Physiotherapy in children with cerebral palsy - BLF

Physiotherapy in 

children with cerebral palsy 

Eva Brogren Carlberg 

PT, Associate Professor 

Dept of Woman & Child Health 

Karolinska Institute 

& 

Handicap & Habilitation 

Stockholm

Intervention for CP 

began 

mid-1940’s 

Initial habilitation 

concepts explored 

and refined 

“Traditional” 

philosophy 

of habilitation 

1980 

New concepts evolved 

out of experience and 

research 

Contemporary 

philosophy 

of habilitation 

Charlene Butler, Ed. D. 

Seattle, USA 

Eva Brogren Carlberg 19 januari 2007 2



Seattle, USA 



Seattle, USA 


Research on ambulatory capacity 

in CP 

• Never achieved by some 

• Loss or deterioration in many 

In teen age due to energy cost 

About age 25 - due to ’physiological burn 

out’ 

About age 45 – due to joint deterioration 

and pain 


Motor 

Growth 

Curves 

'Prognosis for Gross Motor Development in Cerebral Palsy. 

Creation of Motor Growth Curves', Rosenbaum et al., JAMA 2002; 288; 1357-63. 


Other Conceptual Shifts 

• Disability movement 

• Model of disablement 

• Model of service delivery 

• Theory of motor control, motor 

development and motor learning 

• Valid and reliable measures 


Health 

Body function 

& 

Body structure 

Activity 

Participation 

Environment 

Personal factors 

2005 Eva Brogren Carlberg 


Participation 

ICF 

Functional problems in 

children with CP 

• in daily life activities 

Activities 

• functional capacity and performance 

• basic motor functions 

Body functions and 

structure 

• postural problems 

• control of movements 

• muscle strenght 

• spasticity 

• range of motion 

• perception and cognition 

Brogren & Hadders-Algra 2005, Crenna 1998; Damiano t al. 2002, Gormley 2001, 

Porr et. al 2005, van der Heide & Hadders-Algra 2005, Graham, Mayston 2001, Rose 

& McGill 2005, Rosenbaum et al. 2002, Østensjø et al. 2003, 2004 


Strenght 

training 

Health 

Body function 

& 


Activity 

Participation 

Environment 




Training of muscle strength 

• Children with CP can increase muscle strenght 

• Strenght training does not increase the degree of 

spasticity 

• Strenght in children with CP is related to functional 

activities 

• Strenght training promotes a feeling of well-being 

Damiano et al. 1995 DMCN, Darrah et al 1999 Ped Phys Therapy, 

Fowler et al 2002 Physical Therapy Dodd et al 2002 Arch Phys Med Rehab, 

Dodd et al 2003 DMCN, Eagleton et al. 2004 Ped Phys Ther, 

Burley et al 2003 DMCN, Lindström & Larsson Fysioterapeuten 2006 


Range 

of motion 

Health 

Body function 

& 


Activity 

Participation 

Environment 




The effectiveness of passive stretching in 

children with cerebral palsy 

Pin et al 2006 DMCN (review) 

• Seven studies were selected. There was limited 

evidence that manual stretching can increase range 

of movement, reduce spasticity, or improve walking 

efficiency in children with spasticity. It appeared that 

sustained stretching of longer duration was 

preferable to improve range of movement. Methods 

of passive stretching were varied. Further research is 

required given the present lack of knowledge about 

treatment outcomes and the wide use of this 

treatment modality. 


Health 

Body function 

& 


Activity 

Functional 

goaldirected 

training 

Participation 

Environment 




The child as an active problemsolver 

not 

as a passive recipient of treatment 


Management of the motor disorders of children 

with cerebral palsy 

Editors 

David Scrutton, Dianne Damiano, Margaret Mayston 


”It is now generally acknowledged 

that the efficacy of any physical 

treatment lies within the child’s 

day-to-day environment, and to pretend 

otherwise is a professional conceit”. 

David Scrutton sid 1 


McEwen IR, Shelden ML (1995) Pediatric therapy in the1990s: the demise of 

the educational versus medical dichotomy Phys Occup Ther Pediatr 2: 33-45 

Law M, Darrah J, Pollock N, King G et al (1998) Family-centred functional 

therapy for children with cerebral palsy:An emerging practice model Phys 

Occup Ther Pediatr 1:83-102 

Bower E, McLellan DL, Arney J, Campell MJ (1996) A randomized controlled trial 

of different intensities of physiotherapy and different goal-setting procedures in 44 

children with cerebral palsy DMCN 38:226-237 RCT 

Bower E, Michell D, Burnett M, Campell MJ, McLellan DL (2001) Randomized 

controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 

months DMCN 1: 4-15 RCT 

Ketelaar M, Vermeer A, Hart H, van Beek E, Helders PJ (2001) Effects of a 

functional therapy program on motor abilities of children with cerebral palsy Physical 

Therapy 9: 1534-1545 Randomized block design 


Stiller C, Marcoux BC, Olson RE (2003) The effect of Conductive education, intensive 

therapy, and special education services on motor skills in children with cerebral 

palsy Phys Occup Ther Pediatr 3: 31-50 

Lammi BM, Law M (2003) The effects of Family-Centred Functional Therapy on the 

occupational performance of children with cerebral palsy Canadian J of Occ Ther 70 (5): 

285-289 Case studies 

Ödman P, Öberg B (2005) Effectiveness of intensive training for children with cerebral 

palsy – a comparison between children and youth habilitation and conductive education J 

Rehab Med 37: 263-270 

Ödman P.A, Öberg B.E (2005) Effectiveness and expectations of intensive training: A 

comparison between child and youth rehabilitation and conductive education Disab 

Rehab 

Ekström Ahl L, Johansson E, Granat T, Brogren Carlberg E (2005) Functional 

therapy for children with cerebral palsy – an ecological approach DMCN 47:613-619 

Case studies 


Lundqvist L-O (2001) Utvärdering av intensivträningsperioder i 

grupp för barn med cerebral pares Scriptum Nr 2 Örebro 

019-602 58 91 

Engman A, Lind B, Simonsson A (2002) Intensivträningsperioder 

på barn- och ungdomshabiliteringen i Örebro län. Empiricum Nr 1 

Örebro 019-602 71 56 

Conradi H (2001) Kämpa på! Fyra veckors sjukgymnastisk träning 

enligt ett speciellt program för fem barn med cerebral pares. 

Fallstudier FoU Rapport 01-05 Handikapp & Habilitering, Sthlm 

Edin U, Smyth C, Larsson M 

Edin U, Smyth C, Larsson M (2004) Nätverksbaserad målinriktad 

intensivträning NIT FoU-rapport 2, Handikapp & Hjälpmedel, Skåne 

www.skane.se 


Ongoing studies 

Lerdal et al (2003) Utkast till intensivprogram, systematiske tilltak fokusert trening 

og stimulering for å fremme laering og utvikling hos barn med hjerneskade 

Sörlandets sykehus HF HABU Kristiansand 

www.HABU.no 

MOVE programme (Mobility opportunities via Education) 

www.move-europe.org.uk 

Law M, Hurley P och medarbetare –”Function in focus” - 

RCT with two different forms of training – one targeting the environment and the 

other the child. 

Löwing K, Bexelius A, Brogren Carlberg E – Functional, 

goaldirected training in preschool children with CP 


Functional, goaldirected training 

Ammi Bexelius PT 

Kicki Löwing PT, MSc 

Eva Brogren Carlberg PT, PhD 


Inclusioncriteria 

• Cerebral palsy 

• Preschool children 

• Able to understand uncomplicated 

instructions 


Participants 

• 22 children in the intervention group 

• 22 children matched with respect to age 

and GMFCS-level in the control group 

• Age range 1 ½ - 6 years 

• GMFCS level I-IV 

• Integrated in ordinary pre-schools 


Time-line 

for the intervention group 

GMFM 

Continous 

advising of 

parents and 

pre-school staff 

Training period 12 weeks 

Start 

Parental 

education 

GAS 

End 

PEDI 

Other 

measures 

Spasticity, PROM, SMC 


Time-line 

for the control group 

GMFM 

12 weeks 

”Treatment as usual” 

PEDI 


Ella 3 years 7 months 


Ella and her goals 

• Goes to pre-school 

– started when she 

was 1 ½ years old 

• Youngest member of a family of four – 

mother, father, older brother and Ella 

• Cheerful girl, a little shy 

• She likes to play with dolls and she likes 

role-playing with peers 


•Born week 34 

•PeriVentricular 

Leukomalacia (PVL) 

•Diagnosis 

– bilateral spastic CP 

Impairments: 

PROM ↓ dorsiflexion, abduction and left knee 

Spasticity ↑ adductors, plantarflexors 

SMC right foot = 2, left foot = 1 


Ella - GMFCS level III 

Ella’s result GMFM-66 

– 47.68 


Ella born 2002-01-05 

Date of intervju 2005-08-05 

Age 3 yrs 7 mo 

FS 

CA 


Goal attainment scaling 

-2 

-1 

0 

+ 1 

+ 2 


GAS 

+ 2 

+ 1 

0 

-1 

-2 

Much more than 

expected 

More than expected 

The Goal 

Less than expected 

The situation today – the 

starting point 


+ 2 

+ 1 

0 

Goal nr 1- Put on a sweater 

Ella sits comfortably with back support. Ella gets a sweater presented in 

any way and pulls it down and puts it on independently. 

Ella sits comfortably with back support. Ella gets a sweater presented in 

a ’proper’ way and can pull it down and put it on by herself. An adult gives 

verbal support and some physical assistance. 

Ella sits comfortably with back support. The sweater is placed on Ella’s 

head and she can pull it down by herself. She enters her arms into the 

sleeves independently. 

-1 

-2 

Ella sits comfortably with back support. Ella receives help to pull the 

sweater over her face. She enters her arms into the sleeves independently. 

An adult gives verbal support 

Ella sits comfortably with back support. The sweater gets stuck over 

her face when she tries to pull it down. She receives verbal and physical 

support to pull the sweater down and enter the arms into the sleeves 


Five goals were set for each child 

- 

within the Activity domain of 

the ICF 

all within 


Significant differences were found in a 

majority of measured parameters 

• GMFM p< 0.001 - Controlgroup n.s. 

• PEDI – Functional performance p

The Child – Foster Independence 

I can do it 

I can choose 

I can think for 

myself 

Picture of a child 

I am responsible 

I am innerdirected 

and 

self-reliant 


Seattle, USA 


The Physiotherapist - 

Be goal-directed 

and creative! 


Thank you for your attention! 

eva.brogren-carlberg@sll.se

Physiotherapy in children with cerebral palsy - BLF

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