What Specific Treatments Are Available?
Physical, Behavioral, and Other Therapies Therapy -- whether for movement, speech, or practical tasks -- is a cornerstone of cerebral palsy treatment. The skills a 2-year-old needs to explore the world are very different from those that a child needs in the classroom or a young adult needs to become independent. Cerebral palsy therapy should be tailored to reflect these changing demands. Physical therapy usually begins in the first few years of life, soon after the diagnosis is made. Physical therapy programs use specific sets of exercises to work toward two important goals: preventing the weakening or deterioration of muscles that can follow lack of use (called disuse atrophy) and avoiding contracture, in which muscles become fixed in a rigid, abnormal position. Contracture is one of the most common and serious complications of cerebral palsy. Normally, a child whose bones are growing stretches the body's muscles and tendons through running and walking and other daily activities. This ensures that muscles will grow at the same rate. But in children with cerebral palsy, spasticity prevents this stretching and, as a result, muscles do not grow fast enough to keep up with lengthening bones. The resulting contracture can disrupt balance and trigger loss of previous abilities. Physical therapy alone, or in combination with special braces (sometimes called orthotic devices), works to prevent this complication by stretching spastic muscles. For example, if a child has spastic hamstrings (tendons located behind the knee), the therapist and parents should encourage the child to sit with the legs extended to stretch them. A third goal of some physical therapy programs is to improve the child's motor development. A widespread program of physical therapy that works toward this goal is the Bobath technique, named for a husband and wife team who pioneered this approach in England. This program is based on the idea that the primitive reflexes retained by many children with cerebral palsy present major roadblocks to learning voluntary control. A therapist using the Bobath technique tries to counteract these reflexes by positioning the child in an opposing movement. So, for example, if a child with cerebral palsy normally keeps his arm flexed, the therapist would repeatedly extend it. A second such approach to physical therapy is "patterning," which is based on the principle that motor skills should be taught in more or less the same sequence that they develop normally. In this controversial approach, the therapist guides the child with movement problems along the path of normal motor development. For example, the child is first taught elementary movements like pulling himself to a standing position and crawling before he is taught to walk -- regardless of his age. Some experts and organizations, including the American Academy of Pediatrics, have expressed strong reservations about the patterning approach, because studies have not documented its value. Physical therapy is usually just one element of an infant development program that also includes efforts to provide a varied and stimulating environment. Like all children, the child with cerebral palsy needs new experiences and interactions with the world around him in order to learn. Stimulation programs can bring this valuable experience to the child who is physically unable to explore. As the child with cerebral palsy approaches school age, the emphasis of therapy shifts away from early motor development. Efforts now focus on preparing the child for the classroom, helping the child master activities of daily living, and maximizing the child's ability to communicate. Physical therapy can now help the child with cerebral palsy prepare for the classroom by improving his or her ability to sit, move independently or in a wheelchair, or perform precise tasks, such as writing. In occupational therapy, the therapist works with the child to develop such skills as feeding, dressing, or using the bathroom. This can help reduce demands on caregivers and boost self-reliance and self-esteem. For the many children who have difficulty communicating, speech therapy works to identify specific difficulties and overcome them through a program of exercises. For example, if a child has difficulty saying words that begin with "b," the therapist may suggest daily practice with a list of "b" words, increasing their difficulty as each list is mastered. Speech therapy can also work to help the child learn to use special communication devices, such as a computer with voice synthesizers. Behavioral therapy provides yet another avenue to increase a child's abilities. This therapy, which uses psychological theory and techniques, can complement physical, speech, or occupational therapy. For example, behavioral therapy might include hiding a toy inside a box to reward a child for learning to reach into the box with his weaker hand. Likewise, a child learning to say his "b" words might be given a balloon for mastering the word. In other cases, therapists may try to discourage unhelpful or destructive behaviors, such as hair-pulling or biting, by selectively presenting a child with rewards and praise during other, more positive activities. As a child with cerebral palsy grows older, the need for and types of therapy and other support services will continue to change. Continuing physical therapy addresses movement problems and is supplemented by vocational training, recreation and leisure programs, and special education when necessary. Counseling for emotional and psychological challenges may be needed at any age, but is often most critical during adolescence. Depending on their physical and intellectual abilities, adults may need attendant care, living accommodations, transportation, or employment opportunities. Regardless of the patient's age and which forms of therapy are used, treatment does not end when the patient leaves the office or treatment center. In fact, most of the work is often done at home. The therapist functions as a coach, providing parents and patients with the strategy and drills that can help improve performance at home, at school, and in the world. As research continues, doctors and parents can expect new forms of therapy and better information about which forms of therapy are most effective for individuals with cerebral palsy.
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