Management of cerebral palsy
Over time, the approach to cerebral palsy management has shifted away from narrow attempts to fix individual physical problems such as spasticity in a particular limb to making such treatments part of a larger goal of maximizing the person's independence and community engagement. Much of childhood therapy is aimed at improving gait and walking. Approximately 60% of people with CP are able to walk independently or with aids at adulthood. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level, or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.
Because cerebral palsy has "varying severity and complexity" across the lifespan, it can be considered a collection of conditions for management purposes. A multidisciplinary approach for cerebral palsy management is recommended, focusing on "maximising individual function, choice and independence" in line with the International Classification of Functioning, Disability and Health's goals. The team may include a paediatrician, a health visitor, a social worker, a physiotherapist, an orthotist, a speech and language therapist, an occupational therapist, a teacher specialising in helping children with visual impairment, an educational psychologist, an orthopaedic surgeon, a neurologist and a neurosurgeon.
Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents. Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; water therapy; drugs to control seizures, alleviate pain, or relax muscle spasms ; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesisers. A Cochrane review published in 2004 found a trend toward benefit of speech and language therapy for children with cerebral palsy, but noted the need for high quality research. A 2013 systematic review found that many of the therapies used to treat CP have no good evidence base; the treatments with the best evidence are medications, therapy and surgery.
Lifestyle
is recommended for people with cerebral palsy, particularly in terms of cardiorespiratory endurance, muscle strengthening and reduction of sedentary behaviour. Participating in physical activity can supplement or replace some forms of therapy. It has been argued that people with cerebral palsy need to maintain a higher level of fitness than the general population to offset loss of functionality as they age. Access to exercise can often depend on the caregivers' perception of whether it will benefit the person with CP, or barriers in the community. Accommodations in the environment and context has been identified as important when sustaining exercise participation in adults with cerebral palsy. There has been increasing interest in maintaining muscle strength through the lifespan of a person with CP. Aerobic capacity is not routinely assessed in people with cerebral palsy in a rehabilitation context, but Wingate tests have been advocated for use. Behavioural change methods have been used to promote physical activity among young people with cerebral palsy, but there is no significant evidence for these working. It is difficult to sustain behavioural change in terms of increasing physical activity of children with CP. Even though exercise is commonly recommended, there is only a small amount of evidence saying that aerobic exercise is good for gross motor function in children. Exercise can increase wellness in those with cerebral palsy. With regards to sports, the amount of exercise advised should be unique to the demands of the sport in question, the effect of the individual's condition on performance, and the potential to cause worsening of the condition. It is recommended, to encourage integrating moderate to vigorous exercise, including the use of a motor-assisted elliptical trainer. This is thought to improve fitness and the functioning.Function gait training in children and young adults with cerebral palsy improves their ability to walk. There is evidence that antigravity treadmill training may improve the gait and balance of those children with diplegic cerebral palsy, it may also reduce risk of falls in these children.
Hippo therapy, or therapeutic horseback riding, is a physical therapy treatment strategy that uses equine movement. Evidence suggests that those with CP can benefit from symmetry of trunk movement. It is common for horses to sway, so those on them constantly have to adjust their posture. The symmetric, rhythmic, and consistent input that horseback riding provides helps with postural improvement. During horseback riding, a locomotor impulse is sent up the back of the horse. This impulse is then interpreted by the riders body, and it allows for regulation of mediolateral and anteroposterior postural sway, adaptation to new environments, anticipatory and feedback postural control and better use of multi sensory posture and movement related inputs.
A normal vaccination schedule should be adhered to, as preventable diseases may take away energy that a person with CP would normally use in day-to-day life.
Therapy
programs are designed to encourage the patient to build a strength base for improved gait and volitional movement, together with stretching programs to limit contractures. Physiotherapists can teach parents how to position and handle their child for activities of daily living. The need for lifelong physiotherapy for muscle tone, bone structure and preventing joint dislocation has been debated in terms of the costs and benefits of such therapy. Children may find long-term physical therapy boring. Physiotherapy exercises are designed to improve balance, postural control, gait, and assist with mobility and transferring the person with CP, for example from a wheelchair to a bed.Speech therapy helps control the muscles of the mouth and jaw, and helps improve communication. Just as CP can affect the way a person moves their arms and legs, it can also affect the way they move their mouth, face and head. This can make it hard for the person to breathe; talk clearly; and bite, chew and swallow food. Speech therapy often starts before a child begins school and continues throughout the school years.
Biofeedback is a therapy in which people learn how to control their affected muscles. Biofeedback therapy has been found to significantly improve gait in children with cerebral palsy. Mirror therapy has been used to improve hand function and was found to be "generally effective in enhancing muscle strength, motor speed, muscle activity, and the accuracy of both hands". Second-generation mirror therapy, which includes the use of robotics or virtual reality, has been developed since the 2000s, however the evidence supporting this is of low quality.
Massage therapy is designed to help relax tense muscles, strengthen muscles, and keep joints flexible.
Gait analysis is often used to describe gait abnormalities in children. Gait training has been shown to improve walking speed in children and young adults with cerebral palsy.
Occupational therapy helps adults and children maximise their function, adapt to their limitations and live as independently as possible. A family-centred philosophy is used with children who have CP. Occupational therapists work closely with families in order to address their concerns and priorities for their child. Family-centered care is a paradigm that is often used with families with a child with CP. A review of how parents facilitate their child's participation found that parents typically "enable and support performance of meaningful activities" and "enable, change and use the environment", but that there is little written on parents' needs.
CP commonly causes hemiplegia. Those with hemiplegia have limited use of the limbs on one side of the body, and have normal use of the limbs on the other side. People with hemiplegia often adapt by ignoring the limited limbs, and performing nearly all activities with the unaffected limbs, which can lead to increased problems with muscle tone, motor control and range of motion. An emerging technique called constraint-induced movement therapy is designed to address this. In CIMT, the unaffected limbs are constrained, forcing the individual to learn to use the affected limbs. CIMT promotes increased motor function due to structural plasticity in the brain. there was limited, preliminary evidence that CIMT is effective, but more study is needed before it can be recommended with confidence. CIMT, modified CIMT, and forced use are three movement therapies that have been examined. CIMT is defined as "restraint of the unaffected upper limb..., with more than three hours of therapy per day... and is provided for at least two consecutive weeks". Children with hemiplegic cerebral palsy often have sensory impairments as well as motor deficits. CIMT has been shown to be an effective OT intervention to improve proprioception and sensory processing. CIMT has also been found to improve postural symmetry during functional tasks in individuals with CP.
Modified CIMT is defined as "restraint of the unaffected upper limb and less than three hours per day of therapy provided to the affected limb". Forced use is when "restraint of the unaffected upper limb is applied but no additional treatment of the affected upper limb is provided". A review concluded that there is a positive trend favoring all three aforementioned therapies.
A comparison of bimanual training and CIMT found that there was no significant difference between the two in terms of effects. However, bimanual training may be more able to be integrated into a child's daily life, because the goals in bimanual training are more functional. CIMT has some advantages, such as therapists being able to solely focus on the affected arm, and the child having no choice but to use the affected arm in their activities of daily life as their unaffected arm is constrained. In bimanual training, the child may continue to use the unaffected arm to compensate if their therapist or parent does not remind them to use both hands.
However, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Nonspeaking people with CP are often successful availing themselves of augmentative and alternative communication.
Therapeutic tests for assessing balance do not appear to have good evidence for their reliability and responsiveness. The tests with the strongest evidence are the Trunk Control Measurement Scale and the Level of Sitting Scale, Timed Up and Go test, and the Segmental Assessment of Trunk Control.
Certain countries practice intensive physical therapy, but obtaining reliable data on its medium and long-term effectiveness is challenging.