Course:KIN366/ConceptLibrary/Cerebral Palsy

Movement Experiences for Children
KIN 366
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Instructor:	Dr. Shannon S.D. Bredin
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Cerebral Palsy (CP) is a group of non-progressive congenital neurodevelopmental disorders primarily affecting the brain and central nervous system (CNS). Afflicting approximately 2.5 children out of 1000 live births, muscle tightness and lack of coordinated contractile/relaxation patterns causes affected individuals to experience uncontrolled reflexive movements (Koman, Paterson, Shilt, 2004). Caused by stunted prenatal brain growth or brain injury, individuals affected often experience poor balance, spastic movements, postural problems, and poor motor control. Although primarily identified as a movement disorder, it is common for individuals suffering with this condition to also experience severe cognitive, physical, emotional/social, or behavioral delays beginning from birth, and extending throughout their entire lifespan (Bax et al., 2005). Although there is no known cure, the movement experiences of infants can be improved drastically with early intervention, and under the guidance of a knowledgeable multidisciplinary team. Such intervention strategies include physiotherapy, occupational therapy, orthotics, device-assisted modalities, pharmacological intervention, and finally orthopedic and neurosurgical procedures (Koman, Paterson, & Shilt, 2004).

Cerebral Palsy: An Overview

Causes

Cerebral Palsy is primarily caused by prenatal brain abnormalities. However, CP can also be triggered by a problematic birth or injury in the first couple years of life when the CNS is still developing (Miller, 2006). Brain injury can be the result of:

• Brain hemorrhages: bleeding in the brain, which is much more common in premature infants, is thought to be one of the primary causes of CP (Miller, 2006).
• Aphyxic delivery: Often the result of a slow birth or the umbilical cord being wrapped around the infants neck during birth, children who undergo an aphyxic delivery will often demonstrate a very low score on the Aspar Scale. The combination of a low Aspar score in conjunction with a physician being aware that there was minimal oxygen at birth makes CP one of the primary diagnostic possibilities in this circumstance (Miller, 2006).
• Prenatal or infant infection: viral or bacterial infections (such as meningitis) can do much harm to the developing prenatal brain. A mother should be immunized before becoming pregnant to reduce this risk (Miller, 2006).

Despite these known potential instigators of cerebral palsy, about 60% of pregnancies are subject to one of the ‘causes’, but result in an asymptomatic child. In addition, in many children born with CP, the causality is never actually determined, making the exact cuase of the disorder a heavily debated and researched topic (Miller, 2006).

Classification/Type of Cerebral Palsy

The type of cerebral palsy experienced by a child is dependent on where the brain injury occurred. There are generally three classifications of CP (although there is often overlap):

Spastic (Pyrimidal)

Increased muscle tone results in a child with stiff movements and posture. It is the most common of cerebral palsy cases, accounting for nearly 80% of those affected with the disorder. Spastic CP often results in pain or other health concerns, such as joint deformities and muscle soreness, due to the continuous tension placed on the muscles (Novak et al., 2013).

Non- Spastic (Extra- Pyramidal)

Extra- pyramidal CP is generally defined as a decrease in muscle tone and involuntary rhythmic or continuous movements. Due to the location of the brain injury, intellectual impairments are less likely, however language abilities may be affected due to the physical limitations of the oral muscles instead of the cognitive delays of the individual (Novak et al., 2013). There are two types of non- spastic CP:

1. Ataxia: Being the rarest type of cerebral palsy, ataxia affects the entire body; the trunk, arms, hands and legs. Fine motor control is severely compromised, as well as balance and basic movement (Novak et al., 2013).
2. Dystaxic: Characterized by muscle tone that transition from loose to tight (Novak et al., 2013).

Mixed

As its name suggests, mixed CP patients experience symptoms conducive to both spastic and non-spastic cerebral palsy (Novak et al., 2013).

Diagnosis

Making a definitive diagnosis of cerebral palsy is difficult during infancy due to the complex developmental nature of the disorder. A physician may suspect cerebral palsy if the child is developmentally delayed in acquiring the major motor milestones, along with exemplification of abnormal muscle tone and reflexes (Engel, Gallegos, Gertz, Hirsh, & Jensen, 2010). Diagnosis is especially difficult when the infant experiences a head injury later on in childhood because the resulting symptoms of the event could be acute or chronic, making time the ultimate determinant of the potential long term consequences. Of the variety of testing methods available to help in diagnosing CP, a brain MRI has proven to be the most effective, although not necessarily indicative of the severity of the CP symptoms experienced by the child (Miller, 2006). At roughly two years of age, presumptions can be made regarding the magnitude of the condition and the likely developmental path that lies ahead. It has been widely accepted now that valid generalizations about a child’s developmental abnormalities can only truly be evaluated after a child’s second birthday (Engel et al., 2010).

Signs and Symptoms Across Developmental Domains

Signs and Symptoms of cerebral palsy lie on a continuum; varying in seriousness depending on the severity of illness or the type of CP present. Common to all individuals with CP, however, is dysfunctional movements and postural abnormalities (Hoch, 2009). Some individuals may only be symptomatic on one side of the body, or in exclusively the upper or lower body. In less severe cases, or in children who acquire CP after birth, a child may be asymptomatic up to the age of three (Hoch, 2009). Although CP is a non- progressive disorder, the condition goes undiagnosed until the signs of the disorder become more apparent (Hoch, 2009). Despite the fact that cerebral palsy is primarily a movement disorder, it often disturbs the maturation of language skills, cognitive abilities, and social/emotional growth. Looking at childhood development from the dynamic systems perspective, there is a bilateral interplay between all developmental domains. This is why upon onset of CP diagnosis, it is essential that a multidisciplinary team take action immediately to work on and improve all aspects of development (Miller, 2005). Practically applying the information currently known in relation to treating CP patients, means that it is essential to look to all developmental domains to obtain the complete developmental picture of the child.

Movement

One of the first signs associated with CP is irregular postural characteristics; portrayed by either ‘floppiness’ (inability to sit upright) or abnormal stiffness (Hoch, 2009). Along with this, an inability for a child to hold his or her head up and a continued clenching of fists after three months are two signs that have been identified as ‘red flags’ for neurological conditions such as CP (Bax et al., 2005). Developmental delays in rolling, crawling and walking are almost always indicators of possible brain damage and neural delay in the first two years of life. However, due to the vastness of neurological disorders and the similar symptoms encompassing each, if a child is slow to develop these tasks, a doctor may suspect cerebral palsy, but not make any definitive diagnosis (Bax et al., 2005). Due to an abnormal muscle contraction-relaxation pattern, the fluid oscillatory walking motion is replaced by a jerky and slower movement pattern. Oftentimes, children with CP will have their arms tucked into their sides, and their feet will move in a ‘scissor- like’ pattern (Hoch, 2009). Paralysis in a group of muscles and joint contracture have also been observed in more severe cases, causing pain and a limited range of motion about a joint (Bax et al., 2005).

Physical

In more severe or rare cases, physical abnormalities observable as soon as three months after birth can be used to help in the diagnosis of a child with CP early on. Such irregularities include a misaligned spine, a small jawbone, or small head (Miller, 2006).

Cognition

Cognitive function of a child with CP varies greatly and is largely dependent on the location of the brain injury and thus, the type of CP present. Some children are not cognitively affected whatsoever, but some experience symptoms similar to mental retardation (Miller, 2005).

Language

Lack of control over the tongue and facial muscles in many situations causes a developmental delay in language. This delay is presented as a late onset of speech, or a lack of clarity in speech. Delays that are a cause of concern are a lack of babbling by roughly 8 months, and lack of formulating identifiable words by fifteen months (Miller, 2006).

Social/Emotional/Behavioural

These delays in children with CP are more difficult to identify than motor or physical abnormalities due to sociocultural difference, the wide continuum of those that develop social/emotional abnormalities, along with the ability to correlate these problems to children with CP. In general, it is said that it is worrisome if an infant does not smile or acknowledge favorably to the interaction with their mother or caregiver. Further, a child with CP may find it difficult to sleep through the night, an important developmental milestone. Along with this, temper tantrums may be more common in a child with CP due to their inability to communicate their emotion (Miller, 2006).

Developmental Progressions and Shortcomings in Children with Cerebral Palsy

A child with CP develops much differently than a typical infant due to the obvious structural limitations affecting the individual. Motor development and control are the most noticeable developmental delays that become ever much more apparent as the child matures. Despite the fact that that children with CP acquire motor capabilities at a different speeds and in a different manner than those typically developing children, that is not to say that affected children cannot perform functional movements. It is essential that parents or caregivers realize that, although the way their child goes about performing tasks is not in a typical manner, it does not mean that the child’s modality of movement is not valuable in its own right. From a mental/emotional standpoint also, it is crucial that children are reminded that despite their motor experiences being unlike their peers, does not mean they are incapable of performing motor tasks (Miller, 2005). Generally the increase in muscle tone (spasticity) in a child with CP delays the onset of walking. Earlier developmental milestones, such as rolling over and creeping are often observed later than they should in a typically developing infant. Delays in fine motor control often surface at during infancy (Miller, 2006). Many tasks or games played by typical children at the pre- school age (3-5 years) at this age require certain motor skills that a child with CP is not capable of achieving. Fine motor control issues become evident in the child’s lack of ability to precisely control a pen, for example. This phase of development is often marked by trial and error as practitioners and parents work to find the intervention strategies that work best for the affected child (Miller, 2006). The explosion of physical activity that occurs at the Kindergarten age (5-6 years) is unfortunate for a child with CP. In addition, a typical individual at this age is fairly self-sufficient. A child with cerebral palsy however is still very dependent on his or her caregiver for basic tasks in the home, such as grabbing a snack or climbing stairs. It is also at this kindergarten age that the child themselves begins to understand that they are restricted in their abilities, and drastically different from his or her peers. As a caregiver, it is important to focus on what a child can do as apposed to what they cannot do. Constant encouragement and delivery of positive feedback when motor milestones are achieved is crucial to ensure that children maintain good emotional health and confidence in their abilities (Miller, 2006).

Enhancing the Movement Experiences of Children with Cerebral Palsy: A Multidisciplinary Approach

Early diagnosis of CP is crucial to ensuring the maximal quality of life for the child in the future. The reason for this is because once a child has been practicing an incorrect movement pattern for a long period of time, it becomes engrained in his or her motor memory, making it difficult to change. Creating proper movement patterns while the brain is still plastic to new information is a crucial component to maximizing a child’s movement experiences in the future (Shepherd, 2014). Once diagnosed with CP, a multidisciplinary team of professionals must do a full comprehensive assessment of the child, as each individual case of CP is different. Practitioners need to establish what the child can do, what they cannot do, and why. After the assessment, the professionals and the caregivers of the individual must work to create a life-long plan to maximize the motor experiences of the child. In conjunction with motor development, other developmental domains, such as cognition, language, and social/emotional skills must not be ignored (Shepherd, 2014). Specifically speaking to the enhancement of movement experiences in children, there are a variety of techniques and treatment strategies available that have been clinically proven to help children with their mobility. To begin, a comprehensive assessment must be completed by a multidisciplinary team, including physicians, therapists, and caregivers. Early establishment of the child’s neurological function, as well as an appreciation for both the motor milestones that the child has achieved, as well as the ones that have not (Shepherd, 2014).

Physical Therapy

Physiotherapy is one of the most mainstream and principal techniques implemented into the life- long treatment plan of a child with CP. Generally speaking, there are currently three primary approaches therapists take:

1. Bobath concept: Also known as the neurodevelopmental approach, this methodology emphasizes the importance of proper muscle tone in the development of functional movement. A basic level is required for the motor control necessary to complete day-to-day tasks effectively. (McDonald, 1987).
2. Conductive education/behavioral modification: This approach emphasizes attaining movement goals rather than movement quality. Therefore, verbal reinforcement and encouragement are seen as key factors in enhancing the success of the affected child. This process is most important in children with severe CP, who have severely compromised motor skill and cognitive abilities (McDonald, 1987).
3. Sensory integration: A problem with executing movements is the direct result of the inability of a child with CP to process sensory information to the CNS. Emphasis is placed on the child’s proper registration of sensory stimuli and translation into an appropriate response (McDonald, 1987).

Strength Training

This is one of the first steps taken by therapists, as a minimal level of strength is required for proper posture and movement. The number of strength training exercises is seemingly endless, and movement prescriptions obviously depend on the part of the body most affected by CP. A therapist will attempt to correct strength imbalances by working on the weaker musculature, and relaxing the tense muscles. The challenge, however, lies in translating the increased strength into functional movements (Barber, 2009).

Muscle Stretching

The constant neural stimulation of certain musculature results in tension, which greatly inhibits certain movements, and often leads to joint contracture in the future. Physiotherapists work to elongate the muscle manually through massage and stretching. Although this does help to relieve tension, the results are unfortunately quite transient (Tilton, 2004).

Constrain Induced Movement Therapy

This technique is often used in children with hemiplegia CP in primarily their upper body (only one side of the anatomy is affected). For approximately 90% of the day, the non-affected side is constrained (using specialized casts, gloves or slings) from movement, forcing the child to use their spastic side. The thought behind this this technique reaches beyond merely increasing the use of the affected side to increase functional coordination. It has been proven that as the spastic and non-spastic limbs become more symmetrical. This allows for the correction of muscle imbalances, and thus facilitating smoother whole body movements (Shepherd, 2014).

Partial Body Weight Supported Treadmill Training

A child is harnessed at a particular percent of his or her body weight over a treadmill. Research suggests that this form of therapy promotes a faster walking speed, increased coordination, and movement efficiency. In a safe environment, the child is forced to practice the skill of walking, which strengthens the oscillatory motor commands associated with the motion (Shepherd, 2014).

Muscle Education

Children with spastic CP are usually prone to having very weak antagonist muscles to those that are spastic. Simple contraction and relaxation patterns of the antagonist muscles are taught to the child to promote muscle tone in the antagonist muscle groups and muscle awareness (Levitt, 1977).==== Neuromuscular Electrical Stimulation ==== Used for muscle re- education, strengthening, and decreasing spasticity, this technique uses electrical stimulation to ‘awaken’ certain muscle groups. Neuromuscular electrical stimulation has become an especially popular technique to implement when a child is very young and cannot necessarily give reliable reports on other treatment measures (Novak et al., 2013). .==== Neuromuscular Electrical Stimulation ==== Used for muscle re- education, strengthening, and decreasing spasticity, this technique uses electrical stimulation to ‘awaken’ certain muscle groups. Neuromuscular electrical stimulation has become an especially popular technique to implement when a child is very young and cannot necessarily give reliable reports on other treatment measures (Novak et al., 2013).

Whole body vibration

Whole body vibration (WBV) is a training method which exposes an individual’s whole body to low frequency, low amplitude mechanical stimuli via a vibrating platform. The vibrations stimulate the muscle spindles, and send nerve impulses to initiate muscle contractions according to the tonic vibration reflex (as cited in Cheng, Yu, Wong, Tsai & Ju, 2015). Many research studies have found that whole body vibration can suppress spasticity in children with CP, significantly improve the active range of motion in the knees and can improve walking performance (Cheng et al., 2015).

Acupuncture

A relatively new therapy in treating CP, the idea behind acupuncture is that through the needle treatment, some muscle groups can be stimulated, while others relaxed. Some patients have noticed that acupuncture provides some relieve of headaches, back pain, joint pain, or neck pain (Novak et al., 2013). The NIH and the University of Arizona conducted a study that showed acupuncture reduced muscle hypertoncity in children with cerebral palsy (My Child, 2015). Aditionally, another randomized controlled trial at the University of Arizona indicated that acupuncture may provide relief to children with spastic cerebral palsy, and if done early and properly, can help children improve their ability to function physically, but further study is needed (My Child, 2015).

Therapies

Hippotherapy

Hippotherapy is a form of physical, occupational and speech therapy that uses horse movement to “develop and enhance neurological and physical functioning by channeling the movement of the horse”(My Child, 2015). Hippotherapy is often confused with therapeutic horseback riding, in which individuals are taught specific riding skills. This therapy is based on the idea that human neuromuscular development is influenced by a horse’s variable movement pattern which triggers complex physical and mental reactions (My Child, 2015). Physical benefits include improved gross motor skills, trunk core strength, control of extremities, improved postural symmetry, reduced abnormal muscle tone, and respiratory control (My Child, 2015) A study done on 10 children with cerebral palsy found that hippotherapy had a positive effect on the functional motor performance and was a viable treatment strategy for therapists with experience and training in it (Casady & Nichols-Larsen, 2004). Another study found that eight minutes of hippotherapy, but not stationary sitting astride a barrel, resulted in improved symmetry in muscle activity in children with spastic cerebral palsy which suggests that the movement of the horse rather than passive stretching accounts for the measured improvements (Benda, McGibbon, & Grant, 2003). Kwon et al (2015) reported improvements in three measures of gross motor function and balance in an 8 week hippotherapy program with children CP of varying functional levels. In a single case study done on a child with Cerebral palsy Drnach, O'Brien, & Kreger (2010) found that a hippotherapy program as short as 5 weeks yielded positive changes with significant improvements in gross motor function.

Aquatherapy

Aqua therapy uses water and water-induced resistance to ameliorate physical functioning. Water buoyancy makes aerobic and anaerobic exercises safe and effective by allowing an individual to move about freely without placing undue stress on the joints. The medical community widely recognizes aqua therapy as a method in which to rehabilitate, or re-educate, the human body. Water can be a healing force for children with cerebral palsy. During therapy all activities take place in a pool (heated or non-heated) (My Child,2015).

Recreation therapy

Recreation therapy is a treatment that helps to develop and expand physical and cognitive capabilities of children with cerebral palsy while they participate in recreational activities. The range of activites covered is broad from sports that require large motor skills to arts and cultural pursuits that involve fine motor movements. There are many physical, cognitive, and psychological benefits of recreation therapy which include: improved physical adeptness, increased strength and flexibility, improved physical fitness and health, improved athletic prowess, , improved body image, improved well-being and relaxation, and improved coordination to name only a few. A child may start recreation therapy at any age that the chosen modality is appropriate. For example, older children are better suited for organized team sports and complex recreational activities whereas toddlers should be introduced to light sports and playground activities(My Child, 2015).

Climbing therapy

Climbing therapy is a type of training that combines the challenge of coordination, height,weight and strength. It is theorized that the typical climbing posture (abducted and external rotated hips, extended knees and ankle dorsiflexion) might be ideally suited to improve typical intoeing, crouch and equinus gait pathologies in cerebral palsy (Böhm, Rammelmayr, & Döderlein, 2015). A study comparing climbing therapy to physical therapy revealed an improvement in walking speed, step length, step time in both therapies. Gait Profile Score, ankle dorsiflexion and knee flexion was improved in physical therapy, whereas it did not improve in climbing therapy. The difference between therapies was only significant in knee flexion. In conclusion, the use of climbing therapy instead of physical therapy must be critically discussed, as it may deteriorate crouch gait. Future studies are needed to assess the benefits. If your child meets the following three criteria you can discuss with your therapist about climbing therapy and if it is right for your child.

• Walk with or without an assistive device
• Follow two-step directions
• Is able to work in a busy and sometimes loud environment.

(Easter Seals DuPage and Fox Valley, 2014)

Equipment

Orthotics

Orthotics are assistive, substitutive, or corrective external devices that are prescribed to protect a body segment or joints from the stresses that abnormal movement patterns cause. In CP patients, orthotics help to prevent muscle or joint deformity, provide stability, and enhance function of patients (Thompson, Rubin, & Bilenker, 1983). Lower extremity bracing (AFO) is daytime orthotic that comes in a variety of forms and forces the stretch of certain muscle groups. For example, if a child were naturally prone to ankle dorsiflexion, the AFO orthotic would promote plantar flexion. This is often used in postoperative management of CP (Thompson et al., 1983).

Night Splinting

Night splinting takes advantage of the reduction of tone that occurs during sleep to keep the overactive musculature under mild stretch. This technique is also commonly used after surgical intervention to maintain the corrections made in the procedure (Thompson et al., 1983).

Casting

Similar to orthotics, casting inhibits certain muscle positions from occurring. Casting for CP patients are often are made so that the child can be mobile, even when in the cast (Thompson et al., 1983).

Mobility Aids

Progression walkers and crutches can be helpful to allow a child to begin the walking process (Thompson et al., 1983).

Oral Medications

Muscle Relaxants

Acting presynaptically, excitatory mono synaptic and polysynaptic transmission in corticospinal tracts is reduced. Neurolytic blocks act as inhibitory neurotransmitters, and is arguably the most commonly used medication to treat CP (Koman, Paterson, & Shilt, 2004).

Tizanidine

Reduces spasticity in the spinal cord. Due to the side effects of this drug, it is not administered to children under the age of 12 (Koman et al., 2004).

Anticholinergics

Used to treat uncontrolled body movements in non- spastic cases. Although benefits are transient, the medications can stimulate the nervous system if given in large doses, or relax the nervous system if given in smaller doses (Tilton, 2004).

Anticonvulsant Seizure Medications

In more serious cases of CP, seizures are often experienced. In the prescription of these drugs, the type and dosage of medication is crucial (Tilton, 2004).

Anti-Inflammatories

Often prescribed to treat various types of orthopedic, or post surgical pain (Barber, 2009).

Injectable Medications

Botulinum Toxin A (BTX)

Patients who are hypertonic and are resultantly at serious risk of suffering joint contracture in the future in absence of treatment are candidates for this injection. The mechanism by which BTX works is via preventing the fusion of acetylcholine into the postsynaptic neuron. BTX is generally not done on children under the age of two, or on children with fixed hypertonia (diffuse hypertonic patients are ideal). This more invasive treatment is only used if orthotics, physical therapy, and casting have been unsuccessful (Koman et al., 2004). Successful outcomes of these injections in a child is an improve range of motion, decreased pain and muscle tone (Koman et al., 2004).

Intrathecal Baclofen (ITB)

Used exclusively in patients with spastic CP, the goal of these injections is to facilitate care, prevent deformity and diminish pain in patients (Koman et al., 2004).

Alcohol and Phenol

Denatures protein and interferes in the neuromuscular transmission of a nerve impulse, ultimately inhibiting continuous muscle contraction. After the injection (usually in the hip abductors), there is a relatively lengthy period of recovery and pain that can last up to six months before the benefits can be noticed (Koman et al., 2004).

Surgery

With any CP treatment program, the goal is to maximize motor function and minimize the development of secondary problems. Surgery is always a last resort when treating CP, as the invasive nature of the available procedures often comes with risks. That being said, there are certain issues that can only be improved through surgical intervention (Novak et al., 2013).

Selective Dorsal Rhizotomy

Reduces muscle spasticity in CP patients by dividing the posterior spinal rootlets in children preschool age or older. This surgery attempts to identify and then divide out nerve rootlets that are associated with an abnormal motor response while leaving those that function normally. A strict physical therapy program is required after this procedure (Levitt, 1977).

Tendon Lengthening

If a child is experiencing symptoms of extreme muscle tone or co- contraction, surgical lengthening of tendons or muscles is probably the most common surgical procedure. This procedure is usually done when the child is 6-10 years of age, when their gait is relatively mature. Postural instability is often tackled by surgical lengthening of the hips, knees, or ankles to provide a better base of support for the upper body, and hopefully allow the child to maintain better equilibrium (Levitt, 1977).

Physical Activity Guidelines for children & youth with CP

Cerebral palsy’s non-progressive nature means that the impairment will not progress and can ameliorate with treatment, therapy or surgical interventions. It does place stress and strain on a person’s body as it functions with impairment from day-to-day which can cause premature aging, osteoparosis and arthritis (My Child, 2015). Physical activity and a healthly lifestyle are crucial for a healthier future. The American college of sport medicine recommends that those living with CP should view fitness as something that enhances their health, function, and mobility. They recommend that children and youth include cardiorespiratory endurance, muscular endurance, muscular strength, body composition, flexibility, and balance/agility components into their daily life (American College of Sport Medicine[ACSM], 2015). ACSM states that research studies, although few in number and small in sample size, examining the effects of strength and resistance training for persons with CP have shown that they can increase both their muscle strength and endurance with no adverse effects on spasticity or movement patterns (ACSM, 2015). Verschuren et al. (2007) evaluated the effects of an 8-month training program with standardized exercises on aerobic and anaerobic capacity in children and adolescents with cerebral palsy (gross motor function classification system level i or ii). They found a significant training effect for aerobic and anaerobic capacity. Similarly an effect was also found for agility, muscle strength, and athletic competence . On the health-related quality of life measure, the motor, autonomy, and cognition domains all revealed a substantial improvement. They concluded that “an exercise training program improves physical fitness, participation level, and quality of life in children with cerebral palsy when added to standard care” (Verschuren et al., 2007). Similarly, Auld & Johnston (2014) investigated the effect of an eight-week community-based strength and balance exercise group for children with cerebral palsy. They concluded that a community-based, low dose, group exercise program can improve the balance and strength of children with CP within current funding capacity (Auld & Johnston, 2014).

Practical Application for Primary Caregivers

The caregivers or parents of a child with cerebral palsy are the individuals who must manage and apply intervention strategies on a daily basis. Resultantly, successfully applying the management techniques (described in detail above), is far from limited to the knowledge of treatment specialists (Miller, 2005). As a result, it is very important that a healthy liaison develops between a child with CP, caregivers, and the medical practitioners. To begin simply, caregivers must be committed to creating a positive atmosphere that is conducive for optimal development of their child. This necessity is often challenged due to the guilt, fear, anger and anxiety experienced by many parents when it comes to understanding how to manage a child with cerebral palsy. Providing the long-term, high-level care vital for any disabled child with functional limitations can impact both the mental and physical health of the caregiver, ultimately leading to caregiver burnout. Caregiver burnout severely impacts both the development of the child and the health of the caregivers alike. Due to the importance of parents’ emotional health, coping strategies must be explored to ensure that they are managing the stress associated with having a disabled child effectively, and are therefore successful in helping their child progress (Demirhan, 2011). Much of the anxiety experienced by parents is the result of uncertainty regarding how to best manage their child. Resultantly, receiving constant guidance regarding how to best progress with physiotherapy, medications, equipment, and behavioral problems is crucial. It might be extremely beneficial if parents are give the opportunity at least once a week to get out of the home to escape any emotional stress resulting form having a disabled child. This would require a knowledgeable individual to step in and care for the child while the parents are out (Miller, 2006). Furthermore, caregivers may find it hugely beneficial to seek the help of an occupational therapist. Although most of the practical application processes utilized by a occupational therapist have been described above (orthotics, constrained movement therapy, bracing, sitting devices, and joint stretching), occupational therapists are able to provide more consistent help and care as it relates to practically applying treatment strategies in the home setting specifically (Miller, 2006). Home modifications can be made to enhance the movement of a child with CP. Such modifications include (Miller, 2006):

• Replacing steps with ramps.
• Moving obstructions such as furniture from common household pathways.
• Making things such as dressers and refrigerators accessible to facilitate the child in learning how to complete daily tasks.
• Installing arm supports where needed (washrooms for example).
• Making safety features of the home accessible to the child

Occupational therapists may also be able to help caregivers alter or apply prescribed physiotherapy exercises in a manner conducive to the home setting. In addition, exercised can often be modified in a way that makes them more enjoyable for the child to complete. If therapy can be made fun, then the child will be more likely to complete their exercises and approach treatment with a positive attitude (Barber, 2009). In addition, occupational therapists also work to address the barriers of community accessibility. In conjunction with physical accessibility, occupational therapists also attempt to increase a child’s desire to participate or become involved in community groups designed to helping those with disability both physically and emotionally/socially. Oftentimes the occupational therapist has a more ‘hands on’ daily involvement in the child’s life, providing guidance to caregivers and reducing the stress of the parents (Miller, 2006). The practical application as it pertains to specifically enhancing the movement experiences of a child with CP means that intervention strategies are implemented in a manner that feasible and realistically attained for both the caregivers and the affected child. Furthermore, as CP is a complex disorder often spanning across multiple developmental domains, a multidisciplinary team of professionals (doctors, physiotherapists, occupational therapists, speech therapists etc.) are often working with the child separately. It is absolutely essential that all professionals and caregivers communicate with one other regarding the treatment plan and progression of the child. This will ensure that the individualized plan designed to help the child is one that encompasses all developmental domains, and all facets of movement education (Miller, 2005).

Canadian physical activity guidelines suggest that kids (ages 5-11) have at least 60 minutes of moderate to vigorous activity (activities that make them sweat a bit) a day (CSEP, 2014). The health benefits from the appropriate amount of physical activity applies to all children regardless of ability . People with cerebral palsy engage in phsycial activity all the time, it’s a matter of finding an activity that is structured, sustainable and enjoyable for your child (My Child, 2015). Some exercises that can help yout child maintain a high level of fitness include:

• Walking
• Movement
• Swimming
• Aerobics
• Chair exercises (from a seated position in a chair or a wheelchair)
• Organized sports of any kind
• Yoga
• Dancing
• Stretching
• Aqua Therapy

Ways to ensure that your child will maintain their health and movement function:

• Seeking care from a physician that improves one’s health
• Talking openly about bodily changes
• Understanding how and why his or her body is changing
• Maintaining health care records
• Seeking out adaptive equipment when needed
• Making sure a health care is accessible
• Consulting with physical therapists, occupational therapists, fitness trainers and more when a concern develops (My Child, 2015)

Parents should always remember that their children want to play and participate in physical activities just like other children do. There is a modified version for every form of play and recreation, that makes participation of your child a possibility. Often, a parent will need to inquire about how those methods work, and where they can be implemented (My Child, 2015). Sometimes all you need is a little imagination and creativity. Parents may want to take part in the athletic avocation with their child as this can help open up new doors for your child and other children in similar situations. There are many sports that can be modified to fit the needs and interests of people with little or no mobility. People with severe cerebral palsy have taken part in marathons, recreational and competitive swimming, hockey, and even one of the world’s most challenging events, the Ironman Triathlon (My Child, 2015). Aquatic therapy is very popular amongst children with cerebral palsy. (My Child, 2015). My Child (2015) recommends “Buddying up – with a parent, a sibling, or a friend –“ which can create endless possibilities for sport and recreation for children with severe disabilities. Another great idea is to invest in a racing wheelchair. This way your child can compete as a team in marathons, triathlons and walks with a family member or friend.

Movement Opportunities for infants with CP

Play Therapy

Play therapy is both a therapeutic and psychological intervention that uses play to help children with cerebral palsy develop a better sense of inclusion using both directed and non-directed play(My Child, 2015). There are three forms of play therapy. The first form is non-directed play, which occurs when a child is encouraged to engage in any play they wish. This type of play gives a therapist a glimpse of how a child feels, and what issues may be preventing the child from fully expressing him or herself in other situations. Directed play which occurs when the therapist determines how play will proceed. Lastly, is prescribed play which happens when a therapist teaches a child adapted methods of play.

Movement & Sport Opportunities for Children with Cerebral Palsy

There has been a lot of progress in recent years are more and more opportunities are available to children with CP to participate in sports. “Legislation has provided a means to which inclusive, accessible, barrier-free opportunities are afforded to all”(My Child, 2015). In the US The Individuals with Disabilities Education Act (IDEA) was created and passed. This law ensures services, such as sport programs, to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education and related services to more than 6.5 million eligible infants, toddlers, children and youth with disabilities (My Child, 2015). Through this, ALL children (disability or not) may partake in recreation, play and sports – in addition to “fit-in” as they connect with others who are in similar situations, and with those who are not (My Child, 2015). Children with cerebral palsy have as much of a desire as any other child to take part in sports, recreation, and play, but sometimes, they cannot participate in a traditional way (My Child, 2015). For every form of play and recreation, there is a modified version that makes participation a possibility (My Child, 2015). Depending on the extent and severity of the individual’s cerebral palsy, pediatricians and other care team members will likely recommend the least restrictive environment appropriate for each child (My Child, 2015).

Dance and Yoga

Dance without limits provides children with cerebral palsy in British Columbia with a chance to learn how to dance (Cerebral Palsy Association of BC [CPABC], 2015). They also conduct yoga therapy classes that focus on gentle healing movements and individually adapted moves (CPABC, 2015). Both programs are put on by CPABC in Vancouver and Victoria.

Active Video Game Play

Active video games (AVGs) are video games that require body movements such as swinging arms and stepping, beyond that of conventional hand-controlled games. Howcroft et al. (2012) define two extremely impactful and high-potential applications of AVGs: (1) promoting increased daily physical activity for children with and without disabilities, and (2) increasing engagement and participation in physical rehabilitation therapies. In an experimental study the potential of active video game (AVG) play for physical activity promotion and rehabilitation therapies in children with cerebral palsy (CP) was evaluated. Their energy expenditure, muscle activation, and quality of movement was measured to determine the results (Howcroft et al., 2012). The results indicated that moderate levels of physical activity were achieved during the dance and boxing games. Therefore, they concluded AVG play via a low-cost, commercially available system can offer an enjoyable opportunity for light to moderate physical activity in children with CP. Moreover, while all games may encourage motor learning to some degree, AVGs can be strategically selected to speak to specific therapeutic goals (eg, targeted joints, bilateral limb use) (Howcroft et al., 2012).

Special Olympics

Special Olympics is the world’s largest sports organization for people with intellectual disabilities (such as cerebral palsy). To date they have 4.4 million athletes in 170 countries. Currently they offer 32 Olympic-style individual and team sports (Special Olympics, 2015).

Looking to the Future

Researchers today are working to more thoroughly understand the causation of CP, along with better intervention/treatment strategies that will aid in improving the movement experiences of the afflicted child. Currently scientists are examining the following areas:

• Genetic defects: Scientists are collecting DNA samples from affected children and their family members in attempt to establish a coloration between individual genes and the abnormalities that inhibit the brain from developing properly (Thompson et al., 1983).
• Neonatal bleeding in the brain leading to CP is thought to cause the release of harmful and abnormal chemicals that magnify the effects of the original damage. Scientists are working to find new drugs to counteract the damage done by these chemicals (Thompson et al., 1983).
• Systemic hypothermia: This involves the controlled cooling of the body’s core temperature. Research has shown that cooling is an effective treatment in improving the neurodevelopmental outcomes when performed on babies during or directly after birth. Results are usually noticed 18-22 months post treatment, and still much is unknown regarding the mechanism and effectiveness of this modality (Miller, 2006).
• White matter damage: as most cerebral palsy cases are characterized by death of the white matter in the brain, scientists are looking into what chemicals are potentially involved in white matter development, along with how the hormone erythropoietin could potentially reduce the risk of CP in preterm infants (Thompson et al., 1983).

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