Physical Therapy for Pediatric Patients with Cerebral Palsy

Effective Forms of Treatment for Pediatric Patients with Cerebral Palsy

Katherine Torres
Northeastern University
Advanced Writing for the Health Professions

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Abstract
Many forms of therapeutic interventions exist to work with children with cerebral therapy
but none stands out above the rest as being more effective. The topic of cerebral palsy is first
introduced by describing what causes the impairment as well as what different forms of CP are
and how those different forms are categorized. The paper then delves into some of the most
commonly used forms of intervention within the field of physical therapy, including what makes
them effective and what about them does not work. The forms of intervention discussed include
stretching programs, treadmill training, static weight bearing, and postural control through the
use of adaptive seating.

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Introduction
A disorder that affects the physical, social, emotional, and financial well-being of both
patients and their families, cerebral palsy is the leading cause of physical disability for children
in the United States (Gannoltti, Law, et al., 2016). In the United States alone, cerebral palsy has
an incidence rate of about 2 to 2.5 cases for every 1,000 births (Kingsnorth, Orava, et al., 2015).
Commonly referred to as CP, cerebral palsy is described as a group of permanent disorders
affecting the development of movement and posture, causing pain, physical impairment, and
limitations when completing certain tasks (Jeffries, Fiss, et al., 2016). In the past, it was believed
that CP was a result of complications during child birth but it has been found that although this is
the case for an estimated 10% of cases (About Cerebral Palsy- Definition, 2016), other causes
include non-progressive injury or disturbances throughout the development of the fetal or infant
brain, and brain injury later on in life (Franki, Cat, et al., 2014). Although it is non- life
threatening and non-progressive, cerebral palsy is a complicated incurable disorder with many
potential treatment options causing a large impact on the quality of life of any child with this
impairment.
Introduction to Physical Therapy as a form of Intervention
Physical therapy is one of the most commonly used forms of intervention for cerebral
palsy in pediatric patients, often focusing on first setting goals in order to improve motivation
and the overall outcome of therapy for the patient (Franki, Cat, et al., 2014). Because cerebral
palsy is described as a group of disorders, individuals can present with a wide range of motor
ability levels due to the wide variations in severities and classifications. This variety in
classifications and associated conditions is what has led to various forms of treatment, including
stretching programs, treadmill training, weight-bearing, and use of postural control to work

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towards bettering the lives of these children. Despite having a large variety of treatment options,
a major issue within the field of pediatric cerebral palsy is the question of which treatment option
is the most effective due to a limited quantity of available high quality research. Therapists have
been working to find the best form of treatment for pediatric patients for years but they have
consistently found that more research must be done because it is difficult to decide that one
option is better than the rest when most of the research yields similar or incomplete results.
Causes leading to Cerebral Palsy
Cerebral palsy affects movement and posture development extensively due to the nonprogressive disturbances occurring in the developing fetal or infant brain (Chen, Wang, et al.
2013). The four major forms of brain damage that can result in cerebral palsy occur either before,
during, or after birth and are prenatal disturbance of brain cell migration, prenatal poor
myelination of developing nerve cell fibers, perinatal brain cell death, and postnatal nonfunctional or inappropriate connections between brain cells (Cause, 2016). Prenatal
disturbances during the migration of brain cells refers to genetic or environmental factors that
affects the way cells move to their appropriate location during brain development. On the other
hand, poor myelination, or insulation, of prenatal developing nerve cell fibers negatively affects
brain function due to the fact that myelination is meant to help protect nerve cells (Cause, 2016).
The myelin sheath formed around these nerve cells helps to speed up the transmission of
synaptic processes in the brain but not having adequate myelination can disrupt that
transmission, causing developmental problems in the process. Cerebral dysgenesis, although not
one of the most common causes of cerebral palsy, is one form of CP that occurs almost
immediately after conception and causes brain malformation. Cerebral dysgenesis occurs due to
genetic mutations, the potentially damaging inflammatory response of fever during pregnancy, or

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the same inflammatory response caused by the production of cytokines used to fight off some
infections (Cerebral, 2016). Periventricular leukomalacia is another form of brain damage that
most often occurs in the prenatal stages of birth (Cause, 2016). PVL causes damage to white
matter in the brain which can result in spasticity and intellectual impairment and it has been
found that approximately 60 to 100% of infants with periventricular leukomalacia are diagnosed
with cerebral palsy (Periventricular, 2016).
Perinatal brain cell death refers to events that occur while giving birth that could rupture
blood vessels or deprive the brain of oxygen. On the other hand, post natal non-functional
connections between brain cells refers to physical trauma, infections, or asphyxia that could
occur after birth and cause damage on the already developed connections of the brain (Cause,
2016). Epidural hematoma, subdural hematoma, subarachnoid hematoma, and intracerebral
hemorrhage, are all forms of intraventricular hemorrhage, or IVH, which is a type of postnatal
brain damage, often considered a significant risk factor for cerebral palsy (Intraventricular
Hemorrhage, 2015). Brain hemorrhages can be either arterial, which results in a loss of oxygen
to the tissues as arteries transport oxygenated blood to the heart, or venous, which damages veins
returning blood back to the heart. The severity of these hemorrhages are based on the amount of
bleeding that occurs in the ventricles. Grades I and II are a small amount of bleeding that can be
contained in the ventricles and do not usually cause long term problems while Grades III and IV
are more extreme cases of bleeding that lead to swelling or impediment in the brain, causing
fluid build-up in the brain, increasing the pressure in the brain, and potentially causing blood
vessels in the brain to rupture (Intraventricular, 2016). Similarly, hypoxic ischemic
encephalopathy, also known as intrapartum asphyxia, has been found to be another potential
cause of cerebral palsy.

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Classifications and Severities of Cerebral Palsy

Due to the variation in causes leading to cerebral palsy, there is a wide variety of
classifications and severities for CP. A child with cerebral palsy can experience a large number of
problems, often categorized into primary and secondary impairments based on when the
problems arise in comparison to when the child was diagnosed (Jeffries, Fiss, et al., 2016).
Primary impairments are problems that were evident at the time of diagnosis while secondary
impairments often occur over time, can be traced back to the primary impairments, and may even
be prevented depending on the intervention method (Jeffries, Fiss, et al., 2016). Some common
primary impairments are postural stability, motor coordination (Jeffries, Fiss, et al., 2016),
muscle tone, and muscle weakness (Franki, Cat, et al., 2014). Secondary impairments include
decreased range of motion, force production, and endurance (Jeffries, Fiss, et al., 2016). A
common form of classification is the topographical distribution which describes CP based on the
affected body parts, where paresis means weakened and plegia or plegic means paralyzed
(Types, 2016). Another commonly used form of classification is based on motor function, the
ability to control the body in a desired matter (Types, 2016). Spastic cerebral palsy refers to
increased muscle tone and non-spastic cerebral palsy is often associated with less or fluctuating
muscle tone. These terms can be used in conjunction with hypertonia, which results in stiff limbs
and is associated with spastic CP, and hypotonia, which results in floppy limbs and is associated
with non-spastic CP (Types, 2016).
Although both of these forms of classification are used often, the most common system
referred to by other research articles was the Gross Motor Function Classification System
Expanded and Revised, GMFCS- E&R. The GMFCS observes the movement that can be done
without the help of others and distinguishes between each of its five levels based on functional

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limitations (Palisano, Rosenbaum, et al., 2007). The GMFCS originally focused on children until
the age of twelve but in 2007 it was expanded to include ages twelve to eighteen (Palisano,
Rosenbaum, et al., 2007). Based on this classification system, a child becomes more physically
limited and more reliant on assistive equipment with every increasing level (Kingsnorth, Orava,
et al., 2015). Someone with Level I walks without limitations; Level II describes someone who
walks with limitations, including difficulty walking long distances and balancing (Types, 2016).
Individuals at level III [can] ambulate with an assistive [handheld] device such as crutches or a
walker (Verschuren, Peterson, et al., 2014); A child at level IV can usually move with the help
of a manual wheelchair or powered mobility (Types, 2016), although they do sometimes have the
ability to walk short distances with a walker (Verschuren, Peterson, et al., 2014); Someone with
Level IV has severe head and trunk control limitations and need the aid of assistive
technology, such as a wheelchair, to be mobilized (Types, 2016).
Evaluating Different forms of Cerebral Palsy
The GMFCS makes evaluating different forms of therapy easier because it aids in
understanding what the patients motor functions and physical abilities are on a basic level. There
is a wide variety of forms of physical therapy that are used as interventions for pediatric patients
with cerebral palsy. The first step to finding the best form of physical therapy for a pediatric
patient is defining their main problems and setting specific, attainable goals to work towards
their improvement. This step alone is often difficult to accomplish due to the fact that most
children have problems at all levels of the ICF and as a therapist, one [has] to prioritize and
select possible and realistic targets in treatment (Franki, Cat, et al., 2014). For children with
bilateral spastic CP, it has been found that main goals involve focusing on targeting strength,
range of motion, and GMFM-D (Franki, Cat, et al., 2014). Similar to the Gross Motor Function

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Classification System, the Gross Motor Function Measurement (GMFM-88) measures activity
levels in CP patients. That same study looking at children with bilateral spastic CP showed that
lying down, rolling, sitting, crawling, kneeling, standing, walking, running, and jumping are the
main non-patient identified problems based on the GMGM-88 (Franki, Cat, et al., 2014).
Stretching as form of Therapy
Stretching, which is one of the forms of physical therapy most often used for children
with cerebral palsy, has proved to be effective although the understanding of that effectiveness is
still limited. Cerebral palsy contributes to loss of joint range of motion and decreased
movement where stretching is believed to increase muscle extensibility, preserve joint range of
motion for functional movement, and prevent or delay the need for orthopedic surgical
interventions (Wiart, Darrah, et al., 2008). There are multiple forms of stretching that therapists
can use on a child including passive stretching where the therapist does the stretching for the
child, active stretching where the child maintains the stretch, and prolonged stretching where one
position is held for a sustained period of time (Wiart, Darrah, et al., 2008). Studies have shown
that passive stretching can have a positive effect on range of motion and spasticity, especially if it
is sustained stretching occurring for a minimum of thirty seconds (Franki, Desloovere, et al.,
2012). The issue when it comes to stretching as a form of therapy, is that the lack of research
evidence often leads to stretching techniques differing in terms of how long the stretch should be
held and how many repetitions should be completed for it to be effective. Another concern is that
stretching can cause pain and make children uncomfortable which often makes parents hesitant
about the use of this intervention. It has been encouraged that therapists consider using other
functional activities that help the children stretch and increase their flexibility without forcing the
child to be a passive recipient of therapeutic stretching routines (Wiart, Darrah, et al., 2008).

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Treadmill Training as a form of Therapy

A relatively new form of therapy that has recently been used on children with cerebral
palsy is treadmill training. Children with cerebral palsy have a walking pattern characterized by
excessive muscle co-contraction, altered joint kinematics, and a lack of postural reactions
(Mattern-Baxter, 2009). Partial body weight supported treadmill training allows these children to
work on their gait which has been proven to increase their motor learning ability. One study
showed that the children that participated in the study improved their Gross Motor Function
Measure scores from 8% to 23%, with some of the biggest improvements relating to their
walking, running, and jumping abilities. Another study, conducted on 8 elementary school aged
children with minimal to moderate disability, compared children who were following a
traditional method of physical therapy to a group of children doing treadmill training and found
that their gross motor function measurements improved greatly for dimensions D and E. A
different 3 month long study conducted on 10 children ages 6 to 18 found that using treadmill
training 3 times a week improved gait patterns, with the biggest improvement occurring with the
group of children who were ambulatory with assistance (Mattern-Baxter, 2009). Although
evidence does exist proving that pediatric patients with cerebral palsy benefit from high intensity
body weight supported treadmill training, that improvement was not statistically significant,
therefore, similar to stretching programs, more research must be done. The major issue with the
studies done is that they all differ in terms of how long they last, how often the children come
into therapy, the speed at which the treadmill is being used, and how much weight support is
actually being given by the machine itself (Franki, Desloovere, et al., 2012). Once a treatment
protocol is set up and these optimal training conditions are found, there will be stronger evidence
for how useful treadmill training can be for pediatric cerebral palsy patients.

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Static Weight Bearing as a Form of Therapy

Static weight bearing is another commonly used form of therapy for pediatric patients
with cerebral palsy. The theory behind weight bearing as a form of therapy is the idea that it can
increase bone mineral density [significantly in the lumbar spine or femur] and reduce risk of
fractures, reduce or prevent hip dysplasia, improve passive joint ranges of movement, reduce
spasticity [and] improve self-esteem and communication in a more upright position (Pin,
2007). It is believed that static weight bearing can also prevent tightness, restore the length of
muscles by stretching them for longer periods of time, reduce spasticity, improve bone growth,
and stimulate antigravity muscle strength and endurance in children with limited mobility (Pin,
2007). The safest form of weight bearing is completed with the use of walking frames to help
keep the children standing up and pushing weight through their lower extremities (Franki,
Desloovere, et al., 2012). Similar to the evidence found supporting stretching programs and
treadmill training, research supporting static weight bearing as a useful therapeutic intervention
for children with cerebral palsy also brings attention to the fact that more research still needs to
be done. The major issues in terms of static weight bearing is that there is currently not enough
evidence to confidently say that it is an effective form of therapy for cerebral palsy in pediatric
patients. Some of the evidence that does exist comes from smaller studies. Although there is
research proving that it has definitely been effective in increasing bone density and reducing
spasticity, more research must be done.
Postural Control as a form of Therapy
Postural control, often accomplished through the use of adaptive seating in patients with
higher levels of cerebral palsy, has also proven to be an effective intervention, not just in terms of
bettering sitting and standing but also increasing the ability to sequence movements

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appropriately (Chung, Evans, et al., 2008). Adaptive seating refers to the modifications done on
seating devices meant to improve sitting posture and/or postural control in mobility impaired
individuals (Chung, Evans, et al., 2008). In terms of modifying seating devices, the seating can
be changed to include saddle positions, change the angles of the seat or back rest inclination, and
seat inserts or external supports can be added. Saddle position, which consists of a seat the helps
maintain hip abduction and outward rotation, has been found to increase mobility, encourage
midline posture, and equal weight bearing through the lower extremities (Chung, Evans, et al.,
2008). In terms of angling the seat positions, some studies recommend posteriorly tipped seats
for children with CP because they allow for greater hip flexion, decrease posterior pelvic
rotation, and the overuse of hip and trunk extensors while others recommend anteriorly tilted
seats to improve trunk extensor muscle activity and to improve trunk extension (Chung,
Evans, et al., 2008). Seat inserts have been found to improve pelvic alignment and increase
postural stability, both of which are two important improvements for children with higher level
cerebral palsy (Chung, Evans, et al., 2008). Although all of these forms of adaptive seating were
found to improve postural control, more research must be done because no one method proved to
be more effective than another.
Conclusion
Cerebral palsy is the diagnosis most frequently encountered by pediatric physical
therapists (Mattern-Baxter, 2009). The severity with which it affects children is the reason why
a variety of forms of interventions exist within the field of physical therapy. Although cerebral
palsy has a high incidence rate, it has proved difficult to find one form of treatment that is more
effective than another. Some of the most frequently used forms of therapy include stretching
programs, treadmill training, weight bearing, and the use of postural control through adaptive

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seating. All of these forms of treatment have extensive research supporting their effectiveness but
they also have the similar problem that they all encourage more research being done on the
subject. Issues found with the research that already exists includes a small number of participants
in a study, not enough studies done for one specific form of treatment, or comparisons done with
studies that do not follow the same protocol, making it difficult to understand what about the
study format was what made the treatment option effective. Overall, there are a good number of
physical therapy options available to help pediatric patients work with their cerebral palsy but it
is evident that more work still needs to be done in the field in order to make these findings more
clear and concise.

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