Early Intervention in Cerebral Palsy

Introduction

The strength of synaptic connections in the brain are dependent on the amount they are used. Neuronal synaptic transmissions that are used often will become faster and more efficient, while the synaptic connections that are not used will be pruned. Thus, exposure to different experiences and movements will influence the make-up and strength of neural signals in the central nervous system. This is referred to experience-dependent neural plasticity.[1]
Cerebral palsy involves non-progressive damage to the central nervous system of a fetus or infant that affects movement and posture causing activity limitation [2]. However, the secondary changes associated with muscle mis- and dis-use are progressive.

Early physiotherapy interventions have the potential to help a child perform movements and strengthen synaptic connections that would otherwise not be possible due to muscle weakness and poor motor control. In addition, early physiotherapy treatments can help to reduce secondary soft tissue changes such as muscle stiffness and joint contractures. Without such interventions, the child with cerebral palsy may not get the opportunity to practice efficient and effective movements in order to reinforce the neural connections that control these movements. As a result, the child is likely to practice limited, ineffective, energy-consuming movements that may hinder his/or ability to move and function as they get older and larger. Thus, early physiotherapy intervention may help prevent a child with cerebral palsy from reinforcing ineffective movement patterns through repetition.

Goals of Early Physiotherapy Intervention

  • Improve cardiovascular fitness
  • Improve muscle activation and strength
  • Improve motor control
  • Improve effectiveness and variability of movement
  • Preserve muscle length and joint flexibility


Early Physiotherapy Interventions

Interventions should consist of repetitive movements that involve meaningful use of the upper and lower extremities. Although the movements should be repeated to strengthen neural connections, they should be carried out in varied conditions and contexts. Variable practice of repetitive movements can be accomplished by performing the activities in different environments (ie sitting on soft vs hard surfaces) and postures/positions (ie performing upper extremity tasks in standing vs sitting vs kneeling). This type of task-oriented training may lead to experience-dependent plastic changes in the child’s brain, allowing them to reinforce and strengthen appropriate neural connections that will help them to perform meaningful activities of daily living. Exercises should involve active strengthening of hip extensors and external rotators, as well as knee and ankle extensor muscles, and lengthening of hip and ankle flexors. Passive treatments such as assisted stretching should not be a major focus of treatment [3].


Examples of treatments in early infancy include:

  • Weight-bearing through feet such as assisted standing, sit to stand, squatting, step-ups
  • Weight-bearing through hands equally, such as putting hands on floor, wall or mirror; push-ups
  • Reaching, pulling, pushing, grasping, picking up and manipulation of objects of different sizes and textures with hands
  • Actions that lengthen muscles that are prone to contracture: sit-to-stand or crouch-to-stand for hip flexors, and heel raise and lowers for plantar flexors
  • Balancing exercises such as balancing in sitting with hips flexed and balancing the body of the feet in standing
  • Cardiovascular training using treadmill, bike or water
  • Appropriate use of constraint-induced movement therapy to encourage use of paretic side

Role of Therapist

In order to maximize learning, the movements performed by the child should be self-initiating, and allow problem-solving in order to achieve a goal. Thus, it is imperative that therapists avoid being too hands-on by excessively holding or supporting the child while performing tasks. Rather, the therapist should use finger-tip control, or use equipment such as a strap, harness, wheeled apparatus or shoe holders. In addition, the therapist needs to enable the child to practice the desired movement/skill in a way that is challenging but feasible given his/her current physical and cognitive level and abilities. The child must be able to experience errors and successes, and be motivated to continue to try to acquire the desired skill. The therapist must also allow the child to perform the task within varied environments so that the skill can be transferred to different contexts [3].


Conclusion

Cerebral Palsy involves an insult to a fetal or infant brain that results in disordered and limited movement and posture. Although the brain damage is non-progressive, the secondary changes that occur to the infant’s musculoskeletal and nervous systems are progressive, and can be influenced by early experiences. Early physiotherapy interventions can provide the infant with the opportunity to practice functional movements that would otherwise not be possible due to muscle weakness and poor motor control. By practicing meaningful and effective skills in varied environments, the child will have the opportunity to acquire skills that will allow them to be more independent with ADLs and increase their level of participation in society.

References

  1. Nelson CA. Handbook of early childhood intervention. 2nd ed. Shonkoff JP, Meisels SJ, editors. Cambridge: Cambridge University Press.; 2000. The neurobiological bases of early intervention; p. 204–27
  2. Rosenbaum P, Paneth N, Leviton A, et al. A report: The definition and classification of cerebral palsy april 2006. Developmental Medicine; Child Neurology. 2007;49:8–14. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2007.tb12610.x/epdf
  3. 3.0 3.1 Shepherd RD. Cerebral Palsy in Infancy. 1st ed. Churchill Livingstone.; 2013. pp4-18, 29-45, 71-79