Controversial treatment of spasticity: exploring alternative therapies for motor function in children with cerebral palsy

The clinical aspects and effectiveness of suit therapies for cerebral palsy: A systematic review

OBJECTIVES

The aim of this review to evaluate the clinical aspects and effectiveness of suit therapy for patients with cerebral palsy (CP).

MATERIALS AND METHODS

A literature search was performed in the PubMed, SCOPUS, Web of Science, and PEDro databases within the period from the establishment of the relevant database to July 2018. The articles were categorized according to their study design. We included studies published in peer-review journals focusing on the efficacy of suit therapies for CP and excluded review articles, duplications, non-related articles. A narrative synthesis approach was used, as it was not possible to classify extracted and analyzed data, and the overall effect size was unable to be calculated. Data regarding study subjects (number, age, CP type, Gross Motor Function Classification System [GMFCS] level), suit type, intervention including dose of suit therapy, outcome measurements, outcomes, adverse effects, and funding were extracted. The method introduced by Furlan, Pennick, Bombardier, and van Tulder was used to evaluate the risk of bias for the assessment of methodological quality of randomized-controlled trials (RCTs).

RESULTS

A total of 29 studies were included of which 10 were Class I, eight were Class II-III, and 11 were Class IV studies. Studies were heterogenous in design, sample size, study population, and outcomes measured. The methodological quality score of RCTs varied between 4 and 10. The results of the high-quality RCTs showed that wearing the suit along with conventional therapy improved proximal stability, gross motor function, and gait. The Class II-III and IV studies supported the findings of the Class I studies.

CONCLUSION

The major improvements from the RCTs were seen in proximal stability, gross motor function and gait, although grading was unable to be done due to the heterogeneity of included studies. In order to obtain gains in the function, it is important to carefully consider intended use, patient selection criteria, and suit type.

Effects of interventions with therapeutic suits (clothing) on impairments and functional limitations of children with cerebral palsy: a systematic review

BACKGROUND

Therapeutic suits or clothing whether associated with intensive protocols or not, became popular in the rehabilitation of children with cerebral palsy. Studies have reported positive effects of these suits on children's posture, balance, motor function and gait. A summary of current literature may help guide therapeutic actions.

OBJECTIVE

To evaluate the available evidence on the effects of interventions based on the use of therapeutic suits in the treatment of impairments and functional limitations of children with cerebral palsy.

METHOD

Three independent reviewers searched for experimental studies on MEDLINE, SciELO, BIREME, LILACS, PEDro and CENTRAL databases, between October and December 2015 and updated in May 2016. The reviewers evaluated the methodological quality of selected studies using the Checklist for Measuring Quality. The Grading of Recommendations Assessment, Development and Evaluation was used to synthesize the quality of evidence and strength of recommendation.

RESULTS

From the 13 studies, two evaluated the Full Body Suit, two tested the Dynamic Elastomeric Fabric Orthose, three evaluated TheraTogs and six tested the TheraSuit/AdeliSuit protocols. The quality of evidence for the Full Body Suit, the Dynamic Elastomeric Fabric Orthose and the TheraSuit/AdeliSuit protocols was very low for body structure and function outcomes, while the evidence for TheraTogs was low quality. Regarding the activity outcomes, the Full Body Suit and TheraSuit showed very low quality evidence while the evidence for TheraSuit/AdeliSuit protocols were of low quality.

CONCLUSION

Enthusiasm with new therapeutic approaches that argue modifications in the neuromusculoskeletal impairments and functional limitations of children with cerebral palsy need to be guided by scientific evaluation. The low quality of evidence suggests caution in recommending the use of these therapeutic suits. New studies could change the findings of this review.

The impact of hyperoxia on brain activity: A resting-state and task-evoked electroencephalography (EEG) study

A better understanding of the effect of oxygen on brain electrophysiological activity may provide a more mechanistic insight into clinical studies that use oxygen treatment in pathological conditions, as well as in studies that use oxygen to calibrate functional magnetic resonance imaging (fMRI) signals. This study applied electroencephalography (EEG) in healthy subjects and investigated how high a concentration of oxygen in inhaled air (i.e., normobaric hyperoxia) alters brain activity under resting-state and task-evoked conditions. Study 1 investigated its impact on resting EEG and revealed that hyperoxia suppressed α (8-13Hz) and β (14-35Hz) band power (by 15.6±2.3% and 14.1±3.1%, respectively), but did not change the δ (1-3Hz), θ (4-7Hz), and γ (36-75Hz) bands. Sham control experiments did not result in such changes. Study 2 reproduced these findings, and, furthermore, examined the effect of hyperoxia on visual stimulation event-related potentials (ERP). It was found that the main peaks of visual ERP, specifically N1 and P2, were both delayed during hyperoxia compared to normoxia (P = 0.04 and 0.02, respectively). In contrast, the amplitude of the peaks did not show a change. Our results suggest that hyperoxia has a pronounced effect on brain neural activity, for both resting-state and task-evoked potentials.

Efficacy of suit therapy on functioning in children and adolescents with cerebral palsy: a systematic review and meta-analysis

AIM

This systematic review and meta-analysis presents an overview of the efficacy of suit therapy on functioning in children and adolescents with cerebral palsy (CP).

METHOD

A systematic review with meta-analysis was conducted. A comprehensive search of peer-reviewed articles was performed on electronic databases, from their inception to May 2014. Studies included were rated for methodological quality using the Physiotherapy Evidence Database scale. Effects of suit therapy on functioning were assessed using meta-analytic techniques.

RESULTS

From the 46 identified studies, four met the inclusion criteria and were included in the meta-analysis. Small, pooled effect sizes were found for gross motor function at post-treatment (g=0.46, 95% confidence interval [CI] 0.10-0.82) and follow-up (g=0.47, 95% CI 0.03-0.90).

INTERPRETATION

The small number of studies, the variability between them, and the low sample sizes are limitations of this review. Findings suggest that to weigh and balance benefits against harms, clinicians, patients, and families need better evidence to examine and prove the effects of short intensive treatment such as suit therapy on gross motor function in children and adolescents with CP. Therefore, more research based on high-quality studies focusing on functioning in all dimensions of the International Classification of Functioning, Disability and Health perspective is necessary to clarify the impact of suit therapy.

Complementary, Alternative, and Mainstream Service use Among Families with Young Children with Multiple Disabilities: Family Costs to Access Choices

ABSTRACT Families raising a young child with multiple disabilities are charged with significant responsibilities such as learning about their child's condition and navigating mainstream and alternative services. Aim: Describe service choices, costs, out of pocket expenses, and the impact on families. Methods: Survey design using a custom questionnaire was used to collect extensive retrospective and current data. Purposive sampling (N = 29) occurred from one early intervention facility specialized in servicing children with cerebral palsy (CP) and, or multiple disabilities in Australia. Descriptive statistics were used for analysis of data. Results: Twenty-three (79%) families reported caring for a child with CP. Twenty-three families reported using at least one complementary/alternative intervention. Out-of-pocket amounts were reported including: chiropractic services (10 families); naturopathy (9 families); point percussion therapy (7 families), and Chinese medicine (6 families). Expenses resulted in families reporting forgoing clothing items, family entertainment, recreation/hobbies for parents (55%); family holidays (59%); time for parents alone (66%); and health services for parents (38%). Conclusions: Families of young children with multiple disabilities select a wide range of services for their child, with consequential out of pocket expenses. Early intervention professionals can be an important resource for families as they evaluate their choices and select interventions for their child.

Parents' attitudes toward the use of complementary therapy by their children with moderate or severe cerebral palsy

OBJECTIVE

To describe the use of, and attitudes toward, complementary therapy (CT) by parents of children with moderate to severe cerebral palsy.

METHODS

Parents of 32 children with cerebral palsy (age 5-12 years) enrolled in a randomized trial of cranial osteopathy prospectively participated in semi-structured interviews in the home to explore the use of CT and views regarding access to and expectations of these therapies. Interview transcripts were analyzed thematically, and content analysis was used to determine the frequency of use of different therapies.

RESULTS

Sixteen children (50%) had received one or more types of CT, although only three were currently receiving any CT. The primary reasons for trying CT were to reduce children's pain and improve physical function. Parents had limited knowledge of the range of, and possible indications for, CT and expressed concerns about CT safety and effectiveness. Practical considerations of time and cost were also identified. Some parents had strong beliefs about the benefits, and, overall, parents indicated a high level of commitment to finding any treatments, conventional or CT, to help their children.

CONCLUSION

Parents of children with cerebral palsy want to help their child, but they need information, guidance, and practical support to facilitate their decision-making regarding the use of CT. A clearer understanding of factors predictive of optimal outcomes will enable resources to be targeted effectively.

Pursuit of Complementary and Alternative Medicine Treatments in Adolescents With Cerebral Palsy

This study determined the extent to which parents of adolescents with cerebral palsy seek out complementary and alternative medicine services. A regional sample of 166 adolescents (15.5 ± 2.4 years) with cerebral palsy were recruited. Parents completed a questionnaire identifying the complementary and alternative medicine services received over the past year. Most (73.2%) did not currently utilize any of the listed services; 7.3% used 2 or more services. The most commonly used services were massage (15.4%), hyperbaric oxygen (9.6%), and osteopathy (5.7%). Youth with limited hand function were more likely (P = .01) to undergo hyperbaric oxygen. Massage therapy services were more frequent in youth with greater activity limitations (P < .005). Sociodemographic factors were not predictive of use. Approximately one quarter of families sought out these services for their adolescents with cerebral palsy. Many are expensive privately funded treatments. Physicians should openly discuss these options with families, highlighting the current state of knowledge on their efficacy.

Effects of Modified Adeli Suit Therapy on Improvement of Gross Motor Function in Children with Cerebral Palsy

Objective

This study aimed to investigate the effects of the Modified Adeli suit therapy (MAST) on improvement of gross motor function in children with cerebral palsy (CP).

Methods

Thirty-six children with CP assigned by match pairs to three equal groups such as the MAST, the AST, and the Neurodevelopmental Treatment. They were treated for 4 weeks, 2 hr/d, 5 d/wk. All children were tested by the Gross Motor Function Measure (GMFM) at baseline, immediately before and 16 weeks after treatments.

Results

All groups had improvement in the GMFM after treatment (p < .01) and there were significant differences among groups (p < .01). In the follow-up study, no significant improvement in the GMFM was seen within groups (p > .05), but again there were significant differences among groups (p < .01).

Conclusion

The MAST was more effective than using either the AST or the Neurodevelopmental treatment on improvement of gross motor function in children with CP after treatment and at follow-up.

Growing older with cerebral palsy: insiders' perspectives

PURPOSE

Research has shown that adults with cerebral palsy (CP) lose functional abilities earlier than persons who are able-bodied. Because CP is a lifespan disability, developmental therapists should be aware of these changes.

METHODS

We used descriptive phenomenology to understand the unique, lived experiences of adults growing older with CP. Data were gathered through in-depth, semistructured interviews. Open-ended questions asked what it was like to age with CP, how these experiences were understood, how strategies were used to cope with changes, and what are the meanings of these experiences.

RESULTS

A theme, Awareness, Acceptance, and Action, emerged from the data analysis. Participants were aware that their bodies were deteriorating quicker than those of peers who are able-bodied. They developed acceptance that hastened actions toward improving their quality of life.

CONCLUSIONS

These findings provide insights for pediatric therapists who work with children with CP about what may be important to their clients as they grow older.

Unethical prescriptions: alternative therapies for children with cerebral palsy

The US National Center for Complementary and Alternative Medicine (CAM) defines CAM as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine." The problem with said therapies is that, for the most part, their effectiveness is questionable and their side effect profile is essentially unknown. Furthermore, as stated by Rosenbaum, many CAM treatments are based on "at best, anecdotal evidence and at times rather unusual ideas about the biology of the conditions to which they are being applied." In spite of the data shortage,Americans are forecasted to spend more than $42 billion on CAM during 2009. Using a patient for illustration purposes, the author presents 3 CAM treatments that have been advocated for children with cerebral palsy. The current scientific literature on these remedies and their purported benefit is reviewed. The article ends with a discussion on the reasons why prescribing said therapies is contrary to the concept of evidence-based medicine and the tenets of medical ethics.

Complementary and alternative methods in cerebral palsy

There are no published studies specifically addressing complementary and alternative treatments in adults with cerebral palsy (CP). However, national surveys of adults with chronic disabilities document that a majority of them use such treatments, that they are willing to pay out of pocket, if necessary, and that they believe that pursuing such treatment relieves pain, reduces stress and anxiety, and leads to improved feelings of fitness and well-being. Individuals enjoy taking charge of their own health care decisions, and frequently feel more in control with these therapies than with more traditional methods. In contrast to adults, there is some information on complementary and alternative methods (CAM) in children with CP. This article discusses some of the CAM used in children that may be carried over into adulthood, as well as the pitfalls for patients and conventional physicians as they try to sort out what might be helpful and what might be harmful in this arena. Practitioners of both conventional and CAM therapies believe that exercise can be beneficial; accordingly, activities such as recreational sports, yoga, and hippotherapy may be continued from childhood into adulthood. General treatments for stress and anxiety, through such activities as yoga and meditation, though not directed at CP per se, may be more popular for adults than children. Research in this area should first identify what methods are being utilized and then subject these methods to well-designed outcome studies that take into account any associated risks.

The child with cerebral palsy: diagnosis and beyond

Cerebral palsy (CP) is one of the most common conditions we follow in our pediatric neurology offices. This review will hopefully convince you that the care of children with CP extends far beyond the diagnosis. The review addresses issues surrounding diagnosis, coimpairments, prognosis, and family-centeredness of care. It will also deal with routine office follow-up to prevent or identify complications, management of spasticity and other morbidities, alternative and complementary therapies, and finally transition.

Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy

This study compared the efficacy of Adeli suit treatment (AST) with neurodevelopmental treatment (NDT) in children with cerebral palsy (CP). Twenty-four children with CP, Levels II to IV according to the Gross Motor Function Classification System (GMFCS), were matched by age and functional status and randomly assigned to the AST or NDT treatment groups. In the AST group (n=12; eight males, four females; mean age 8.3 y [SD 2.0]), six children had spastic/ataxic diplegia, one triplegia and five spastic/mixed quadriplegia. In the NDT group (n=12; nine males, three females; mean age 8.1 y [SD 2.2]), five children had spastic diplegia and seven had spastic/mixed quadriplegia. Both groups were treated for 4 weeks (2 hours daily, 5 days per week, 20 sessions). To compare treatments, the Gross Motor Function Measure (GMFM-66) and the mechanical efficiency index (EIHB) during stair-climbing were measured at baseline, immediately after 1 month of treatment, and 10 months after baseline. The small but significant time effects for GMFM-66 and EIHB that were noted after 1 month of both intensive physiotherapy courses were greater than expected from natural maturation of children with CP at this age. Improvements in motor skills and their retention 9 months after treatment were not significantly different between the two treatment modes. Post hoc analysis indicated a greater increase in EIHB after 1 month (p=0.16) and 10 months (p=0.004) in AST than that in NDT, predominantly in the children with higher motor function (GMFCS Levels II and III). The results suggest that AST might improve mechanical efficiency without a corresponding gain in gross motor skills, especially in children with higher levels of motor function.

Pharmacotherapy of spasticity in children with cerebral palsy

Spasticity is one of the most common symptoms presented by neurologic patients. Apart from surgical management, drug therapy is an important treatment of children suffering from spasticity. In this review, recent advances in the pharmacologic armamentarium are reported in detail. In particular, there are oral medications (benzodiazepines, baclofen, dantrolene sodium, alpha 2 adrenergic agonists) and parenteral medications (botulinum toxin type A and B, alcohol). Moreover, there is also baclofen that can be administered intrathecally. There are some reports supporting the use of intramuscular alcohol (45% and/or 5-7% phenol) to reduce spasticity without the loss of voluntary movement or loss of sensation. Among these drugs, intrathecal baclofen is one of the most effective substances that can reduce spasticity significantly in the upper and lower extremities. Finally, the effectiveness of therapy with botulinum toxin type A in the management of spasticity is analyzed. Botulinum toxin type A reduces hypertonia in the injected muscles for a period of 2 to 4 months without important side effects. The purpose of this article is to provide an overview of available oral and parenteral drugs for treatment of spasticity in cerebral palsy and to outline indications and contraindications.

Complementary and alternative therapies for cerebral palsy

The optimal practice of medicine includes integrating individual clinical expertise with the best available clinical evidence from systematic research. This article reviews nine treatment modalities used for children who have cerebral palsy (CP), including hyperbaric oxygen, the Adeli Suit, patterning, electrical stimulation, conductive education, equine-assisted therapy, craniosacral therapy, Feldenkrais therapy, and acupuncture. Unfortunately, these modalities have different degrees of published evidence to support or refute their effectiveness. Uncontrolled and controlled trials of hippotherapy have shown beneficial effects on body structures and functioning. Studies of acupuncture are promising, but more studies are required before specific recommendations can be made. Most studies of patterning have been negative and its use cannot be recommended. However, for the other interventions, such as hyperbaric oxygen, more evidence is required before recommendations can be made. The individual with CP and his or her family have a right to full disclosure of all possible treatment options and whatever knowledge currently is available regarding these therapies.

Complementary and alternative medicine in developmental disabilities

Developmental disabilities (DD) are defined as a diverse group of severe chronic conditions due to mental and/or physical impairments. Individuals with developmental disabilities have difficulty with major life activities including language, mobility, and learning. Developmental disabilities can begin anytime during development--from prenatal up to 22 years of age, and the disability usually lasts throughout a person's lifetime. Autism spectrum disorders, cerebral palsy, mental retardation, and attention deficit hyperactivity disorder are common conditions falling within the definition of developmental disabilities. Complementary and alternative medicine (CAM) is becoming increasingly utilized in the general population for treatment of everything from the common cold to complex and chronic medical conditions. This article reviews the prevalence of different types of CAM used for various developmental disabilities.

Hyperbaric oxygen in the treatment of patients with cerebral stroke, brain trauma, and neurologic disease

Hyperbaric oxygen (HBO) therapy has been used to treat patients with numerous disorders, including stroke. This treatment has been shown to decrease cerebral edema, normalize water content in the brain, decrease the severity of brain infarction, and maintain blood-brain barrier integrity. In addition, HBO therapy attenuates motor deficits, decreases the risks of sequelae, and prevents recurrent cerebral circulatory disorders, thereby leading to improved outcomes and survival. Hyperbaric oxygen also accelerates the regression of atherosclerotic lesions, promotes antioxidant defenses, and suppresses the proliferation of macrophages and foam cells in atherosclerotic lesions. Although no medical treatment is available for patients with cerebral palsy, in some studies, HBO therapy has improved the function of damaged cells, attenuated the effects of hypoxia on the neonatal brain, enhanced gross motor function and fine motor control, and alleviated spasticity. In the treatment of patients with migraine, HBO therapy has been shown to reduce intracranial pressure significantly and abort acute attacks of migraine, reduce migraine headache pain, and prevent cluster headache. In studies that investigated the effects of HBO therapy on the damaged brain, the treatment was found to inhibit neuronal death, arrest the progression of radiation-induced neurologic necrosis, improve blood flow in regions affected by chronic neurologic disease as well as aerobic metabolism in brain injury, and accelerate the resolution of clinical symptoms. Hyperbaric oxygen has also been reported to accelerate neurologic recovery after spinal cord injury by ameliorating mitochondrial dysfunction in the motor cortex and spinal cord, arresting the spread of hemorrhage, reversing hypoxia, and reducing edema. HBO has enhanced wound healing in patients with chronic osteomyelitis. The results of HBO therapy in the treatment of patients with stroke, atherosclerosis, cerebral palsy, intracranial pressure, headache, and brain and spinal cord injury are promising and warrant further investigation.

Effectiveness of intensive training for children with cerebral palsy – a comparison between child and youth rehabilitation and conductive education

OBJECTIVES

To compare the short-term effectiveness of 1 intensive training period in child and youth rehabilitation with Move&Walk conductive education and describe the effects of 1 intensive training period in terms of changes at 1 year. The amount and influence of additional consumption of training during the 1-year follow-up was also analysed.

DESIGN

Quasi-experimental with 2 groups: Lemo (n=23) and Move&Walk (n=29).

PATIENTS

A total of 52 children with cerebral palsy, age range 3-16 years.

METHODS

Data included repeated measures with Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory-Functional Skills (PEDI-FS). Data on additional consumption of training was collected at the 1-year follow-up.

RESULTS

There was no difference in proportion of change on the clinical measures between the training programmes, except for a higher proportion of improvement on the GMFM total score in Lemo. At the group level, small improvements were shown on GMFM and PEDI FS in the short-term and on PEDI FS only at 1 year. A higher proportion of children who participated in repeated intensive training periods showed improved social functioning.

CONCLUSION

No major differences were shown between the 2 training programmes. One intensive training period facilitated small improvements in gross motor function. The majority of children had a high consumption of training during the 1-year follow-up and the added value of repeated intensive training periods was limited.