New Clinical and Research Trends in Lower Extremity Management for Ambulatory Children with Cerebral Palsy




Cerebral palsy (CP) is the most prevalent physical disability in childhood and includes a group of disorders with varying manifestations. This article focuses on current and future intervention strategies for improving mobility and participation during the lifespan for ambulatory children with CP. The provision and integration of physical therapy and medical and orthopedic surgery management focused primarily on the lower extremities are discussed here. Some of the newer trends are more intense and task-related exercise strategies, greater precision in tone identification and management, and a shift towards musculoskeletal surgery that focuses more on promoting dynamic bony alignment and less on releasing or lengthening tendons. Advances in basic and clinical science and technology development are changing existing paradigms and offering renewed hope for improved functioning for children with CP who face a lifelong disability with unique challenges at each stage in life.


Overview of current care of motor disorders in cerebral palsy


Cerebral palsy (CP) is the most prevalent physical disability originating in childhood. The latest figures in the United States indicate that the incidence of CP is 3.6 per 1000 children, with males affected to a greater extent than females. Because no cure is yet available or imminent for CP, the motor disability persists throughout the lifespan and interferes with normal developmental and aging processes, which alter its presentation with time. The current standard of care for the motor disorder in CP consists of regular physical therapy, followed by multiple, and often concurrent, medical and surgical interventions, most intensively in early childhood through preadolescence. Although a growing list of treatments have been shown to individually improve motor outcomes, few definitive practice guidelines have been proposed for the management of CP due to limited and fragmented scientific evidence to support multidisciplinary (combined) intervention approaches. Consequently, tremendous variation exists among different practitioners, settings, and geographical areas in the types of treatments prescribed, the timing and sequencing of interventions, and the range of treatment intensity or frequency. Choice of, and response to, intervention is further complicated by the fact that CP is not a single disease entity with a known causal pathway; it is, instead, a heterogeneous group of disorders with varying etiologies, brain injury patterns, and associated health conditions.


However, despite these challenges, substantial progress is being made in the understanding and management of CP as the pace of research efforts in this population has accelerated markedly in recent years. The focus of this article is on the major clinical and theoretical shifts or trends that occurred during the past decade in the medical, surgical, and therapeutic approaches to improving mobility, and more specifically ambulatory abilities, in children with CP. Some of the more dramatic changes in the field have been conceptual and have fundamentally altered how we perceive, classify, and assess a child with CP and how we gauge success of our interventions. New treatments and intervention strategies have also emerged with varying degrees of evidence to support them. Three-dimensional, computer-based analysis of walking and other functional motor tasks has continued to expand the knowledge of normal versus disordered motor control and to quantitatively measure outcomes from interventions designed to improve specific motor skills. Brain and musculoskeletal imaging technologies are also advancing rapidly, and they provide insights into the neuropathology and pathomechanics of CP that were unattainable before their advent.




Major conceptual changes in goal setting and classification of CP


New Models of Disability


The hallmark of CP is a motor control deficit that differs across individuals in distribution, presentation, and severity. For decades, the direct goal of medical treatment for the motor disability was to alleviate the associated motor impairments, such as spasticity and muscle contracture, with the assumption that functional improvements would ensue. However, that was not necessarily the case, and it was realized that the relationship between impairments and functional activity was neither strong nor linear in many cases. Several conceptual models of disability, most prominently and most recently the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF), have shifted the primary focus of treatment to the level of activity and participation of the individual patient. Given family and patient goals in those realms, a treatment plan is proposed and implemented, that may still recommend treatments to address specific impairments in body structures and functions, but could also involve alterations in the environment to improve access or suggestions for family lifestyle changes to increase participation in fitness, sports, or activity-based recreational activities, among other approaches. Many new evaluative measures reflecting these different domains have emerged and are useful in clinical practice and research. The development of parent and child report measures has been particularly notable, and computer-adapted technologies are now being used to obtain comprehensive information in an efficient, user-friendly manner. Although improving activity and participation should be the major treatment priority, interventions that maintain the status quo or minimize future deformity or disability are also beneficial in this population, which may regress in function with time, most dramatically in adulthood.


New and Expanded Classification Schemes


Traditional categorization of subtypes of CP had been based on the primary type of tone disorder and the distribution of the motor involvement, for example, spastic quadriplegia, with each diagnostic category including individuals with a broad range of clinical involvement. The advent of functional classification scales in CP has had a profound effect on determining the prognosis for mobility and related goal setting, improving family and professional communication, and significantly enhancing research design and interpretation. The Gross Motor Functional Classification Scale (GMFCS), which has been adopted universally, categorizes a child’s functional mobility ranging from level I, which indicates the highest level of mobility with only minor limitations in more challenging tasks and environments, to level V, which indicates complete dependence on others for mobility. This article primarily addresses those in levels I to –III, who have the capacity or potential for independent, assisted or unassisted, walking. The even more recent Functional Mobility Scale (FMS) expands the assessment of walking ability by rating performance at 3 different distances (5, 50, and 500 meters) that correspond to the 3 major environments that children typically need to navigate: home, school, and the community.


A more global, multiaxial classification scheme for CP has been proposed that encompasses the primary and secondary tone disorders, anatomic distribution of the neurologic involvement, and the functional mobility and upper extremity skill classification, associated impairments, and brain imaging results, yielding a more comprehensive description of the individual patient that should ultimately lead to a more well-focused treatment plan. For example, a child previously categorized as having spastic hemiplegia could now be described in this new classification scheme as having unilateral motor involvement with the presence of both spasticity and dystonia, Manual Ability Classification System level II and GMFCS level I, respectively, with a mild seizure disorder and mild learning deficits, and having MRI evidence of a neonatal stroke.




Major conceptual changes in goal setting and classification of CP


New Models of Disability


The hallmark of CP is a motor control deficit that differs across individuals in distribution, presentation, and severity. For decades, the direct goal of medical treatment for the motor disability was to alleviate the associated motor impairments, such as spasticity and muscle contracture, with the assumption that functional improvements would ensue. However, that was not necessarily the case, and it was realized that the relationship between impairments and functional activity was neither strong nor linear in many cases. Several conceptual models of disability, most prominently and most recently the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF), have shifted the primary focus of treatment to the level of activity and participation of the individual patient. Given family and patient goals in those realms, a treatment plan is proposed and implemented, that may still recommend treatments to address specific impairments in body structures and functions, but could also involve alterations in the environment to improve access or suggestions for family lifestyle changes to increase participation in fitness, sports, or activity-based recreational activities, among other approaches. Many new evaluative measures reflecting these different domains have emerged and are useful in clinical practice and research. The development of parent and child report measures has been particularly notable, and computer-adapted technologies are now being used to obtain comprehensive information in an efficient, user-friendly manner. Although improving activity and participation should be the major treatment priority, interventions that maintain the status quo or minimize future deformity or disability are also beneficial in this population, which may regress in function with time, most dramatically in adulthood.


New and Expanded Classification Schemes


Traditional categorization of subtypes of CP had been based on the primary type of tone disorder and the distribution of the motor involvement, for example, spastic quadriplegia, with each diagnostic category including individuals with a broad range of clinical involvement. The advent of functional classification scales in CP has had a profound effect on determining the prognosis for mobility and related goal setting, improving family and professional communication, and significantly enhancing research design and interpretation. The Gross Motor Functional Classification Scale (GMFCS), which has been adopted universally, categorizes a child’s functional mobility ranging from level I, which indicates the highest level of mobility with only minor limitations in more challenging tasks and environments, to level V, which indicates complete dependence on others for mobility. This article primarily addresses those in levels I to –III, who have the capacity or potential for independent, assisted or unassisted, walking. The even more recent Functional Mobility Scale (FMS) expands the assessment of walking ability by rating performance at 3 different distances (5, 50, and 500 meters) that correspond to the 3 major environments that children typically need to navigate: home, school, and the community.


A more global, multiaxial classification scheme for CP has been proposed that encompasses the primary and secondary tone disorders, anatomic distribution of the neurologic involvement, and the functional mobility and upper extremity skill classification, associated impairments, and brain imaging results, yielding a more comprehensive description of the individual patient that should ultimately lead to a more well-focused treatment plan. For example, a child previously categorized as having spastic hemiplegia could now be described in this new classification scheme as having unilateral motor involvement with the presence of both spasticity and dystonia, Manual Ability Classification System level II and GMFCS level I, respectively, with a mild seizure disorder and mild learning deficits, and having MRI evidence of a neonatal stroke.




Factors that influence ambulation in CP, and the role of medical care


Promoting, improving, or restoring the ability to walk is arguably the most common motor goal in neurorehabilitation medicine. Walking status is clearly related to the type and severity of the neurologic deficit, but is not necessarily predetermined by those as illustrated by the conceptual framework of the ICF. It can be influenced in a positive or negative direction by personal factors that may include other associated impairments, as well as emotional, behavioral, and motivational factors. It can also be affected by an individual’s physical, social, and cultural environments and the medical care environment, which is the primary focus of this article. In the following 3 sections, the authors summarize the state of the science of medical, surgical, and physical therapy interventions aimed at improving ambulatory function in CP. Although each of these treatment categories are discussed in individual sections, it must be noted that optimal outcomes often depend on the administration of multiple types of interventions administered concurrently or sequentially.




Physical therapy trends for ambulatory children with CP


The scientific basis underlying neurologic physical therapy has increased exponentially in the past decade. Before these advances, therapy was dominated by the use of a neurodevelopmental therapy (NDT) approach that has failed to produce consistent clinically significant effects on activity or to demonstrate superiority over alternative approaches. Evidenced-based therapy approaches that are task related and more intense in terms of the amount of practice or effort are being advocated. The use of external devices, such as free weights, weight machines, electrical stimulation units, treadmills, and so on, is also increasingly common in therapy and home programs.


One of the major goals of physical therapy for children with CP in GMFCS levels I to III is to promote independent mobility that includes the ability to ambulate, among other forms of mobility. To accomplish this, children must have adequate active range of motion that is not exceedingly impeded by spasticity, dystonia, or contracture; sufficient strength to maintain body weight support, in some cases with an assistive device; and motor control abilities to allow them to advance their limbs forward to take steps in an effective and efficient manner (eg, minimal scissoring or internal rotation at the hips, minimal crouch in stance, sufficient knee flexion and/or ankle dorsiflexion in swing to allow for foot clearance). The speed and energy costs of walking are also major factors in how functional the gait pattern will be for an individual child. Each of these aspects must be evaluated and addressed by the multidisciplinary team to optimize gait function. Physical therapy can have little, if any, effect on the control of tone abnormalities that require medical and neurosurgical interventions or on the correction of contracture or bony deformity that requires orthopedic surgery; however, it can have a unique and potentially substantial impact on increasing muscle strength and aerobic conditioning and potential in improving lower extremity coordination and speed in this population.


Although stretching is still a component of therapy programs, the use of passive stretching alone has not been shown to be effective, and the impairment of a body structure level goal, such as maintaining muscle length with time, is now more effectively accomplished by interventions such as strength training, dynamic or static orthoses, botulinum toxin (BoNT) injections, or other spasticity-reducing medications or surgeries, although still in combination with manual stretching techniques. As noted above, once a contracture develops, orthopedic surgery to lengthen tendons is often required if the restriction in range impairs function or positioning. Using muscle ultrasound imaging, Shortland and colleagues demonstrated that the fiber lengths of spastic pennated muscles are not necessarily shorter in CP than in age-matched peers, but the length of the aponeurosis is shorter because of decreased fiber diameter resulting from muscle weakness. Their resultant conclusion that strengthening may be a more effective strategy for increasing length in those muscles than stretching runs directly counter to traditional NDT tenets to avoid strengthening or any excessive physical effort so as not to exacerbate spasticity. This long-standing, but unsubstantiated, belief has been increasingly challenged in the literature, and strengthening and other intense activity-based programs are now commonly used in pediatric rehabilitation for children with and without spasticity. Dodd and colleagues conducted a systematic review of the strength training literature in CP. At that time, only 10 research studies met the criteria, which included only 1 randomized controlled trial. Most (8/10) reported significant strength increases as a result of the program. Two studies reported improvements in activity, and 1 study reported improvement in self-perception. No negative effects, such as reduced range of motion or increased spasticity, were reported. Further studies and literature reviews have corroborated these results and similar positive results from programs that involve or include aerobic training.


Intense task-specific training has been shown to be effective in several neurologic populations and CP, with the most conclusive findings in CP, demonstrated in intense upper limb training paradigms. For task-specific training in the lower extremity, locomotor training paradigms are commonly used and reported, with many studies incorporating partial body weight–support systems in addition to motorized treadmills. A recent review of the literature on treadmill training in CP demonstrated fairly consistent positive effects on walking speed and the Standing and Walking, Running and Jumping dimensions of the Gross Motor Function Measure. However, no randomized trials that compared treadmill training to over-ground walking of the same intensity have been published to date in CP, even though reviews in stroke and spinal cord suggest that it is the intensity of walking practice, rather than the use of a device, that produces the positive functional outcomes. Regardless of whether the results are similar with or without an external device, the use of treadmills and other exercise devices has transformed motor rehabilitation by reinforcing the effectiveness of intense practice, enabling individuals unable to support their own weight to practice walking more easily, and the use of motors and/or added weight support has helped to push people to the limits of their capabilities. Depending on the goal and the exercise protocol designed to accomplish that goal, treadmills can be used to increase strength through progressive loading, increase coordination by training spinal circuits, improve aerobic condition through endurance training, and increase gait speed by progressing belt speeds with time. Thus far, strength and aerobic training and treadmill training programs have been evaluated during short time intervals, but it is important to realize that these are short-term programs in the context of a lifelong disability, and although the effects may be modest, greater functional benefits are likely to accrue with time.


The delivery of physical therapy services has changed dramatically with time, because health insurance in the United States no longer supports the amount of therapy that may be necessary to improve or maintain optimal physical conditioning, with the exception, perhaps, of therapy that follows surgery, which is often more intense. It has now been clearly demonstrated that ambulatory children with CP are far less active than their peers without CP, with the amount of activity directly proportional to their GMFCS level. Decreased activity can lead to loss of strength and increased muscle stiffness, and ultimately to decreased function with time, and it leads to other general health problems in all individuals, with those with motor disabilities being at even greater risk. Physical activity has additionally been shown to contribute positively to mental and emotional functioning. Given the changes in health care policy and the recognition that regular and fairly intense physical activity should be part of a daily routine, therapists have been forced to adapt their practices and help families develop other strategies to ensure that their child is as active as possible, in as safe a manner as possible. Identifying activities that are sufficiently physically challenging, enjoyable, or feasible enough to be sustainable and safe for long-term use is a critical element of anticipatory guidance for youth with CP, and to the extent possible, therapists should have input into the design and implementation of these activities. For example, older children may be able to participate in an exercise program at the local YMCA; however, an understanding of their disability and specific impairments is essential in the design of that program, and therapists should be involved in the process to ensure safety and maximum effectiveness. Alternatives to activities that may exacerbate abnormal joint stresses should be considered, such as pool exercises, cycles, or elliptical trainers, in lieu of prolonged treadmill use. For those who are unable to ambulate well outside of the home, adapted and motorized cycles and many over-ground mobility devices are available for recreational or therapeutic use. Beyond the physical and emotional benefits, the importance of activity-based therapies for promoting true neural recovery and restoration in those with brain lesions is just beginning to be realized and is rapidly transforming physical therapy goals and practices.


There has been development of multiple intensive therapy or education-based programs, such as conductive education and Adeli Suit programs, which provide some benefits because of their strong focus on activity and independence, but which also raise some concerns. These programs have failed to demonstrate superior effectiveness over other approaches despite their significantly greater time intensity; they fail to identify the ‘active’ ingredients, making it hard to determine which aspects of the programs are effective and which are not; they often place additional financial and time constraints on families; and their intensity is not sustainable over the long term, so children may regress when these programs end. Although some of these programs do demonstrate the importance of enhanced training or activity, therapists and the health care system need to ensure that children and families are provided the most effective, time efficient, and preferably community-based therapy programs that are well integrated with other services. To enhance the amount of physical activity and participation, children should be strongly encouraged to participate in self-chosen adapted or regular sports and physical recreational activities. As children transition into later adolescence and adulthood, the responsibility increases for them to establish and maintain their own activity-based goals as part of their own healthy lifestyle choices.


Finally, in addition to the delivery or development of exercise programs, therapists perform many roles that have not been well studied or evaluated scientifically, but are likely to be of critical importance to families and patients and to other members of the multidisciplinary team. As an example, they provide expert advice on how to hold and position a young infant with CP so as to safely promote motor development, they recommend assistive devices to promote mobility, and they may fabricate orthoses or work closely with orthotists and physicians in determining the optimal type of orthosis for an individual patient depending on his/her abilities and goals. Therapists are often a major source of medical information to the family and, because of their regular contact with the child and family, they may often be the first to recognize the potential need for other treatments and may work with the family in communicating with or identifying a physician or surgeon who will evaluate the child for other interventions.




Medical management of motor disorders in ambulatory patients with CP


Overview of Recent Changes in the Approach to Diagnosis and Treatment


CP is a group of disorders of movement and posture with varying causes. As the knowledge of specific neurologic disorders has expanded, more of the specific causes of motor and movement disorders in children, such as hereditary dystonias and the ever-expanding group of mitochondrial disorders, can be potentially identified. Whether these disorders should be grouped with the cerebral palsies remains unclear. In the future, identifying specific disorders will be increasingly important as specialized treatments for these conditions become available.


Patients with CP present with both positive and negative features of the upper motor neuron syndrome at the level of body structures and functions in the ICF model. These include a variety of tone abnormalities ranging from hypotonia to hyperkinesis. Because patients with CP were traditionally classified by their predominant tone abnormality, that is, spasticity or dyskinesis, the nuances of mixed tone disorders were often missed. Selective, specific therapies increase the importance of correctly identifying mixed patterns of abnormal tone. For example, a patient with mixed spastic dyskinetic CP is not a good candidate for selective dorsal rhizotomy (SDR), but may be a candidate for intrathecal baclofen therapy (ITB). Mixed tone disorders require a more studied approach when considering treatment options.


In the past, the selection of medical treatment for motor disorders associated with CP often started with what was viewed as less invasive treatment, later moving to more invasive interventions. This hierarchical model has largely been replaced by an integrated model where several interventions are used in series, or often concurrently, and at various times throughout a patient’s life. For ambulatory patients with CP, several treatment modalities may be selected at the same time. For example, BoNT to address focal tone issues such as an equinus foot or flexed knee may be combined with physical therapy to strengthen the antagonist and maximize function, with orthoses to provide additional stretch, and with oral medications at night or during the day to reduce spasms. This integrated treatment approach is often provided by an interdisciplinary health care team of physicians and therapists. In the 21st century, few clinicians work in isolation when providing care for patients with CP. Most pediatric hospitals and clinics provide interdisciplinary care in one form or another, although the composition of the team and its functional model varies widely across institutions. Team models range from structured programs to a loose affiliation of clinicians who communicate by e-mail, telephone, or written records. Even when located in remote locations, many clinicians now have access to the Internet and can thereby contact colleagues with whom they may consult. This enhanced communication has fundamentally transformed the relationships among individuals from differing disciplines and the way care is delivered to patients. Enhanced communication among medical, rehabilitation, and surgical specialists has increased the knowledge of all practitioners involved in the team, with patients as the ultimate beneficiaries of resultant improved care and coordination.


Interdisciplinary teams have also moved towards incorporating evidence-based medicine into daily practice, no longer relying solely on past or anecdotal experience to make decisions about care for individuals with CP. Future studies must critically evaluate the short- and long-term impact of treatment effects on function and quality of life. In the past, most studies focused on impairments instead of function or participation. There have now been a number of studies evaluating the functional efficacy of BoNT therapy, SDR, and ITB. To date, only few oral medication studies have evaluated effects of treatment on function or participation. It is critical for future studies of medical management techniques to incorporate functional assessment in outcome data. Key to this evaluation is to develop outcome tools that are meaningful and are sensitive to change and to prescribe only those interventions that provide clinically important changes in patient function.


Rationale for Treatment Selection


Recent years have seen a greater focus on ‘tone management’, primarily to minimize the development of contractures and facilitate ease of movement. An increasing array of medical treatment options, including medications, biologic agents, and surgical interventions, are available for management of abnormal muscle tone in patients with CP. A thorough understanding of neurophysiology and pharmacology is required to guide clinicians in selecting the most appropriate medications or agents. Although often requested, there are no medical treatments that ameliorate other impairments associated with CP, that is, weakness, balance, and motor control. Other factors affecting patient function and participation include patient motivation, family commitment, social support, access to intervention/treatment, and geographic location. Clinicians must consider all of these issues when selecting from available treatment options and interventions.


Medical management of the motor disorders in children with CP is most often provided by 1 or more physicians, including physiatrists, neurologists, developmental pediatricians, and orthopedists. One of the first decisions for physicians is to determine whether treatment or intervention is needed. Not all abnormal tone is harmful. There may be benefits to increased tone, including preserved skeletal and muscle mass, decreased edema, aiding standing and transfers, prevention of decubiti, and reduced deep vein thrombosis risks. Treatment should only be initiated if the abnormal tone is symptomatic. The next decision is when to initiate treatment. Medical interventions may be initiated in infancy if deemed necessary. This decision is based on a detailed clinical assessment, review of therapy notes, and evaluation of the patient’s impairments, body structures (passive range of motion [PROM], active range of motion), and functional capabilities. Physicians must evaluate/observe patients as they perform functional activities to identify problem muscles and work with them to establish treatment goals. The physical therapist or occupational therapist treating a patient weekly may identify different problems/goals than the MD who sees a patient quarterly. Input from each member of the team is critical to the decision-making process.


Once problematic muscle tone has been identified, the next step is to determine the choice of intervention or interventions from among the many options available. Options include oral medications and injectable agents (BoNT, phenol, alcohol). ITB therapy, SDR, and deep brain stimulation are tone-reducing treatments that require surgical intervention. Once the pump is implanted, however, ITB becomes a medical intervention. These and other interventions are often performed in series or in combination during the course of a patient’s life.


Complementary and alternative medicine (CAM) may also be recommended by physicians or chosen by families. CAM options for treating patients with CP include acupuncture, massage, homeopathic remedies, herbal treatments, and magnet therapy, to list a few, each with varying degrees of evidence available. It is important for clinicians to ask about use of these treatments, particularly herbal medications, as these may interact with prescribed medications.


Treatment of abnormal tone is frequently initiated to facilitate other interventions, such as therapy, casting, and bracing/splinting. Medical treatment is continually revised and continued as needed, based on review of clinical and functional goals set by the team, patient, and family. Medical therapy is directed toward improving symptoms, not only at the impairment level, but also at the level of improving function. Functional goals as defined by Mayer and colleagues include passive function (functional activities that happen to the patient, such as hygiene or dressing) or active function (activities that the patients perform for themselves). Decisions regarding when to begin, change, or stop medical therapy are based on short- and long-term treatment goals and responses to treatment.


Many clinicians advocate BoNT therapy as the initial treatment for young ambulatory children with CP and problematic focal spasticity or dystonia. The goals of early BoNT treatment include preserving PROM/ prevention of contractures, facilitating therapy, improving mobility/gait, and delaying orthopedic surgery. Other treatment options, including oral medications, are added as needed, based on response to BoNT treatment and treatment goals. A bedtime dose of valium or baclofen may be added to the treatment plan to decrease spasms or pain and increase compliance with nighttime splinting. BoNT therapy is often recommended throughout early childhood. Continued treatment is based on a patient’s response to BoNT therapy and treatment goals. Oral medications are less frequently used during the day due to central nervous system (CNS) side effects, including sedation, impaired learning, and other cognitive side effects, but are appropriate for some children with CP, with or without BoNT. Because of dosing limitations with BoNT treatment, this may be combined with phenol or alcohol blocks (eg, obturator nerve block for adductor tone/ scissoring in ambulatory patients) to allow a greater number of muscles to be treated than if BoNT was used alone.


Efficacy of BoNT requires accurate placement of the toxin within the target muscle(s). A variety of approaches are used, including anatomic guidance/palpation, electromyography (EMG), and electrical stimulation. Ultrasound has been used for decades to guide biopsies and procedures. Advances in high frequency transducer technology have led to an explosion of ultrasound use in musculoskeletal imaging, including guidance for BoNT therapy. Ultrasound allows the painless, accurate identification of target muscles and is therefore frequently preferred by patients over other localization techniques. Other advantages cited are increased ease of identifying deep muscles or muscles with overlapping anatomy, reduction of administration time, and lack of requirement for the larger needles in comparison to the EMG-guided technique.


Although better spasticity management is purportedly diminishing the need for future orthopedic surgery, many children who initially benefit from BoNT therapy later require orthopedic surgery (see following surgical section). BoNT may be provided before muscle lengthening, osteotomy, or single event multilevel surgery. This perioperative treatment has been shown to reduce muscle spasm, postoperative pain, length of stay, and use of pain medication. Some clinicians continue to advocate BoNT therapy throughout a patient’s lifespan. Treatment is often reinitiated during accelerated teen growth to address increased dynamic tone, ROM limitations, and changes in gait. BoNT therapy in ambulatory adult patients may also be helpful in preserving ROM, gait, and mobility and in reducing pain.


Based on regular reevaluation of symptoms, impairments, and function, a patient’s medical treatment is continually modified. In some centers, SDR is frequently recommended for ambulatory patients with spastic CP. This is most often performed between the ages of 4 and 8. Some clinicians advocate performing orthopedic procedures first and then reevaluating the patient’s function before proceeding with SDR, whereas others favor spasticity intervention first. There are no guidelines in the literature to support one algorithm over the other. Functional improvement after SDR is highly dependent on patient selection. Comprehensive, interdisciplinary evaluation is essential, including evaluation of strength, motor control, and mobility. In many centers, ITB is used most frequently in nonambulatory patients (GMFCS levels IV–V). Other centers advocate ITB to improve ambulation in patients with CP. In studies with careful selection criteria, improved long-term ambulation in patients receiving ITB is supported by the literature.

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Apr 19, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on New Clinical and Research Trends in Lower Extremity Management for Ambulatory Children with Cerebral Palsy
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