Neurodevelopmental Treatment Of Cerebral Palsy (CP) In Children
One of the most common childhood neurological disabilities is cerebral palsy (CP). Cerebral palsy is caused by abrasions of the central nervous system (Labaf, Shamsoddini, Hollisaz, Sobhani, & Shakibaee, 2014). These abrasions cause motor and sensory impairments that progress over time (Arnould, Bleyenheuft, & Thonnard, 2014). Impaired gross motor function, and postural control are both common issues in children diagnosed with cerebral palsy. About 60% of motor disabilities in school-aged children is due to cerebral palsy (Khalil, Elweshahy, Abdelghani, Omar, & Ahmed, 2018, p. 522). This condition also causes a child to experience physical limitations that affect his or her upper limbs (Jackman, Novak, & Lannin, 2013).
Evidently, upper limb limitations leads to a negative impact on the child’s ability to participate in activities such as handwriting. Without intervention, this population of children face the risk of developing contractures which is detrimental to functional motor skills. Orthotics have been prescribed to children with neurological conditions (such as cerebral palsy) to improve their upper limb skills and functional activities. There are a variety of orthotic devices that are recognized for reducing limitations in CP. Specifically, hand splints are intended to support a fragile muscle or joint (Jackman, Novak, & Lannin, 2013). Furthermore, Neurodevelopmental Therapy (NDT) is a popular approach used to treat children with CP. In addition to decreasing motor-sensory disturbances, NDT is constructive in improving postural control. (Turker, Korkem, Ozal, Gunel, and Karahan, 2015). NDT is a form of treatment method indented to restore regular movement patterns decreasing the amount of abnormal reflexes and muscle tone (Park & Kim, 2017). Occupational therapists use NDT to utilize positioning and handling techniques. This enhances the ability to complete functional tasks in children with CP (Smith & O’Brien, 2015). Assessment and intervention of children with CP is best accomplished by a multidisciplinary team. The aim is to minimize disability, improve quality of life, and encouraging participation in society (Khalil et al, 2018).
The focus of this literature review is to fully explore the research behind the use of Neurodevelopmental treatment in children with spastic cerebral palsy compared to the use of orthotics to improve postural control and gross motor function for sitting and handwriting. According to Arnould, Bleyenheuft, and Thonnard (2014), the ability of the hands to operate correctly requires optimal central nervous system functioning, which is altered in cerebral palsy. The study focused on hand skills that included stereognosis, proprioception, touch-pressure detection, grip strength, gross manual dexterity, and fine finger dexterity. Among the hand skills that were examined, gross manual dexterity measures were the strongest in regards to manual ability. Besides gross manual dexterity, stereognosis in the dominant hand was the only hand skill investigated in the study that was directly related to both gross and fine hand motions and coordination (manual ability).
The impact that gross manual dexterity has on stereognosis demonstrates object recognition via touch sensation. This requires the object to be moved in an individual's hand to perceive the shape of the object. In hand manipulation has been reviewed to be essential when identifying objects. Manual ability is contributed by grip strength and ultimately impacts gross manual dexterity. This is demonstrated by the connection between hand strength and dexterity; both hand strength and dexterity are impacted by grip strength. Children with cerebral palsy have lesser grip strength, which may influence a child’s ability to hold and sustain the grip of objects. Gripping objects is also affected by sensory inputs. Sensory inputs are crucial in regards to anticipatory grip-lift and control activities and tasks. However, the study displayed that sensory impairments were not significant in the completion of manual activities. The results from the path analysis show that gross manual dexterity in both hands and stereognosis in the dominant hand were positively correlated to manual activity, although grip strength was negatively correlated to manual ability through its affiliation with gross motor dexterity. However, one-third of the deviation in manual activity, measures could not be explained by hand skills.
The results show manual activity, is not only the integration of hand skills in daily tasks and activities and should be treated by supporting activity-based interventions (Arnould, Bleyenheuft, and Thonnard, 2014). In addition to the relevance of fine motor ability in individuals with CP, gross motor functions are also affected. Motor functions are considerably correlated with a number of impairments, ranging from postural stability, spasticity, to quality of movement. (Curtis, et al, 2014, p.351) This study demonstrated a close correlation with segmental trunk control and hand-eye coordination and head stability. (Curtis et al., 2024, p.352) A study by Butler et al. conveyed an additional correlation between the use of SATco test and Gross Motor Function Measure (GMFM66) for sitting in 24 children with CP. Trunk control is a vital component of the development of motor function. A study by (Curtis, Butler, Saavedra, Bencke, Kallemose, Sonne-Holm, and Woollacott, 2014) recognizes the significance of segmental trunk control as a factor in identifying the gross motor function skills in children with CP. Furthermore, allowing for more specific therapeutic goals in clinical practice.Some studies have shown that hand splints and orthotics could be used as a treatment method for cerebral palsy.
Jackman, Novak, & Lannin (2013), compared functional splints to non-functional hand splints. Non-functional hand splints are worn either at bedtime or for short periods of time to increase muscle length. Functional hand splints are created to improve outcomes in activities and participation, like handwriting. The results of the study indicated that hand splints may have a slight positive impact on upper limb skills when combined with some form of therapy. However, the positive effect of the hand splint weakened at two to three months after splint removal. In fact, children with cerebral palsy receiving splint therapy along with traditional therapy, will have slight improvement in upper limb skills. However, conclusions cannot be drawn due large confidence intervals and further research should be done.
Recently, a study has been conducted to investigate the effects of suit-orthosis on postural sway during seated reaching tasks in children with CP. The suit-orthosis was expected to improve postural stability, and can help with arm function control during postural sway when preparing to reach for objects. Anticipatory and compensatory postural adjustments (APA, and CPA respectively) are required to successfully complete the task of reaching (Pavao, Visicato, da Costa, de Campos, & Rocha, 2018). APAs and CPAs are two mechanisms of the central nervous system that are used to maintain equilibrium (Santos, Kanekar, & Aruin, 2010). Participants were divided by the Manual Ability Classification System (MACS) I and II-III, and were asked to reach for an object in both a no-suit condition compared to a suit-orthosis condition. The suit-orthosis improved postural stability and decreased the velocity of center of pressure (CoP) sway at MAC II-III in APA, while the MAC I increased the anterior-posterior (CoP) displacement during CPA (Pavao et al., 2018).
According to Labaf, Shamsoddini, Hollisaz, Sobhani, & Shakibaee (2015), Neurodevelopmental Therapy (NDT) is commonly used to treat cerebral palsy. In this study, the treatment group received NDT for 3 months. The control group received home exercise, including routine movement therapy. To assess gross motor abilities of children with cerebral palsy, the GMFM (GMFM-88) was utilized. The GMFM observed dimensions of lying and rolling; sitting; crawling and kneeling; standing and walking; and running and jumping. The results show that after NDT there were improvements in GMFM scores between the control group and the experimental group. The results prove that NDT displays improvements in gross motor function and postural stability. However, another study investigated the effects of NDT on spasticity, strength, and gross motor function in children with cerebral palsy. Physical therapists certified in NDT administered the treatment for 35 min/day, 2-3 times a week for one year. After one year of NDT, only spasticity was decreased; muscle strength and gross motor function were not significantly improved (Park & Kim, 2017). Turker, Korkem, Ozal, Gunel, and Karahan (2015), studied the efficacy of neurodevelopmental based goal-directed therapy (GDT) on motor functions, and daily living activities of children with CP. Treatment plans that integrate motor function development coupled with goals that support activities and adaptation to daily living skills of children were noted as practical and advantageous. GDT considers a child’s learning ability by incorporating activities aimed at individualized goals, while approaches such as NDT focus on motors response regulation.
Overall establishing a relationship between participation and activity is impactful towards effective NDT treatment (Turker, Korkem, Ozal, Gunel, & Karahan, 2015).
