Physical management will cover five main areas:
- postural management - posture as a base for movement and to lessen deformity
- movement facilitation - providing the child opportunities to experience and practise gross movement sequences and fine movements within and outside a stable base
- environment - the opportunity to experience their external environment, such as touch, balance
- providing equipment to make the child's daily management easier for carers (e.g. bathing aids), postural equipment (e.g. seating, lying boards) and mobility equipment (e.g. suitably adapted pushchair or wheelchair); this is often done in close conjunction with an occupational therapist.
Factors influencing the management of the child
There is a generally accepted view that well-organised intervention can radically improve the outcome for many children with CP. This is particularly noticeable when comparing outcomes to those children in countries where no treatment is available.
Many children will require treatment throughout school, but even those who do not should have regular follow-up appointments to ensure that nothing untoward is changing as they grow and for review of equipment needs.
School leaving and adult life
The healthcare team need to be fully acquainted with the previous history and that the young adult (or carers) understand what their needs are, what their responsibilities are and from whom to seek help.
Liaison with orthopaedic services
The physiotherapist should be part of, or in close contact with, the orthopaedic consultant and, if orthotics or surgery are required, be fully involved in the child's post-operative management.
A major problem with physiotherapy is the lack of evidence for its clinical effect. Over the years, there have been a number of studies to prove the effectiveness of physiotherapy in children with an established diagnosis of CP. As a consequence of a failure to reach a consensus in defining treatment principles and goals, no consistent conclusions can be drawn from these or any other study results. Some clinicians have suggested that it is possible to alter the structure of the central nervous system (CNS), with workers such as Vojta, Doman and Katona; with Katona suggesting that very early treatment can eradicate CP in about one-third of patients. However, very early diagnosis can be unreliable. Some clinicians think that it is possible to train the CNS in basic patterns of movement and in function. Others see physiotherapy as teaching patients alternative strategies, including traditional movement therapies, and preventing secondary pathologies and deformity from occurring. Given these different approaches, and the lack of firm evidence for its clinical effect, the type of treatment tends to vary depending on the experience, aptitude and particular skill of the physiotherapist, the severity of the child's disorder and intellectual abilities, social circumstances of the family and healthcare staff availability. The long-term aims should always bear in mind the child's likely future life as an adult and relate the treatment to optimising that period of their life.
HemiHelp and Kiki's Children's Clinic have collaborated to create a DVD which aims at incorporating physio exercises into day-to-day life, available from here.