Treatment of Cerebral Palsy and Motor Delay

Sophie Levitt, Anne Addison

• Publisher: Wiley-Blackwell
• Year: 2018
• ISBN:
  9781119373599
• Edition: 6
• Topic: Medicina
• Subtopic: Fisiologia

Treatment of Cerebral Palsy and Motor Delay is a highly practical, easy-to-read resource for all paediatric practitioners and students working with the developmental abilities and difficulties of children, providing a thorough overview of cerebral palsy and its treatment.

The sixth edition has been thoroughly revised and updated to integrate the latest evidence-base on motor control and motor learning, whilst still retaining Sophie Levitt's eclectic, holistic and functional approach. It includes greater detail on paediatric occupational therapy, classification systems, the latest systematic reviews of research, as well as an expanded chapter on adolescents and adults with cerebral palsy. The chapter on equipment has also been increased so as to be of further relevance to occupational therapists.

Supported by clear diagrams and photographs, as well as summaries to consolidate learning, it outlines therapeutic approaches and suggests treatment and management options, providing a wealth of practical information. The book promotes positive relationships between therapists, people with cerebral palsy and their families.

1
The clinical picture for therapy and management

Cerebral palsy, the most common cause of childhood disability, is the name for ‘a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non‐progressive disturbances that occurred in the developing foetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behaviour, by epilepsy and by secondary musculoskeletal problems’ (Rosenbaum et al. 2007a). Parents, families, and children are likely to experience emotional and social difficulties. The severity of the cerebral palsy itself may range from total dependency, extremely limited communication, and immobility to the ability to talk, carry out independent self‐care tasks, walk, and run. Mild to severe motor difficulties are usually experienced by children according to their severity. Many children and young people with a diagnosis of cerebral palsy are able to access mainstream primary, secondary, and further education. Changes to legislation, advances in technology, and increasing positive attitudes towards disability in society have resulted in opportunities for individuals with cerebral palsy.

Incidence of cerebral palsy

The prevalence of cerebral palsy has consistently been reported to be about 2–2.5 per 1000 live births (1 in every 400 children) over the last 20 years in the Western world. However, in some cases, motor delay that initially presents as cerebral palsy may not be ‘cerebral palsy’ but a more generalised developmental delay resulting from other conditions such as learning disabilities, progressive neurological conditions, and genetic conditions that can only be recognised later, when a definite diagnosis can be made (Cans 2000).

Motor dysfunction

The motor dysfunction results in disorganised and delayed development of the neurological mechanisms of postural control, balance, and movement. The muscles activated for these motor aspects are therefore inefficient and uncoordinated. Individuals have specific impairments of tone, weakness, atypical patterns of muscle activation, and excessive co‐contractions. There are absent or poor isolated movements (poor selective motor control), atypical postures, and problems with the use of hands in daily tasks. Biomechanical difficulties result from both the neuromuscular dysfunction and secondary musculoskeletal problems, which add to this complex picture.

The motor dysfunction changes with both growth and the individual’s whole development. Change particularly depends on how individuals use their bodies. Although the brain damage is not progressive, the motor and musculoskeletal problems may increase in late childhood, adolescence, and adulthood; physiotherapy and occupational therapy is needed to prevent or minimise these.

What matters most to a child, parents, and family is the child’s difficulties in function and participation in daily life. Therapists need to address these difficulties together with a child and parents, or directly with an adolescent and older person with cerebral palsy (see Chapters 2, 3, and 4). Therapists will assess the motor abilities of an individual and detect emerging functional abilities that can contribute to functional activities. It is also encouraging to know that functional activities and participation in daily life can be developed and difficulties minimised even though basic impairments cannot strictly be cured.

Professionals also differ in their views as to which impairments can be minimised, and, if not, when to compensate for these, such as by using task adaptation or equipment to promote engagement in functional tasks. Views or opinions on the underlying motor dyscontrol can be controversial, which is not surprising given that not all the neurological mechanisms are fully understood. Research into the basic dyscontrol and its related biomechanics is continuing.

The first edition of this book (Levitt 1977) presented a synthesis of valuable contributions from different therapy systems, some of which had been regarded as mutually exclusive. This synthesis or eclectic approach has been further developed and continued with current contributions in the new edition of this book. As many colleagues are now not wedded to any one system of therapy, selections of their views are presented as well as those from our own studies and experience. Current research studies are also given as evidence for specific clinical techniques that need to be part of the eclectic approach.

As a child does not ‘move by neurophysiology alone’ various ideas of motor and other learning have been integrated into the general therapy framework. The influence of the environmental and social contexts of a child’s function are considered as we know that learning takes place in a child’s home, school, and community. A child learns best in a familiar environment when therapy is part of a child’s activities that are meaningful to that child. It is primarily a child’s own intrinsic motivation, encouraged and supported by people in a child’s daily life as well as by therapists, that has a profound impact on the child’s achievements. Adolescents and older individuals also need consideration of their specific contexts. Many individuals with cerebral palsy face physical indoor and outdoor environmental constraints, differing social attitudes, and sometimes poor availability of services, all of which can be a barrier to their functional abilities. Therapists, together with individuals and their parents, share their strategies to overcome barriers and provide facilitators throughout an individual’s life.

Associated impairments and disabilities

Kilincaslan and Mukaddes (2009), in a large clinical trial, suggested that children with a diagnosis of cerebral palsy are also at risk for other neurodevelopmental disorders such as autism, which adds to parental concerns. Brain damage in cerebral palsy may also be responsible for severe cortical visual impairment (Dutton and Bax 2010; Dufresne et al. 2014) and hearing impairments. Many children are also found to have visual problems such as squint (strabismus) and short or long sight (Odding et al. 2006; Dufresne et al. 2014; Dutton et al. 2014). Hearing impairment is not as common (Odding et al. 2006). Children may have problems with non‐verbal communication, speech, and language, as well as experiencing aberrations of perception. It is thought that visual perceptual difficulties may be experienced by around 50% of children with cerebral palsy (Ego et al. 2015). However, self‐directed movement through space leads to the development of visual–spatial competencies (Campos et al. 2000; Coté 2015), which suggests that children with cerebral palsy are likely to develop these skills more slowly.

A number of children with cerebral palsy have difficulties performing certain movements, even though there is no paralysis, because the patterns have not developed. This is sometimes described using the umbrella term of dyspraxia (Lee 2004). This can involve movements of limbs, face, eyes, or tongue. There may be disorders of memory of motor sequences (Lesný et al. 1990). Tactile sensation, proprioception, two‐point discrimination, and perception may be impaired (Odding et al. 2006). A study by Yekutiel et al. (1994) found sensory impairment in the hands of children, and more recent studies suggest that tactile deficits are prevalent in over...