Neurodevelopmental Therapy or Strengthening Exercises for cerebral palsy child

 Neurodevelopmental Therapy or Strengthening Exercises  for cerebral palsy child

 Neurodevelopmental Therapy
 
In the 1960s and early 1970s, pediatric therapists for CP appeared distinct
from therapists who trained on poliomyelitis cases and from there quickly
developed a cadre of therapists who practiced neurodevelopmental therapy
(NDT). Neurodevelopmental treatment has gone through a long evolution
over the years. Time has forced it to become more eclectic and become one
of the most commonly used intervention strategies for children from infancy
through adulthood with CP.1 Since the conception of NDT by Dr. Karl and
Mrs. Berta Bobath in the 1940s, the scientific community’s understanding of
the brain and the conceptual framework of NDT has evolved. As our understanding
of how the brain inspires and controls movement evolves, so does
the theory of NDT into what is currently accepted as the Dynamic Systems
Theory. In this way NDT is a “living concept.”2 It adapts and grows as
knowledge of the brain’s function is revealed.
Using the Dynamic Systems Theory, NDT-trained therapists are able to
use a variety of handling techniques. These specialized techniques encourage
active use of appropriate muscles and diminish involvement of muscles
not necessary for the completion of a task. Child-directed and -initiated
movement tasks are critical to the success of neurodevelopmental treatment.2
Therapists practicing NDT set functional individual session goals, which build
upon each other to facilitate new motor skills or improve the efficiency of
learned motor tasks. Improvements in efficiency can include decreased energy
used during a task, decreased work required of the muscles during a
task, and habituation of new patterns of movement. These tasks are specific
to and driven by the functional needs of the child. In NDT the child takes an
active role in treatment design. The therapist must be constantly evaluating
their input into the child’s movement with the goal of active, habituated, independent
movement.
NDT is a problem-solving approach focusing on the individual’s current
needs while aiming for the long-term goal of function across the lifespan.2
Occupational, speech, and physical therapists as well as educators can use
NDT. The benefits of utilizing NDT include improved ability to perform
functional activities appropriate to the needs of the individual, active participation
of the child, improved strength, flexibility, and alignment, and improved
function over a lifespan. NDT is not an exclusive treatment for individuals
with CP.
NDT-trained therapists have completed an 8-week pediatric or a 3-week
adult course, and some, an additional 3-week infant postgraduate course.
Rehabilitation Techniques 345
Practicing therapists can be found in every community. Therapists can learn
about the theory and techniques at a variety of continuing education courses
offered throughout the year and over the course of many years.
 
Strengthening Exercises
 
In past years, several clinical myths existed about what one should never provide
to patients with CP, such as “no plastic for spastics” when prescribing
orthoses or “never strengthen spasticity.” Recent research has provided evidence
to dispel these myths and bring a new level of awareness of how children
with CP can be helped. It has always been known that increased tone
is not the only or even the most significant impairment of CP, but that there
is poor recruitment of muscle unit activity and inconsistent maintenance of
maximum efforts. Research that investigates muscle strengthening has contributed
to this understanding.
More than 50 years ago, Phelps proposed that resisted exercise “to develop
strength or skill in a weakened muscle or an impaired muscle group” was an
integral part of treatment in CP.3 Shortly thereafter, physical therapists denounced
strengthening for their patients with upper motor neuron syndromes
based primarily on the clinical concern that such strong physical effort would
exacerbate spasticity. However, scientific evidence has been accumulating
in recent years that dispels this contention and supports the effectiveness of
strength training for improving motor function in CP as well as in other
neuromotor disorders. Muscle strength is related to motor performance and
should be an integral part of a rehabilitation program that addresses other
impairments which inhibit motor performance in this population, such as
muscle–tendon shortening, spasticity, and coordination deficits.
It has been shown that even highly functional children with spastic CP
are likely to have considerable weakness in their involved extremities compared
to age-related peers, with the degree of weakness increasing with the
level of neurologic involvement.4,5 If a child has at least some voluntary
control in a muscle group, the capacity for strengthening exists. In the absence
of voluntary control, strength training is more problematic, but may
be facilitated by the use of electrical stimulation or by strengthening within
synergistic movement patterns. However, strengthening is only justifiable if
the ultimate goal is to improve a specific motor skill or function. Therefore,
a child with little or no capacity for voluntary muscle control is unlikely to
experience substantial functional benefits from a strength-training program.
Most ambulatory children with CP have the capacity to strengthen their
muscles, although poor isolated control or inadequate length in the ankle
dorsiflexor or the hamstring muscles may limit progress in some patients.
Nonambulatory children may also experience improvements in their ability
to use their upper extremities, transfer more effectively, or engage more
actively in recreational and fitness activities. Invasive procedures such as
muscle–tendon lengthening, selective dorsal rhizotomy, intrathecal baclofen
pump implantation, or botulinum toxin injections may improve muscle length
and/or control so that muscles can then be strengthened more effectively.
In turn, strength training may serve to augment or prolong the outcomes of
these procedures.
To participate in a strength-training program, the child must be able to
comprehend and to consistently produce a maximal or near-maximal effort.
Children as young as 3 years of age may be capable of this, but waiting to
augment the program until the child is age 4 or 5 years is more realistic.
 
 Neurodevelopmental Therapy or Strengthening Exercises  for cerebral palsy child

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