1. Cerebral Palsy
Do we know it all?
By
Rajul vasa B. Sc. P T
Applied movement scientist
Mumbai [India]

2. Till date………
 Till date what is well understood is that
cerebral palsy is a non progressive condition
from lesion in the brain,
 at birth
 before birth (intra uterine)
 during infancy or childhood.
 It is also known that with growing age child
does deteriorate with ongoing secondary and
tertiary problems of muscle contracture, joint
stiffness, spasticity and abnormal dyskinetic
movements.

3. Current belief…..
 Cerebral palsy cannot be cured, but a host of
interventions can improve functional abilities,
participation, and quality of life Peter Rosenbaum in Cerebral
palsy: what parents and doctors want to know [BMJ 2003;326:970–4]
 Today's mainstream physical rehabilitation methods
of cerebral palsy is "managing" the child with his
limitations because treatment is only palliative.
 Unfortunately as Physical medicine continues to
remain in primitive state, dependence on expensive
high tech engineering devices is on increase to help
ambulate child instead of equipping the child’s brain
and body from within for independence.

4. No cure!
 No cures are available or imminent for
the majority of the disorders that have
been categorized as CP, and potential
positive effects of most interventions
on most individuals with CP tend to be
modest at best. Damiano DL. Activity, activity, activity: rethinking our
physical therapy approach to cerebral palsy. Phys Ther. 2006;86:1534 –1540.

5. Foreseeable future
 For at least the foreseeable future, cerebral
palsy will not be a curable disease and we
will not be able to reverse the underlying
Pathophysiology. Therefore, the goal of
treatment is to assist with the child’s motor
and cognitive development and to prevent
the occurrence of secondary injury
1. Ref: Is Cerebral Palsy a Wastebasket Diagnosis? Terence D. Sanger, MD, PhD Journal
of Child Neurology Volume 23 Number 7 July 2008 726-728
2. Ref: A systematic review finds that methodological quality is better than its reputation
but can be improved in physiotherapy trials in childhood cerebral palsy by Regina
Kunza et al Journal of Clinical Epidemiology 59 (2006) 1239e1248

6. Is Cerebral palsy a wastebasket diagnosis?
 Perhaps intended image of the term “wastebasket diagnosis “
is many different etiologies are thrown together in a single
syndrome without any attempt at establishing order.
Furthermore, a wastebasket is not just a receptacle; it is a
receptacle with a purpose. So an additional intended image
might be that a diagnosis, once thrown in the wastebasket,
can then somehow be discarded because it fulfills no useful
therapeutic role. Another image that is perhaps unintended
but that nevertheless reflects a frequent and unfortunate
reality is that a child with a wastebasket diagnosis may be
discarded as well, in the sense that child neurologists are not
often involved in the long-term care of children labeled with
“cerebral palsy.” Is Cerebral Palsy a Wastebasket Diagnosis? Terence D. Sanger, MD,
PhD Journal of Child Neurology Volume 23 Number 7 July 2008 726-728

7. Costs
 Cost of services to these children and their families is
substantial, with health costs alone estimated at $1,406
per family per year (over $6 billion per year) [1]. Non-
reimbursed costs to families for services, equipment, and
lost family income can amount to thousands of dollars
each year. Honeycutt et al. [2] state that the extra
economic lifetime costs associated with cerebral palsy is
$800,000 per person.
 [1] U.S Department of Health and Human Services: Research plan for the
National Center for Medical Rehabilitation Research. Washington, DC: U.S.
Department of Health and Human Services; 1993.
 [2] Honeycutt AA, Grosse SD, Dunlap LJ, Schendel DE, Chen H, Brann E,
Homsi G: Economic costs of mental retardation, cerebral palsy, hearing loss,
and vision impairment. In Using survey data to study disability: results from the
National Health Interview Survey on Disability. Research in Social Science and
Disability, 3 Edited by: Altman BM, Barnartt SN, Hendershot GE, Larson SA.
Amsterdam: Elsevier; 2003:207-228

8.  In Sweden there was a lively debate criticizing child and
youth rehabilitation for being too pessimistic about the
development of the child, making the children passive by
compensating too much with assistive devices and
environmental adaptations and failing to support active
functional and more intensive training. There was also a
debate among professionals whether treatment of the
capacities of the child was sidelined in favour of actions
taken to support social aspects and participation of the
child in their environment. Another suggestion as to why
treatment was sidelined was the uncertainty about
treatment effects and utility from the aspect of health.

Ref. effectiveness of intensive training for children with cerebral palsy – a comparison
between child and youth rehabilitation and conductive education Pia O¨ dman and
Birgitta O¨ berg J Rehabil Med 2005; 37: 263–270
Ref. Forssberg H, Sanner G, Ro¨sblad B. Renaissance for physiotherapy in
treatment of Cerebral Palsy. [Rena¨ssans fo¨ r sjukgymnastik I behandling av CP-
skadade]. La¨kartidningen 1998; 95: 1660–1664.

9. Part and Parcel
 Poor general health conditions, repeated infections
with cough, cold, fever from slightest changes in
weather, indigestion, bowel troubles, softening of
bones, bony growth disturbances with without
mal formation of bones and joints, delay in motor
development with perceptual cognitive difficulties,
sometimes hearing and visual problems, memory
problems, seizures, reflex muscle twitches
invariably misunderstood as seizure, spasticity,
contracture are considered as part & parcel of the
condition.

10. Contemporary treatment
 Treatment of CP children is palliative, symptom based.
 Attempt in multidisciplinary rehabilitation efforts is to
analyze the severity of the symptoms and the condition
to manage the lives of CP children and support higher
levels of function with use of special devices!
 Contemporary physiotherapy interventions attempt to
stretch Muscles to their limits on a regular basis to
maintain length. Stretching is highly painful and
tightness reappears again and again despite regular
stretching. This must make all of us to rethink how
fruitless is stretching and should child go thro’ painful
regime for no gain?

11. Physical therapy
 Physical therapy, along with orthopedic surgery, has been
the mainstay of the rehabilitation management of CP for
decades but What is less clear is the extent to which
physical therapy can alter the motor prognosis or make a
clinically significant change in the level of disability or
degree of participation for any given child. Traditional
therapy approaches have been shown for the most part to
be marginally beneficial ref DeJong G, Horn SD, Conroy B, et al. Opening the black
box of poststroke rehabilitation: stroke rehabilitation patients, processes, and outcomes. Arch Phys
and demands serious
Med Rehabil. 2005;86(12 suppl 2):S1–S7.
reconsideration to re evaluate if, therapy offered itself is the
cause of concern in terms of painful passive stretching of
muscles without much benefit except suffering pain.

12. Packaged Approaches
 Pediatric neuro rehabilitation in contrast to adult
neuro rehabilitation seems to be more “susceptible”
to packaged approaches that incorporate many
different types of exercises, making it more difficult
to decipher the active ingredients that may be
producing any positive treatment effects that are
seen
 we need to identify what specific treatments,
components of treatments, or “doses” of treatments
work and to ultimately be able to prioritize
treatment options based on relative efficacy in
specific patient groups.

13. Radical reorientation in thinking
 Neuro-developmental therapy approaches, which espoused for
many years that one should “never strengthen spasticity” because
this would only serve to worsen spasticity and make patients stiffer.
Based on research evidence to the contrary, the incorporation of
strength training into physical therapy regimens for people with CP
and other CNS disorders has become increasingly prevalent over
the past decade. A systematic review published in 2002 listed 10
studies that showed consistent and significant gains in strength as a
result of varied short-term programs in both the upper and lower-
extremity muscles in individuals with CP. ref Dodd K, Taylor N, Damiano
DL. Systemic review of strengthening for individuals with cerebral palsy. Arch Phys
Med Rehabil. 2002;83: 1157–1164. ) this is a radical reorientation in thinking ,
yet the CP child around the world is struggling to get out of the
clutches of therapy that does not promise cure and rehab experts
are not ready to see the negative side of therapy itself.

14. Effectiveness of therapy?
 It is difficult to evaluate the effectiveness of any
motor therapy approach for a host of reasons. Chief
among them is that standardizing the treatment is
difficult as there is no discrete dosage administered
under specific, invariable constant condition. The
dosage or amount of time in therapy could be held
constant, but specific aims of different therapists
vary. While the treatment setting could be
standardized, the child’s family background and
educational intellectual capacity varies and cannot
be standardized. Medical treatment and dosages of
sedatives also may not be constant.

15. Dosage
 The ‘dose’ of physiotherapy intervention (e.g.,
frequency, duration, etc.) is often decided following
tradition and modified by economic considerations;
the dose is seldom evidence-based and therefore the
optimal dosage is not known.

16. Evidence based research and clinical research
 Research evidence is important to be able to
generalize any treatment approach universally.
 When it comes to movement science there is
infinite variability in physical movement and
there is unlimited influence of forces on
movement variability. Scientific research
design has highly restricted boundaries and
dichotomizing is critical essence of evidence
based research. Scientific research in
movement science leaves behind critical
essence of Macro; one whole to focus on
micro.

17. Global Local
 Focus on local is another critical issue in evidence
based research making the conclusions made from
tubular vision without any light from integral
interrelations among global when human body
and brain and all major physiological systems
work in integration with one another for
homeostasis.
 Human body and brain always remains under
high influence of gravity.

18. Investigations
 information necessary for developing
postural motor control of a child is
"written“ & “expressed” by the
musculoskeletal system directly therefore
instrumental methods of diagnostics (MRI,
X-rays, EEG, EMG etc.) becomes only of
supplementary value as against the value to
money if compared with the physical
assessment.

19. Parent’s frustration
 Parents in search of solution visit different
multidisciplinary experts for expensive treatment but get
frustrated when these experts usually end up only with
special evaluations to identify special label to be given to
their child under the umbrella term cerebral palsy to
learn that there is no cure and they could try alternative
medicine, acupressure, acupuncture etc but must stretch
tight muscles every day and assist their child in function
and that parents need to learn how to cope with the
child’s day to day needs and be mentally prepared for
future surgical needs to release contracture and tightness
in adductors of hip for basic hygiene and cleaning etc.

20. Powerful India