From ‘one size fits all’ to tailor-made physical intervention for cerebral palsy

Authors


The physical treatment and management of cerebral palsy was relatively straightforward until the middle of the last century. It perhaps could have been described as a ‘one size fits all’ orthopaedic approach, with a priority to align the muscles and joints with surgery and/or splints, largely based on experience with survivors of the polio epidemic. The physical therapist’s main task was to maintain the splints (along with the orthotist) and to try and encourage the child’s developmental milestones. However, in the middle of the 20th century the proponents of changing nervous system functioning arrived on the scene, and the emphasis changed to a focus on modifying tone and movement in the hope of improving daily function. While many of the ideas of that time are compatible with what we now know about activity-driven neuroplasticity, they did not have the complete answer either. By the mid-1970s those ideas had progressed with the realization that changing tone and movement did not automatically lead to improved function, but that it was necessary to work within the functional tasks (activities) needed by the person to participate in daily life.1 A further progression was the advent of a task-focused approach.2 Now, in the 21st century, there are a plethora of treatment ideas and more emerge all the time, presenting a challenge to both professionals and to children and their families alike as to which physical interventions will be the most helpful.

How can that decision be made? We need to look to the basic sciences, apply the available classification and measurement tools, and ultimately consider the needs of the children and their families in order to provide a tailor-made intervention for the individual to enable optimal participation in society. So often intervention studies for cerebral palsy try to show that one intervention is superior to another, but perhaps a better approach would be to acknowledge that there is no singular ‘right way’ to provide physical therapy for the person with cerebral palsy and to focus on determining what works best for whom and at what stage of the lifespan. There are many tools to select from, according to the job to be done,3 but the selection and appropriate use of the tools also requires an understanding of the nature of the job. For that we need to look to the scientific literature about the biology of cerebral palsy, the science of growth, development and learning, the relevant intervention studies, and draw on our clinical experience. Central to the decision- making process are the child and family themselves, who according to the family-centred approach which we now adhere to, are the experts on the child and their needs. Indeed tailor-made means that there is a high degree of involvement of the end-user in the production of the item. There are perhaps also a few specific points to consider as part of the process.

Setting appropriate goals is integral to successful outcome. We now have several useful structures to assist us as we determine these goals with the child and family. The introduction of the functional classification systems for motor function (Gross Motor Function Classification System),4 manual ability (Manual Ability Classification System),5 and the recently introduced scale for communication (Communication Function Classification System),6 in addition to the predictive curves for gross motor function7 and the child’s context (e.g. cultural/environmental factors), offer a good starting point for goal setting. Goals also need regular review and adjustment as needed, so measurement is another important ingredient and should be routine practice for every physical therapist.

The science of neuroplasticity has made it very clear that any intervention needs an active participant who practices sufficiently challenging tasks that are meaningful to him or her. The International Classification of Functioning Disability and Health (ICF)8 has greatly assisted therapists to pitch their intervention in such a way that it focuses on activity and participation. Impairment-based intervention is often criticized, but becomes rational when viewed in the context of providing a means to the achievement of activity and participation goals. Whether the intervention is to strengthen muscles using progressive resistance exercises, the use of botulinum toxin to reduce hyperreflexia (spasticity), or hands-on therapy guidance to achieve a task, it is the end-point of task achievement that should be the therapy focus.

To achieve effective tailor-made intervention also requires an appreciation of several balancing factors. It is well known that cerebral palsy is primarily a neurological condition, but because of growth and development of all systems, in particular the musculoskeletal system, it is essential to consider both the neural and biomechanical restraints of the condition, e.g. spasticity versus passive muscle stiffness. As well as the balance between neural and non-neural (biomechanical) factors, there is a need to achieve a balance in unimanual versus bimanual training for the child with hemiplegia;9 child-focused versus context-focused therapy;10 hands-on versus hands-off; technology-assisted training (e.g. robotics) versus self-initiated practice – to name only a few.

Therapy needs to be tailored to the individual’s needs and abilities, and be consistent with developmental and functional goals and not simply address ‘impairments’ at the biomedical level of body structure and function. While there are no formulae for intervention we now have ways to evaluate and document progress, so that in the not too distant future we might have a robust evidence base to determine what works best for whom and at what stage of the lifespan. Physical therapy, indeed the treatment and management of cerebral palsy, is in an exciting era!

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