1.
What is the Best Evidence for Physiotherapy in
Children with Cerebral Palsy?
Diane L. Damiano, PhD PT
National Institutes of Health
Bethesda, MD USA

2.
Cerebral palsy – what we know:
• Most common physical disability in childhood
• No cure but learning more about causes, & how
to prevent or lessen severity of some types of CP
• Families have greatest impact on their child’s
development and well-being and our roles are to
help and support them in this

3.
• In many parts of the world, children w/ disabilities:
• Are hidden or shunned, no access to education or basic
health care
• Have little voice in setting goals for their own lives
• Experience more frequent neglect/abuse
• Have little or no adaptive equipment or access
• Are passive recipients of treatments done to them
• Are removed from home and community for care
• Receive care that is not evidence-based
Children with CP are Children First!

4.
• Family Support and Education
• Facilitate goal setting with the family
• Resource for services & opportunities for their child
• Recommend strategies for positioning, handling and training
their child in the home
• Clinical Evaluation:
• Assessment of motor capabilities of the child
• Assess need for orthoses & assistive devices to promote
independence and mobility
• Provide Direct Treatment or Parent Coaching
Roles of Therapists

5.
Five Key Principles for Physiotherapy
1. Intervention should aim to change a child’s function
& ability to participate in everyday life and society
2. Therapy should be directed by child & family goals
3. Treatment should be in natural settings where
possible (home & community)
4. Children should be actively engaged in therapy
5. Interventions should be grounded in basic science &
evidence from clinical trials

6.
Measuring “success” of therapy
• Changing a body structure or function not enough
(e.g. strength, range of motion)
• Must meet a child/family goal or change level of
activity or participation to be meaningful
• Benefits must outweigh risks
• Costs to family (money and time) must be reasonable
• Must be practical, acceptable, and feasible (and
available)

7.
Physiotherapy and Level of CP
• GMFCS can help families & therapists set more
realistic & achievable goals for children
• Treatments may not challenge more functional
children or may be too hard or not appropriate for
those less functional
• Recognize few treatments can move a child from
one level to another, but it is possible
• Some children may lose a level in adulthood (Level
III-V are at highest risk)

8.
GMFCS (Clasificación de la Función
Motora Gruesa)
• NIVEL I - Camina sin restricciones
• NIVEL II - Camina con limitaciones
• NIVEL III - Camina utilizando un dispositivo
manual auxiliar de la marcha
• NIVEL IV - Auto-movilidad limitada, es posible que
utilice movilidad motorizada
• NIVEL V - Transportado en silla de ruedas

9.
CP is not a “non-progressive” disorder
• Evidence of decline in mobility in adolescents: GMFCS-Expanded
and Revised Motor Growth Curves

10.
• “Conscientious, explicit, and judicious use of current
best evidence in making decisions about the care of
individual patients” (Sackett 1997)
Evidence-Based Practice

11.
• Optimal care compromised!
• Time spent on ineffective therapy takes time that
could be spent on more effective ones
• Funding for treatment will be withdrawn
• Family ‘faith’ in medicine deteriorates
• Alternative treatments are explored & utilized
When EBP is Not Implemented

12.
• Right to therapy: ”Legislation has preceded
evidence for the efficacy of physical therapy”
• Little evidence to support NDT; need to explore
use of strengthening to improve gait
• Home programs important for sufficient practice
• Early intervention: no efficacy for improving
motor prognosis or achieving milestones
Evidence for Physiotherapy in CP 20 years ago
(Barry, 1996)

13.
Traditional Therapies
• These were developed in advance of more recent
science and are now “outdated” (e.g. Bobath)
• Many have no basis at all and some may even can
cause harm (e.g. Vojta, hyperbaric oxygen)
• Evidence supports more intensive task-specific or
activity based approaches

14.
• 25 yr retro/perspective on CP research success:
– Evolution of rehab approach: family centered, EBP: UE
rehabilitation, strengthening, fitness, BWSTT
– Advances in classification, outcome measures, motor
prognosis (GMFCS), > interest in adults
– Beginning to understand mechanisms of activity-
dependent plasticity
Cerebral Palsy: Definition, Assessment &
Rehabilitation (Richards, Malouin 2014)

15.
Preferentially
use this
approach
Proven
Effective
Do NOT use this
approach.
Choose
alternative
Proven
Ineffective
Measure effects.
Were goals met?
Uncertain
EffectInsufficient
evidence
No
evidence
Conflicting
evidence Novak & McIntyre, 2010

16.
Novak et al, 2013

17.
WORTH IT LINE
EFFECTIVE
INEFFECTIVE
DO ITS+
PROBABLY DO ITW+
UNKNOWN IN CP?
PROBABLY DON’T DO ITW-
DON’T DO ITS -
Novak et al, 2013

18.
Scientific Basis for Physiotherapy in CP
• No one single “science of physiotherapy”; field based
on solid scientific principles from several disciplines*:
1. Exercise physiology: muscle & bone structure &
function, joint flexibility, physical conditioning
2. Kinesiology/ Motor learning: motor skill and
coordination
3. Neurophysiology/ Neuroscience: how the brain controls
movement & how movement alters the brain
*ALL REQUIRE CHILD TO BE AN ACTIVE PARTCIPANT

19.
Exercise Physiology Principles in CP
• Wolff’s Law: Bones (and muscles) develop and
remodel in response to stresses placed on them
• Osteopenia/porosis: major problem in non-
ambulatory children
• Muscle weakness in CP due to brain injury and
inactivity (window of opportunity)
• Basic principles no different in CP, but may have
special considerations (e.g. muscles to target) to
enhance safety and effectiveness Strength X
BW

20.
What we know about strength in CP
1. Children with CP are weak
2. Strength in CP related to function
3. Children with CP can get stronger
5. Strengthening can have functional benefits
6. Strengthening does NOT increase spasticity!

21.
Strength & Mobility in CP* (1990s)
GMFCS LEVELS
*Leg strength related to walking speed in CP (r=0.70)

22.
Muscle Strengthening
• Multiple reviews in CP & other conditions showing that strength can
be increased (Dodd, Tayl0r & Damiano 2002; Taylor, Dodd & Damiano 2006)
• Changes in gait speed & other aspects of functioning noted often but
not consistently
• Depends on ‘dose’ and ‘duration’. Must be done properly & for
sufficient time to achieve benefits
• Must be maintained across lifespan

23.
Motor Learning Principles (1980s)
• Motor learning = set of internal [brain] processes associated
with practice or experience leading to relatively permanent
changes in the capability for responding (Schmidt 1988)
• Carr & Shepherd (stroke rehabilitation) emphasized that
patients with brain injury can improve skill with training
– sensory input should come from self-generated movement, not
sensory input provided by therapist
– instruction, feedback & participation are essential to learning
– practice needs to be repetitive & task-specific (intensive)
– transfer into activities of daily living needed to persist

24.
Emerging Principles from Neuroscience
• Training optimally should include:
• Self-initiated movement & physical effort
• Underlying loose but variable rhythm (CPG)
• Sufficient practice and intensity
• Mental engagement (cognitive effort)
• Involve error recognition and correction
• Be meaningful & motivating to patient

25.
“All learning involves the development of new
connections in the brain”
Dr. Otto Friesen
Neural Circuits Seminar

26.
• Physiotherapy for cerebral palsy: historical
review. (Eva Bower, 1993): “In view of the fact
that brain damage cannot be reversed in
cerebral palsy, it seems unlikely that there will
be recovery other than maturation and
compensatory movement.”
View of the Brain 20+ Years Ago

27.
Neurobiology of Physical Activity
 Health benefits of exercise known for decades
 Now recognizing effects of activity on the brain:
 Muscle (electrical) activity or inactivity (e.g. amputation,
SCI) can dramatically alter brain pathways
 Activity signals the brain to “grow” or “decay” (NGF)
 Motor training can improve cognition, memory
 Linked to less depression & anxiety, better sleep

28.
Upper Limb Training Success
• Best evidence among all therapeutic approaches.
• Intense training with incremental challenge and progression;
shown to alter brain pathways
• So far utilized only on children with unlateral CP
• Similar approach in legs now studied with initial positive
results (Bleyenheuft)

29.
• No similarly strong clinical evidence for lower
limb training
• Legs task requirements different than arms:
– Need more anti-gravity strength & postural control
– Incorporate spinal locomotor rhythms & reflexes
– Gross (vs. fine) motor (walking vs. manipulating)
– Requires coordination within and across limbs
• Intense training in legs often use devices, but
with mixed success (devices may assist too much)
Lower Limb

30.
DESARROLLO / KEY POINTS
• Temas: Activity is key ingredient; limbs used least
probably need the most training. The sooner, the better.
The more, the better. Passive treatment not helpful!
• Temas: Children with CP need as active a lifestyle as
possible, but that requires effort – from them, their
parents, clinicians and society
• Temas: Physiotherapists must learn and use best
available scientific evidence to help children & families
• Temas: What happens outside of therapy matters most!

31.
Gracias / Thank you