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What is the best evidence for physiotherapy in cheldren with cerebral palsy? Diane. L. Damiano, Phd PT

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What is the best evidence for physiotherapy in cheldren with cerebral palsy? Diane. L. Damiano, Phd PT

  1. 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. 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. 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. 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. 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. 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. 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. 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. 9. CP is not a “non-progressive” disorder • Evidence of decline in mobility in adolescents: GMFCS-Expanded and Revised Motor Growth Curves
  10. 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. 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. 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. 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. 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. 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. 16. Novak et al, 2013
  18. 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. 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. 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. 21. Strength & Mobility in CP* (1990s) GMFCS LEVELS *Leg strength related to walking speed in CP (r=0.70)
  22. 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. 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. 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. 25. “All learning involves the development of new connections in the brain” Dr. Otto Friesen Neural Circuits Seminar
  26. 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. 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. 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. 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. 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. 31. Gracias / Thank you