Health

Hippotherapy

Hippotherapy is specialized physical therapy that takes advantage of the three dimensional movement of a horse during walking to facilitate movement responses in children with cerebral palsy riding the horse. The name is from the Greek word “hippos,” which means horse. There have been several studies looking at the effect on children with cerebral palsy and either recreational horseback riding therapy or therapist-directed hippotherapy. Both have been shown to increase gross motor function. Some small studies have shown improvement in some ADLs as well.

It has been theorized that riding a horse while it is walking mimics classic pelvic movement during walking in a person without any disability. One study compared riding a horse to sitting on a barrel to show that the symmetry of movement obtained was not just from stretching muscles that would be found when riding a horse. They found improved symmetry of muscle activity after riding. There has been some suggestion of more efficient energy expenditure in walking after hippotherapy, as well. There are a number of therapy programs around the country for hippotherapy, and children who participate have a broader smile in describing this than in any other therapy visit I have seen.

Aquatic Therapy
Another area of therapy generally described with a huge smile by children is aquatic therapy. Any therapy in a swimming pool offers many potential benefits and is a logical choice for children with cerebral palsy. The buoyancy of water supports their body so that they can more easily stay upright and move. It also protects their joints. With the resistive forces offered by water, one can get a great strengthening program. Moving an arm or leg, particularly with a paddle or kick board or something else to increase resistance, is a great strengthening activity. A key concern is to avoid fatigue. Aerobic programs in the water are excellent.

Programs can be facilitated by use of many floating objects, including kick boards, pool noodles, life jackets or other floating devices. By holding onto the wall or having a therapist or a volunteer assist in having individual exercise programs, one can work on technique in walking or other movements. In a group program, there is increased motivation and social benefit by using games and races to work on cooperation and/or competition.

An aquatic exercise program allows working on fitness even for a child with significant mobility limitations who cannot do land-based activities. Aquatic programs have been shown to increase the lung capacity in children participating in long-term exercise programs. In choosing a program for one’s child, it is important to make sure that it is a safe aquatic environment with experienced personnel. The combination of aerobic exercise, strengthening exercise, social interaction and fun is a wonderful combination.

Pet Therapy
Pet therapy is thought to have been developed in 1976 by a nurse named Elaine Smith who noticed how well patients responded to a golden retriever. She then developed a program for training dogs to visit institutions with their patients. There are several companies now that specialize in certifying dogs as therapists and dogs must be registered with them prior to visiting health care facilities. Dogs have been shown to relieve stress, lower blood pressure and raise spirits.

Many rehabilitation facilities have pet therapy programs where the dogs either just come for a visit or provide encouragement for children. There are some programs where the therapist will schedule a time with the dog and work for example with a child’s involved arm to pet or brush the dog, perhaps even using a wrist weight to develop more strength or use an adapted brush. There are programs also for reading with dogs including a program called RAED (Reading Assistance Education Dogs). The dogs go to school and students with reading difficulties read to the dogs.  By having a nonjudgmental listener, the children can practice on improving their reading skills in a non-threatening manner.

There are also dogs trained to be assistance dogs for children with severe cerebral palsy and other diagnoses. They can assist with opening doors, picking up dropped objects or other daily activities. Some dogs are trained to take care of their owner when they have a seizure. Certainly, there is a great potential social benefit for a child who has an assist dog as it becomes a conversation starter and attracts social interaction with other children.

Play Therapy
Play has been described as the work of childhood. Play is the leading activity for most children. It is felt to be critical in child development. Children with motor disabilities, not to mention possibly visual, hearing or cognitive deficits, have barriers in spontaneous play. Therefore, it is critical to maximize opportunities for play for children with cerebral palsy. Computer games is one area that has had tremendous growth in children. It is a worthwhile form of play and important; however, in most cases it lacks the physical and social component. It is important to structure play opportunities for children with disabilities. This can be done by scheduling play dates. It can also be done by becoming involved with structured activities within the community.

For example, in Charlotte, North Carolina, the Mecklenburg County Park and Recreation Department has a therapeutic recreation division that provides many activities year round. There are adaptive sports including adaptive baseball, soccer, lacrosse and golf. Putt-Putt for those who are visually impaired and beep ball, which is baseball for those with visual impairments, are offered. Camps also offer activities such as art, crafts, music, sports, games, theater, dance and cooking.

There are also sports leagues for adaptive flag football, soccer and cheerleading for those events. For a period of play in the neighborhood or at one’s school, it is important to create a safe environment for all children including those with physical impairments and those without. It is important to have accessible play areas that encourage social interaction, creativity and allow as much independence as possible. Sometimes rules to games can be adapted for children depending on their physical impairments.

Adapted Sports and Adventures Program (ASAP) in Charlotte has many group programs for the enjoyment, socialization, and physical well-being of children, teens, and adults with physical disabilities. The goal is to develop an active lifestyle and integrate individuals into community activities. Water skiing, basketball, soccer, rugby, and downhill skiing are some of the activities they offer and which are shown here. They sponsor Winners on Wheels, a scouting experience for 5 to 12 year-old children with mobility impairments. They work on projects, attend events and sports clinics. Their goal is empowering children to grow and contribute to society.

The Americans with Disabilities Act (ADA) of 1992 was civil rights legislation to protect people with disabilities from discrimination. This requires public accommodations to make reasonable modifications, including play areas, to accommodate individuals with disabilities if readily achievable. More and more playgrounds nationally have barrier-free areas where all children, those with and without disabilities, can play together and learn together. This is important for all children in developing language skills, social interactions, decision-making abilities and cognitive growth.

Children need to be comfortable and have opportunities to play that will help them develop in all aspects including socially and physically. It is important to help children develop skills that allow them to play with other children and maximize those social and physical opportunities. The ability to play helps solidify a child’s social opportunities and membership in a peer group. Children learn by doing, so playing can offer many opportunities for physical practice, cognitive practice and social practice, as well as plain fun.

In considering toys for children with physical disabilities, there are several basic considerations. The first is the child’s individual interests and age and if it is appropriate for those. Next is consideration of safety for that child and ability of the toy. Additionally, if the toy encourages interaction it gains another facet of use. If the toy has a multisensory appeal, this may be appropriate for children of various ages, interests and skills. It is important that the child can activate the toy easily. A good toy allows the child to be creative and express oneself. If the toy can be used in various positions for the child, such as on their wheelchair tray, that is beneficial. The most appealing toys for many children are those that are in the popular culture. For example, many of the children whom I see today play with Spiderman, Shrek, Dora and Sponge Bob Squarepants.

For children with significant physical disabilities, there are now robotics arms, which can perform play activities. With the advent of technology and computer toys, having a robotic arm with a computer and the ability to perform a function that the child is unable to do for him/herself are potentially exciting options.

Physical activities with other children enhance social acceptance. Children who do well socially in elementary school have a better opportunity to do well academically and develop their social skills for their lifetime. Play can help enhance self-confidence.

Acupuncture
Another means of treatment for children with cerebral palsy is acupuncture. Most of the literature is from China and therefore rather difficult to analyze for those who do not read or speak Chinese. In reading abstracts in English, there are many reports that indicate the intelligence quotient or IQ is increased in infants who have early acupuncture and there is a decreased rate of cerebral palsy in those who are at risk. They also claim there is an improvement in language function in children with cerebral palsy. The amount of specific information available is small and difficult to evaluate. Certainly, acupuncture is used increasingly in many aspects of Western medicine and has been shown to be effective in many areas. It has been used for thousands of years successfully in China.

Acupuncture is based on the Chinese medicine concept of the flow of qi or chi or energy. Acupuncture is performed to establish the normal flow of chi. It is used with small needles and sometimes electric current as well. It has been shown to warm the arms and legs and to decrease painful spasms. There is also a study that shows there is decreased drooling in children with cerebral palsy. One study showed some improvement in GMFM score.

Whole-Body Vibration Training
This is a new type of exercise that been used in postmenopausal women trying to decrease osteoporosis and prevent bone fractures after a study found that high frequency mechanical strain stimulated bone strength in animals. It was found that this may modify risk factors for bone fractures by improving bone mineral density and improving balance. Both of these would be useful in those with cerebral palsy. In one recent study of children with spastic cerebral palsy a decrease in spasticity in knee extensors was found.

Hyperbaric Oxygen (HBO)
Another controversial yet enormously popular type of treatment for children with cerebral palsy, is hyperbaric oxygen. This treatment has spread worldwide with websites and anecdotal information reporting amazing changes that have excited parents around the globe. Due to the enormous popularity and broad use with no scientific evidence, a group performed double-blind placebo-controlled study to evaluate the effectiveness and possible side effects of this treatment.

In this study, 111 children were divided in two groups, one of which got hyperbaric oxygen, which is 100 percent oxygen at 1.75 atmosphere absolute (ATA), and the other children were in a placebo or sham treatment with 21 percent oxygen, which is the percentage in room air and 1.3 ATA. This study found that both groups of children showed an increase in gross motor function with no differences between the two groups. They also showed improvement in self-control, auditory attention and visual working memory, again with no difference between the two groups.

The areas of difference between the two groups were in apparent reading skill in which the sham group showed eight areas of improvement out of 13 and the active hyperbaric oxygen group improved in only one dimension. Most of these changes persisted for three months afterwards. There was no improvement in visual attention, processing speed or verbal span memory. It was also found that the parents’ perceptions of the child’s cognitive function, particularly attention and impulsivity, were higher than the children’s actual ability.

Many hypotheses were investigated to look for possible explanations for why both the sham and HBO treatment showed positive findings. It was thought that the promotion of parent-child interaction in an unusual fashion and these children facing uncertainties in uncomfortable new situations involving other children and families was quite a stimulating environment and part of the reason for improvement in both groups. Additionally, cumulative practice showing increased familiarity with testing may just show a testing effect of improvement as opposed to actual improvement in some of the test results.

The conclusion of this vigorous study is that hyperbaric oxygen did not improve the condition of children with cerebral palsy compared to slightly pressurized air. This is a significant study and it remains to be seen if this will change the popularity of this well-advertised, expensive and time-consuming therapeutic approach.

Vojta
There are a number of controversial treatments of cerebral palsy. In the 1970s, Dr. Vojta proposed that the development of cerebral palsy could be prevented in at risk infants and motor behavior can be improved in infants with fixed cerebral palsy. Dr. Vojta’s articles are in German. He proposed reflex inhibition of spasticity in perinatal encephalopathy by means of voluntary movement using developmental old structural movements. He talked about cerebral coordination disturbances (CCD) and classified these based on the abnormality of the postural reflexes.

Therapies to counteract abnormal reflexes emphasized reflexogenic motion reflex creeping and reflex turning as well as kinesiologic connection with tonic connect reflexes. There was emphasis on automatic control of upright posture and movement using kinesiologic facilitation. Some articles reported significant increase in blood pressure, by up to 60 mmHg during reflex reversion and 52 mmHg during reflex supporting exercises. These articles raised concerns about the cardiovascular risk associated with this increase in blood pressure.

Additionally, there are several articles that discuss the psychological aspects of early physiotherapy and potential adverse psychological side effects of the Vojta method. Some ask about possible negative effects of Vojta physical therapy on the mother-child relationship, particularly stress at the beginning of therapy, with recommendations for psychological information and support. There are limited scientific journal articles about this therapy published in English. 

Craniosacral Therapy
Craniosacral therapy is based on a theory that there is a cranial rhythm through the head, spinal cord and body that is transmitted through mechanical forces. The therapy then is used to remove anything that blocks the flow of rhythm through the cerebrospinal fluid. Reportedly with light touch, practitioners can feel this rhythm and they can use light corrective pressure on particular points to correct abnormal flow of impulses. There have been no studies that show effectiveness of this treatment and there have been several studies that report experienced practitioners of this treatment did not agree on findings when examining the same person at the same time. There are several studies that conclude there is little or no scientific basis for this treatment.

Experimental  Braces and Suits
Flexible compression bracing used with the goal of improving stability and movement control without interfering with the joint movement options includes the stabilizing pressure input orthosis (SPIO) or the Nancy Hilton brace. This is custom fit for stability, movement and control. The goal is improving the base of support and movement control. Sensory and biochemical factors probably contribute to its success.

An Adeli Suit is an adaptation of the suit used by Russian cosmonauts to counteract the adverse effects of zero gravity, which included muscle atrophy and osteopenia. This has been modified for children with cerebral palsy to include a vest, shorts, headpiece and knee pads with a belt with rings at the hips that allow controlled exercise against resistance. There are no studies published in English that either support or reject its effectiveness. A similar approach has been to use a tight-fitting lycra suit to improve positioning and gait, but most children did not tolerate this due to heat and discomfort.

Patterning
Patterning or the Doman and Delacato method was developed in the 1950s and 1960s. This group stated that normal development occurs in established sequence, therefore therapies should have the child undergo frequent repetitive steps in a specified developmental sequence. They would have families recruit friends and volunteers to spend hours a day moving the child’s body, going through specific patterns of motion. There were problems with parents feeling guilty when the children had not progressed.  Expenses were significant and siblings received less attention. The American Academy of Pediatrics reported that there was no special merit to this treatment and it has largely fallen out of favor.