What is the Best Evidence for Physiotherapy in Children with Cerebral

Palsy?

Diane L. Damiano, PhD PTNational Institutes of Health

Bethesda, MD USA

Cerebral palsy – what we know:• Most common physical disability in childhood• No cure but learning more about causes, & how

to prevent or lessen severity of some types of CP• Families have greatest impact on their child’s

development and well-being and our roles are to help and support them in this

• In many parts of the world, children w/ disabilities:• Are hidden or shunned, no access to education or basic

health care• Have little voice in setting goals for their own lives• Experience more frequent neglect/abuse• Have little or no adaptive equipment or access• Are passive recipients of treatments done to them• Are removed from home and community for care• Receive care that is not evidence-based

Children with CP are Children First!

• Family Support and Education• Facilitate goal setting with the family• Resource for services & opportunities for their child • Recommend strategies for positioning, handling and training their

child in the home• Clinical Evaluation:

• Assessment of motor capabilities of the child• Assess need for orthoses & assistive devices to promote

independence and mobility

• Provide Direct Treatment or Parent Coaching

Roles of Therapists

Five Key Principles for Physiotherapy

1. Intervention should aim to change a child’s function & ability to participate in everyday life and society

2. Therapy should be directed by child & family goals3. Treatment should be in natural settings where

possible (home & community) 4. Children should be actively engaged in therapy5. Interventions should be grounded in basic science &

evidence from clinical trials

Measuring “success” of therapy

• Changing a body structure or function not enough (e.g. strength, range of motion)

• Must meet a child/family goal or change level of activity or participation to be meaningful

• Benefits must outweigh risks• Costs to family (money and time) must be reasonable• Must be practical, acceptable, and feasible (and

available)

Physiotherapy and Level of CP• GMFCS can help families & therapists set more

realistic & achievable goals for children• Treatments may not challenge more functional

children or may be too hard or not appropriate for those less functional

• Recognize few treatments can move a child from one level to another, but it is possible

• Some children may lose a level in adulthood (Level III-V are at highest risk)

GMFCS (Clasificación de la Función Motora Gruesa)

• NIVEL I - Camina sin restricciones• NIVEL II - Camina con limitaciones• NIVEL III - Camina utilizando un dispositivo

manual auxiliar de la marcha• NIVEL IV - Auto-movilidad limitada, es posible que

utilice movilidad motorizada• NIVEL V - Transportado en silla de ruedas

CP is not a “non-progressive” disorder• Evidence of decline in mobility in adolescents: GMFCS-Expanded

and Revised Motor Growth Curves

• “Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett 1997)

Evidence-Based Practice

• Optimal care compromised!• Time spent on ineffective therapy takes time that

could be spent on more effective ones • Funding for treatment will be withdrawn• Family ‘faith’ in medicine deteriorates• Alternative treatments are explored & utilized

When EBP is Not Implemented

• Right to therapy: ”Legislation has preceded evidence for the efficacy of physical therapy”

• Little evidence to support NDT; need to explore use of strengthening to improve gait

• Home programs important for sufficient practice• Early intervention: no efficacy for improving

motor prognosis or achieving milestones

Evidence for Physiotherapy in CP 20 years ago (Barry, 1996)

Traditional Therapies• These were developed in advance of more recent

science and are now “outdated” (e.g. Bobath)• Many have no basis at all and some may even can

cause harm (e.g. Vojta, hyperbaric oxygen)• Evidence supports more intensive task-specific or

activity based approaches

https://www.google.com/url?url=https://fearmastery.wordpress.com/2013/04/20/more-on-living-in-the-present/&rct=j&frm=1&q=&esrc=s&sa=U&ei=3xYUVZTXFou6ogT1hIKABQ&ved=0CBYQ9QEwAA&sig2=m2fblhNcN6F5Gq252qebnA&usg=AFQjCNEa4bq9Ur8BSkDOixkNrEcPFJC9Og

• 25 yr retro/perspective on CP research success:– Evolution of rehab approach: family centered, EBP: UE

rehabilitation, strengthening, fitness, BWSTT– Advances in classification, outcome measures, motor

prognosis (GMFCS), > interest in adults – Beginning to understand mechanisms of activity-

dependent plasticity

Cerebral Palsy: Definition, Assessment & Rehabilitation (Richards, Malouin 2014)

Preferentially use this

approach

Proven Effective

Do NOT use this approach. Choose

alternative

Proven Ineffective

Measure effects. Were goals met?

Uncertain Effect

Insu

ffici

ent

evid

ence

No

evid

ence

Con

flict

ing

evid

ence

Novak & McIntyre, 2010

Novak et al, 2013

WORTH IT LINE

EFFECTIVE

INEFFECTIVE

DO ITS+

PROBABLY DO ITW+

UNKNOWN IN CP?

PROBABLY DON’T DO ITW-

DON’T DO ITS -

Novak et al, 2013

Scientific Basis for Physiotherapy in CP

• No one single “science of physiotherapy”; field based on solid scientific principles from several disciplines*:1. Exercise physiology: muscle & bone structure &

function, joint flexibility, physical conditioning 2. Kinesiology/ Motor learning: motor skill and

coordination3. Neurophysiology/ Neuroscience: how the brain controls

movement & how movement alters the brain *ALL REQUIRE CHILD TO BE AN ACTIVE PARTCIPANT

Exercise Physiology Principles in CP • Wolff’s Law: Bones (and muscles) develop and remodel in

response to stresses placed on them• Osteopenia/porosis: major problem in non-ambulatory

children • Muscle weakness in CP due to brain injury and inactivity

(window of opportunity)• Basic principles no different in CP, but may have special

considerations (e.g. muscles to target) to enhance safety and effectiveness Strength X BW

What we know about strength in CP

1. Children with CP are weak 2. Strength in CP related to function3. Children with CP can get stronger5. Strengthening can have functional benefits 6. Strengthening does NOT increase spasticity!

Strength & Mobility in CP* (1990s)

GMFCS LEVELS

*Leg strength related to walking speed in CP (r=0.70)

Muscle Strengthening

• Multiple reviews in CP & other conditions showing that strength can be increased (Dodd, Tayl0r & Damiano 2002; Taylor, Dodd & Damiano 2006)

• Changes in gait speed & other aspects of functioning noted often but not consistently

• Depends on ‘dose’ and ‘duration’. Must be done properly & for sufficient time to achieve benefits

• Must be maintained across lifespan

Motor Learning Principles (1980s)• Motor learning = set of internal [brain] processes associated with

practice or experience leading to relatively permanent changes in the capability for responding (Schmidt 1988)

• Carr & Shepherd (stroke rehabilitation) emphasized that patients with brain injury can improve skill with training– sensory input should come from self-generated movement, not sensory

input provided by therapist– instruction, feedback & participation are essential to learning– practice needs to be repetitive & task-specific (intensive)– transfer into activities of daily living needed to persist

Emerging Principles from Neuroscience

• Training optimally should include:• Self-initiated movement & physical effort• Underlying loose but variable rhythm (CPG) • Sufficient practice and intensity• Mental engagement (cognitive effort)• Involve error recognition and correction • Be meaningful & motivating to patient

“All learning involves the development of new connections in the brain”

Dr. Otto FriesenNeural Circuits Seminar

• Physiotherapy for cerebral palsy: historical review. (Eva Bower, 1993): “In view of the fact that brain damage cannot be reversed in cerebral palsy, it seems unlikely that there will be recovery other than maturation and compensatory movement.”

View of the Brain 20+ Years Ago

Neurobiology of Physical Activity Health benefits of exercise known for decades Now recognizing effects of activity on the brain:

Muscle (electrical) activity or inactivity (e.g. amputation, SCI) can dramatically alter brain pathways

Activity signals the brain to “grow” or “decay” (NGF) Motor training can improve cognition, memory Linked to less depression & anxiety, better sleep

Upper Limb Training Success• Best evidence among all therapeutic approaches.• Intense training with incremental challenge and progression;

shown to alter brain pathways• So far utilized only on children with unlateral CP• Similar approach in legs now studied with initial positive

results (Bleyenheuft)

• No similarly strong clinical evidence for lower limb training

• Legs task requirements different than arms: – Need more anti-gravity strength & postural control – Incorporate spinal locomotor rhythms & reflexes– Gross (vs. fine) motor (walking vs. manipulating)– Requires coordination within and across limbs

• Intense training in legs often use devices, but with mixed success (devices may assist too much)

DESARROLLO / KEY POINTS

• Temas: Activity is key ingredient; limbs used least probably need the most training. The sooner, the better. The more, the better. Passive treatment not helpful!

• Temas: Children with CP need as active a lifestyle as possible, but that requires effort – from them, their parents, clinicians and society

• Temas: Physiotherapists must learn and use best available scientific evidence to help children & families

• Temas: What happens outside of therapy matters most!

Gracias / Thank you