculoskeletal system without the restriction of clothing allows the therapist to collect information about the initiation of movement, asymmetries, dynamic joint movement, reflexive behavior, support surface contact, and changes that occur with transitions that are difficult to visualize with clothing left on. Movement responses of the child can gradually be influenced directly by the therapist. Many children associate immediate undressing in a new environment with a doctor’s office, and the chance to establish rapport is lost. In some instances, it is preferable to have the parent gently remove some of the child’s clothing or even to leave the child dressed during the first therapy session. Gaining the trust of the child and parent is crucial during the first few sessions.

The International Classification of Functioning, Disability and Health (ICF) ^, is well known in the field of health care and allows one to see the overall interaction of the person with his or her environment, activities, and participation in the presence of the health condition. Fig. 10.6 depicts this health care model with examples of behaviors and information of which the therapist should be cognizant while collecting data for later integration into a treatment plan.

World Health Organization Disablement Model.

This table provides all areas of classification in the World Health Organization-International Classification of Functioning, Disability and Health model (ICF) . Examples of each category are given as a reference point for collection of data for your assessment.

(Adapted from the International Classification Model of Functioning, Disability and Health (ICF) Model–World Health Organization http://www.who.int.easyaccess2.lib.cuhk.edu.hk/classifications/icf/icfbeginnersguide.pdf . Developed by C Senesac ©2018.)

Examination of the child’s status is more likely to be adequate if the therapist follows the child’s lead when possible. Photos or video recording are beneficial in capturing the interactions and movement patterns of the child; however, parents must be consented prior to using these forms of documentation. Sánchez and colleagues reinforces this idea of video recording as a way to further assess segmental posture of the head and trunk. In addition, the Segmental Assessment of Trunk Control (SATCo) has been found to have excellent reliability and good absolute agreement in children with CP, and offers another objective estimate of sitting trunk control.

Often notes can be organized later to conform to a specific format. It is possible to jot down essential information while observing the child moving spontaneously or while the parent is holding the child. Reactions to the supporting surface will differ in these circumstances. After the session, the therapist will need to record the salient information either electronically, or by hand as part of the evaluation, sending a copy to the primary care physician. Attention should be given to the typical movements of the child and to those postures that the child spontaneously attempts to control. Building a treatment plan will be based on the strengths of the child noted in these first encounters and will serve as a foundation to build the plan of care (POC). Eye alignment is important; the correspondence between visual and postural activity relates directly to quality of movement control. It is important to note the interaction between the two sides of the body. In noting atypical reactions and compensatory movement patterns, the therapist must also indicate the position of the body with respect to the supporting surface. There is a tendency to compile more pertinent data by learning to cluster observations and relating one to the other. Figs. 10.7 and 10.8 provide examples of how to group data collected during observation and handling of the child. Children are vibrant beings. Their choices of position tell us something about their movement behaviors and how comfortable they are in particular situations. Although it is important to see the child in every position, making smooth transitions from one to another will ensure that the child is secure and give the therapist a more accurate assessment of the child’s abilities. Noting the “preferred” position or movement strategy can provide information about the ability to conform to a support surface, the initiation of movement from the surface they are weight bearing on, muscle tightness, muscle tone distribution, and movement variety in the child’s repertoire.

World Health Organizational format for assessment.

(Using the WHO terminology to help organize and record data while assessing a patient. Adapted from the International Classification of Functioning, Disability and Health model of the World Health Organization. Developed by Claudia Senesac © 2018.)

Assessment form organized by categories. Organizing and recording data for patient assessment. WB , Weight bearing; ROM , range of motion.

(Developed by Claudia Senesac © 2018.)

Standardized assessments are often used by facilities to document the developmental level of the functioning of a child with disability and to justify treatment. The Gross Motor Function Measure (GMFM) was developed to assess children with CP and has good reliability and validity for children aged 5 months to 16 years. This assessment is well studied in the literature and often used to document a baseline and progress, but can also serve to help develop a POC. The Gross Motor Function Classification System (GMFCS), developed in 1997, is often used in conjunction with the GMFM. ^, The GMFCS has five levels of classification for gross motor function, emphasizing movement initiation related to sitting, walking, and mode of mobility. Descriptors of motor function span an age range of 2 to 18 years, reflecting environmental and personal factors. Both of these tools have also been used in research studies as a measure to meet inclusion criteria and as outcome measures. The GMFM continues to be investigated for use in different populations and those with visual impairment.

The Pediatric Evaluation and Disability Inventory (PEDI) assesses children aged 6 months to 7.5 years in three domains: social, self-care, and mobility. A computer based version of this instrument, Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), has demonstrated strong construct validity and reliability in children with CP. Both versions of this tool have been used to track outcomes over time. The Functional Independence Measure for Children was developed as a test of disability in children aged 6 months to 12 years. This assessment covers self-care, sphincter control, mobility, locomotion, communication, and social cognition. Often the decision to use an instrument to assess development will be left up to the clinician or facility. To date, there is no single tool that will cover all the categories necessary to document change in a child with CP, so the clinician will need to rely on observational skills to describe quality of movement and response to changes in position in space and handling. Each child will differ in the ability to separate from her or his parents. Spontaneity of movement, interest in toys, general activity level, and communication skills will also vary from child to child. Responding to the specific needs of the child enables the therapist to set priorities more effectively. If fatigue is likely to be a factor, it is important first to evaluate those reactions that present themselves spontaneously, followed by direct handling to determine the child’s response and potential for more typical movements. Movements or abilities for which there is a major interference from spasticity, primitive reflexive responses, or poor balance reactions (righting, equilibrium, and protective reactions) may be better checked at the termination of the assessment so that the child remains in a cooperative mood as long as possible. Information regarding favorite sleeping positions, self-care independence, and any equipment used at home can be requested as the session comes to a close.

Clinical reasoning involves taking information from the assessment, including observations, results from standardized tools, family input, and the therapist’s handling of the child to formulate a treatment plan. Placing this information into a framework that makes sense to the therapist, the physician, other health professionals, and the family will assist in goal writing. Refer to Figs. 10.9 and 10.10 as examples of evaluation formats that are easily incorporated.

Posture Picture Reference evaluation tool for recording and organizing data. PE , Physical education; ACA, Adjusted chronological age; CA, chronological age; E, equilibrium reactions; GM level, gross motor level; LE’s, lower extremities; PE, protective extension; R, righting reactions; ROM, range of motion; UE’s, upper extremities.

(Developed by Claudia Senesac © 2018.)

Evaluation Form Standard Format. ACA , Adjusted chronological age; CA , chronological age; DOB , date of birth; DOV , date of visit; GM , gross motor; HEP , home exercise program; ICD , International Classification of Diseases; LTG , long-term goal; OM , oral motor; PCP , primary care physician; PMH , past medical history; RTC , return to clinic; STG , short term goal.

(Developed by Claudia Senesac © 2018.)

Reactions to placement in a position

If the child totally avoids certain postures during spontaneous activity, these are likely to be the more important positions for the therapist to evaluate. Observing how the child conforms to the support surface and how much contact there is with the surface will provide information about the ability to initiate movement from the surface. Support surface contact is essential for weight bearing and weight shifting to occur; both are critical for movement. Placement of the child in the previously avoided position will permit the therapist to feel the resistance that prevents successful control by the child. As mentioned previously, this may be held for the end of the assessment. The parent should play an active role in the assessment whenever possible. Continued dialog with the parents reveals factors such as the frequency of a poor sitting alignment at home or a habitual aversion to the prone position. Gathering general information about the child’s habits in her or his environment can further enhance the therapists’ understanding of how well the child is integrating the visual-motor system, perception, and motor systems; that is, tilting the head when looking at books or watching TV may indicate neck tightness and/or difficulty with functional vision skills. These contributions by the parents establish the importance of good observation and the need for parents and the therapist to work cooperatively as a team. Therapists of different specialties need to initiate continued communication to coordinate therapy objectives. According to the guide for typical development, infants should be able to maintain the posture in which they are placed before they acquire the ability to move into that position alone.

The problems presented by CP occur to some extent as a reaction to the field of gravity in which the child moves. Visual perceptions of spatial relationships motivate and determine movement patterns while the child must react at a somatic level to the support surface. It is helpful therefore to attempt placement of the infant or child into developmentally or functionally appropriate postures that are not assumed spontaneously ( Fig. 10.11 ). Resistance to placement indicates an increase in tone, a structural problem, or an inability to adapt to the constellation of sensory inputs for that alignment. A movement that resists control by the therapist will be even less possible for the child. What appears to be a passive posture may hide rapid increases in hypertonicity when movement is initiated or instability of a proximal joint when weight bearing is initiated. A child may have learned to avoid excitation of the unwanted reactions and may fix the body position to avoid the alignment that cannot be controlled. Another child may enjoy the sensory experience of accelerated changes in postural tone and deliberately set them off as a means of receiving the resulting stimulation to his or her system. These movement behaviors provide the therapist with valuable information for treatment planning.

Baby treatment must be dynamic and precisely oriented to individual needs.

Nutritional aspects of neuromotor function

Nutrition is viewed as providing an important biochemical base and foundation for enhanced human performance. It is not uncommon for children with CP to have feeding difficulties resulting in poor nutrition. Children with neurodevelopmental problems may present with difficulty managing food and liquids in their mouth, swallowing, and digestive issues. The more severely involved the child the higher the prevalence of feeding issues.

Poor nutrition effects energy levels, behavior, and physical and cognitive functioning. In the first 2 years of life patterns for sucking, managing food in the mouth, and control of the related structures (including head control) are developing. ^, As the child grows and matures it is critical that they receive the essential nutrients. This can be problematic in someone that has difficulty isolating motor control over large and small muscles throughout their body. Gastroesophageal reflux is also common in infants and older children with developmental problems.

In some infants, reflux decreases or subsides as the muscular stress is reduced in the tissues of the neck, upper thoracic, and cervical region. Furthermore, allergies may also play a role in inadequate caloric intake. To supplement nutritional intake in the child with CP, the individual child must be considered with regard to age, size, activity level, and growth factors. ^, The rehabilitative process places increased demands on the entire system and requires fuel to set the stage for improved muscle function.

Protein, carbohydrates, and adequate hydration are sources that build muscle and provide fuel, which provides a foundation for strengthening and the advancement of motor skills in populations without disability. ^{, , ,} A well-balanced diet will provide the requisite energy for exercise. Little research has been done specifically on children with CP; therefore appropriate levels of protein needed during exercise in this population of children are yet to be determined. Studies investigating feeding issues in neurodevelopmental disabilities are beginning to emerge in the literature. These studies are exploring assessment tools to better evaluate the problems and potential interventions providing a better understanding for clinicians and families. Therefore it is crucial to discuss these issues with the family using caution in treatment unless specifically trained to do so. A nutritional consultation is warranted when concerns arise in this area.

Consideration of supplemental oxygen

Oxygenation of the blood is responsible for the delivery of oxygen to muscle tissue. It is generally accepted that respiratory support increases incrementally to permit faster or stronger movement patterns in a typical individual. Therapists often note that children with CP resist moving into new ranges of movement and that respiratory adaptation does not occur automatically. Supporting the child in the novel posture until a respiratory adaptation is noted results in acceptance of the new experience. Oxygen needs increase in children during growth spurts or when mastering more vertical postural alignments. Increased oxygen is also required for sustained activity such as continuous walking. Incorporating breathing exercises into therapy interventions can help support the child’s movement strategies. Children with developmental disabilities have few opportunities to exercise at an intensity level high enough to raise their heart rate. Monitoring oxygen saturation, heart rate, and blood pressure are easily done in a therapy session and can be tracked over time to document progress and to help guide the therapy intervention.

In 2016, Garcia and colleagues performed a careful study of 215 children with CP who were identified by chart review with signs and symptoms of obstructive sleep apnea (OSA) and surveyed with the Pediatric Sleep Questionnaire, for inclusion in the study. They found that children with CP were at a higher risk of OSA with increased severity of their condition, and the risk increased in the presence of seizure activity.

Decreased oxygen levels have been associated with impaired cognitive and physical performance in the literature. In the presence of inadequate peripheral oxygen saturation, low levels of oxygen can be administered during the night. This practice has been used with selected low tone and athetoid children for improved energy during the day during growth changes, but formal study is needed on a larger group of children with CP. Better oxygenation of the tissues can also result in increased nutritional intake and consequently improved energy levels. The therapist should work closely with the primary care physician or pulmonary specialist if there are concerns in this area. It may be suggested that a child have a sleep study to determine oxygen saturation at night while sleeping.

Role of the therapist in direct intervention

The primary role of the therapist is in direct treatment or physical handling of the child in situations that offer opportunities for new motor learning. This should precede and accompany the making of recommendations to parents, teachers, and others handling the child. Positioning for home, general handling, and exercise recommendations should always be tried first by the therapist during a treatment session to ensure that the chosen techniques are successful. As noted for the initial assessment, many interventions will cause a reaction unique to the particular youngster. ^, It is the role of the therapist to analyze the nature of the response that is accompanied by adaptation inadequacies, to analyze the movement problems, and to choose the most effective intervention ( Fig. 10.14 ). It will then be possible for other persons to manage play activities and to supervise independent functioning that reinforce treatment goals.

The two sides of the body ( A and B ) often respond very differently to the same task, and therapy must be adapted accordingly.

The therapist working with these children becomes an important and trusted resource to the family. At times the therapist who has had the more consistent contact with the child becomes the facilitator of better communication between the parents and medical or health care professionals. The child who starts early and continues with the same therapist may make this person a confidant and share concerns that are difficult or uncomfortable for the child to explain to parents or others. It is a challenge for the therapist who follows the same child for an extended time to come up with appropriate goals and new activities to continue positive change. The therapist should always consider quality of life for each individual in their care. Part of direct intervention is to recognize when the amount of therapy can be reduced and replaced with recreational activities with peers or community involvement. In 2014, Gannotti and colleagues provided a framework for dosing in pediatric rehabilitation for children with CP. This model is strongly based on the ICF model of the World Health Organization and serves as a path to evaluate multiple parameters affecting dosing interventions. This path-based model can serve as a guide for the therapist in decision making related to dosing. There remain many unanswered questions about dosing in children with CP and brain damage. Two papers published in 2014, including Giannotti’s study, suggest that a “systematic and in-depth analysis of dosing questions” combined with an “interdisciplinary approach” is critical in advancing research in this area. ^,

Case management and direct intervention

Simple documentation of observed changes in a child over a series of regular clinic visits is still too common for many children with CP. Regular appointments, with periodic assignment of a new piece of equipment, do not constitute active treatment. Physical intervention in the form of direct handling of the child is considered a conservative treatment by most physicians. Therapists need to demonstrate their unique preparation and describe their interventions in ordinary language so that families as well as other health care professionals understand the importance of specific treatment versus general programs of early stimulation, which are designed for neurologically intact infants. Demonstrating a clear understanding of the foundational theories that your treatments are based on is essential for justification of your interventions.

The prognosis for change in CP is too often based on records of case management rather than on the effect of direct and dynamic treatment by a well-prepared therapist. Bobath, back in 1965, accurately documented the developmental sequence expected in the presence of spasticity or athetosis. Her book consolidates some observations of older patients that help professionals understand the uninterrupted effects of the CP condition. In any institution, one can observe the tightly adducted and internally rotated legs, the shoulder retraction with flexion of the arms, and the chronic shortening of the neck so commonly seen as the long-term effects of CP. The long-term influence of fluctuating muscle tone results in compensatory stiffness or limited movement patterns to create a semblance of the missing postural stability, while a limited number of movement patterns with limited degrees of freedom are used to function ( Fig. 10.15 ).

Attempted movement activates atypical patterns and restrictions; restrictions are revealed with limited degrees of freedom available for function.

Within the clinical community there is increasing evidence that soft tissue restrictions further limit spontaneous movement in children with CP. The fact that these restrictions are often found in infants suggests that they originate early rather than as a gradual result of limited ranges in movement. Because of the tendency of soft tissue to change in response to any physical trauma or strong biochemical change, some of these characteristics might be influenced by the position in utero or originating with traumatic birth experiences, and they could be exacerbated by daily use of limited patterns of movement. Tissue restrictions can also occur with immobilization or general infectious processes. Soft tissue responds to the application of gentle sustained pressure simply from the weight and heat of one’s hand with careful consideration by the therapist of techniques used to manipulate the tissue and joints. A therapist must be prepared to defend his or her approach with a solid foundation, theory, and objective outcomes. Objective documentation is important when dealing with any population but is essential for demonstrating therapeutic change.

Applying specific soft tissue treatment techniques to improve mobility and to decrease tonus for any person with a neuromotor disorder creates the need for immediate follow-up with practice of new functional skills using this improved available range of motion. The stretching of muscles in CP has been shown to change muscle tone and to improve range of motion, which can open a window of opportunity to practice functional skills. Caution should be exercised to avoid creating excessive tissue mobility in a given area of the body, which can destroy the delicate patterns of coordination that permit synergic function in the person with CP.

Functional activation of the body after each specific mobilization or stretching technique is strongly recommended to integrate the tissue change. Well documented in the literature on current motor control and motor learning is the need to practice, practice, practice. Practice time is related to skill performance; the amount and type of practice are determined by the stage of learning that an individual is in and the type of task to be learned (see Chapter 3 on motor control and learning). Interestingly, most of what we know about motor control and motor learning is based on individuals who are “typical,” and it is yet to be determined whether the same principles that are considered important in healthy individuals apply to people with disability. However, it makes sense that practice would influence the use of any new or relearned skill.

An occupational therapist, Josephine Moore, emphasized some important points for therapists regarding the concept of increasing functional demands on the central system and the importance of the neck structures in developmental movement sequences. Children with spasticity often have a lack of developmental elongation of the neck, whereas children with athetoid or dystonic movement lack neck stability and consistent postural activation. Tone changes often originate with changes in the delicate postural interrelationship between head/neck and body or with ambient visual processing. An alert therapist will observe these changes and be able to relate them to the initiation of movement and adapt the therapy session to facilitate or inhibit their influence.

Restak, in his book The New Brain, confirms the continual reorganization of the brain in response to new input. Several animal and human studies on neuroplasticity have confirmed that the brain reorganizes after an injury and that this reorganization is shaped by rehabilitation and motor skill learning.

Our understanding of how the brain works and the mechanisms for neuroplasticity are ever changing. Hartwigsen suggested that having a better understanding of compensatory mechanisms in the brain would increase our understanding of how the brain reorganizes. In 2018, Gaberova and colleagues undertook a systematic review of the literature on task-related functional MRI in children with hemiplegia. The review included sensory, motor, and speech studies. They reported that the sensory system was the most rigid to reorganize and the speech system the most flexible. This appraisal of the literature concluded that reorganization is variable, and dependent on the severity and timing of injury, and the development of each of these individual systems.

In the child with CP, the therapist looks for subtle changes in the child’s response to determine newly integrated sensorimotor learning. For example, excessive emphasis on extensor responses in the prone posture for the older child can jeopardize the quality of neck elongation in sitting, so it is essential to work on the components necessary for control of the new posture desired and in reaching for a balance of function versus quality of movement when possible.

Therapy intervention is far from innocuous when it is responsibly applied. A truly eclectic treatment approach comes with clinical experience and personal consideration of observations of the functional problems presented by the complex issue of CP at different ages. Priorities in intervention strategies have a practical aspect, and new developments in our knowledge lead us forward in clinical applications. Continued research and understanding of the intricacies of typical development offer many new clues for new effective interventions. With high-quality treatment intervention, the need for direct therapy service as a crucial aspect of case management for these children is confirmed. Clinical findings in individual case studies need to become part of the professional literature to strengthen the efficacy of intervention in this population.

Special needs of infants

The direct treatment of infants deserves special mention because there are significant differences in intervention strategies for the infant and the older child. Aside from the delicate situation of the new parents, the infant is less likely to have a diagnosis and often presents a mixture of typical and atypical characteristics. It is essential that the clinician have a strong foundation in the nuances of typical developmental movement and early postural control. ^,

Direct intervention can be offered as a means of enhancing development and overcoming the effects of a difficult or preterm birth. However, it will be important to pursue a diagnosis for the infant who reaches 8 or 9 months of age and continues to need therapy because most third-party payers often require a diagnosis beyond that of developmental delay or prematurity.

Infants with early restrictions in motor control should be followed until they are walking independently, even if they no longer need weekly regular therapy. Infant responses can change rapidly as the therapist organizes the components that contribute to movement control. When present, soft tissue restrictions should be treated initially to have more success with facilitated movement responses. Careful observation is essential because all but the severely involved infant will change considerably between visits. The therapist should invest some time in training the parents to become skilled observers while appreciating the small gains made by their infant and reenforcing the positive changes with the family while remaining realistic and hopeful for the future of their child. It is better to not predict the future motor competency of a child in the early infant stages because the infant will change dramatically over the first year of life. Predictions often limit the therapist in their treatment approach when perceived expectations or limitations are placed on the patient. If one predicts that a child will not stand and walk, the therapist has little impetus to work on those skills. Physiotherapist Mary Quinton, who developed a treatment regime for infants in 2002, wrote specific intervention strategies for babies ( Fig. 10.16 ). In addition, infant massage can be an important adjunct to improve the bonding of mother and child and to improve physiological measures such as abdominal gas, restlessness, and general stiffness. ^, Referral to other health care professionals is essential in the presence of possible allergies, new neurological signs, visual or auditory alterations, and persistent reflux or nutritional issues. There is always the possibility of seizures when some brain dysfunction is present, and neurological evaluation should be recommended if this is a concern.

Mary Quinton, British physiotherapist, is widely recognized as the originator of effective infant intervention.