Multimodal Approach to Treatment for Children with Cerebral Palsy
Written by Dr. Mirav Newman, PT, DPT
In my 20 years of practice as a pediatric physical therapist, I have seen many changes in the intervention strategies for children with cerebral palsy. I recall my professors in PT school talking about my “therapy tool box”. This is a concept I have incorporated into my practice since my early days as a therapist. I trained as an orthopedic manual therapist for the first 5 years of practice. As I transitioned to work with pediatric patients, I continued to use my manual skills to help with range of motion, pain, and most importantly alignment in posture and gait. I remember one continuing education course I took, when the instructor said he believed an adult orthopedic therapist was best at working with adults, but his wife, a pediatric therapist could always be more versatile and work with all patients because pediatrics is all the skills rolled into one. Children with cerebral palsy have a multitude of challenges including orthopedic concerns, strength deficits, sensory integration challenges, atypical neurologic function, functional limitations and sometimes behavior problems as well. I have spent my life learning about all aspects of therapy related to as many of these issues so that I could do the best for my patients.
I believe that a multimodal approach to pediatric physical therapy results in the best outcomes. Use of evidence based intervention is essential. And letting go of old concepts is equally as important. But what does a multimodal approach to pediatric physical therapy mean, exactly?
Google defines multimodal as “having or using a variety of modes or methods to do something. In relation to learning, “ Multimodal learning suggests that when a number of our senses – visual, auditory , kinesthetic- are being engaged during learning, we understand and remember more. “ (Caroline Lawless, 2019). In relation to pediatric physical therapy, it is important to view the child as a whole body. We should be using all of our tools and incorporating multimodal approaches.
First: Always start with the basics of alignment in all postures and during gait. Use of straps, tape, orthotics, positioning to optimize alignment. Assess and treat range of motion, strength and abnormal tone with evidence based techniques. For example, we now know short duration stretching in the clinic is not effective. Therefore, using long duration stretching for a home program is essential. I like to use a NADA chair at home for hamstrings daily. I also like a wedge for standing to use while the child is standing doing ADL’s for Achilles stretching, at home daily.
Next, I screen and assess the child’s ability to process sensory information. I have devised a sensory screen for PTs that we use in our clinic. Many children present with some sensory processing dysfunction that we must address in order to effectively treat the movement disorder.
I also use electrical stimulation to address strength, range of motion, and abnormal muscle tone. In PT school I was taught to never use electrical stimulation with children with neurologic disorders. Today we know it is possible to do so, both safely and effectively. Electric Simulation is a green light in our body of evidence. I have also learned the spastic muscle is not always strong. We now strengthen spastic muscles. I stimulate the gastroc-soleus musculature of a child that toe walks and the same of a child that walks with a crouched gait.
I also continue to use some of the principles of NDT and facilitation techniques to analyze movement, identify abnormal movement patterns and to guide typical movement.
Additionally, I use the basic principles of motor learning because motor learning occurs best when the child initiates and carries out the movement on her own. I don\’t use passive therapies. I have learned that task specific training is most effective and helps children strengthen their muscles best. Just as a baseball pitcher trains his muscles during actual pitching practice.
Over the years many basic principles have remained the same. However, many have changed. Some of the aforementioned modalities and techniques are more recently mentioned in the literature. Some are not recent but seem to take years to catch on. I am grateful for all the researchers and teachers and revolutionaries that changed the face of pediatric physical therapy, and continue to do so. It is my responsibility to read and keep up with the research and evidence around treatment approaches, and plan my approach from there. We cannot keep treating children with cerebral palsy the same way we did in 1990. After all, were we doing a good job then at avoiding orthopedic complications, preventing contractures, and optimizing function? Was our intervention successful? I believe we can do better. When working with children with CP, remember to keep it multimodal, and always start with alignment.
Let’s celebrate CP month by highlighting our patients but also by learning about the best ways we can serve the children and their families.