What is the recommended approach for the rehabilitation of a child with cerebral palsy (CP)?

Rehabilitation of Children with Cerebral Palsy

Children with cerebral palsy should receive early, task-specific, motor training-based interventions that harness neuroplasticity, with constraint-induced movement therapy (CIMT) for hemiplegia and Goals-Activity-Motor Enrichment (GAME) for all CP subtypes, delivered in home-based settings whenever possible. 1

Core Rehabilitation Framework

Early Intervention Principles

The rehabilitation approach must begin immediately upon diagnosis or high suspicion of CP, as infants who do not actively use their motor cortex risk losing cortical connections and dedicated function. 1 Delaying intervention causes harmful modifications to muscle and bone growth that become progressively harder to reverse. 1

Three primary goals guide all rehabilitation efforts: 1

• Optimize motor, cognition, and communication outcomes through interventions promoting neuroplasticity
• Prevent secondary impairments (hip displacement, contractures, chronic pain, scoliosis)
• Support parent/caregiver mental health to reduce stress, anxiety, and depression

Subtype-Specific Motor Interventions

For Hemiplegic CP (unilateral involvement): 1

• Constraint-induced movement therapy (CIMT) produces better hand function in both short and long-term outcomes
• Bimanual therapy as an alternative approach
• Treatment selection depends on functional goals and child tolerance

For Diplegic CP (bilateral, lower limbs predominant): 1

• Learning Games Curriculum
• Task-specific gait and mobility training
• Regular hip surveillance with anteroposterior pelvic radiographs every 6-12 months starting at 12 months of age 1

For All CP Subtypes: 1

• Goals-Activity-Motor Enrichment (GAME) intervention shows superior motor and cognitive outcomes at 1 year compared to usual care
• Home-based delivery is preferred as children learn best in natural settings with personalized, enjoyable training 1

Essential Intervention Characteristics

Physical and occupational therapy must incorporate: 1

• Child-initiated movement (not passive manipulation)
• Task-specific practice targeting functional activities
• Environmental adaptations stimulating independent performance
• Repetitive, progressively adapted exercises
• Age-appropriate, goal-oriented activities

Intensity and setting matter: 1

• Interventions should be intense and enriched
• Home-based programs produce better outcomes than clinic-based approaches
• Training must be personalized to the child's enjoyment to maintain engagement

Communication and Cognitive Support

Speech-language pathology interventions should: 1

• Foster parent-infant transactions early
• Implement Hanen "It Takes Two to Talk" and "More Than Words" programs
• Provide alternative and augmentative communication (AAC) when speech is inadequate or impossible (1 in 4 children with CP are nonverbal) 1

Prevention of Secondary Complications

Musculoskeletal Surveillance

Hip monitoring protocol: 1

• Anteroposterior pelvic radiographs every 6-12 months beginning at age 12 months
• Early detection prevents displacement requiring surgical intervention (affects 1 in 3 children) 1

Contracture prevention: 1

• Regular surveillance and early intervention reduce rates of contracture and scoliosis in bilateral CP
• Structured, standardized follow-up programs with early intervention against muscle hypertonia prevent complications 2

Pain Management

Critical consideration: 3 in 4 children with CP experience chronic pain. 1

• Avoid procedural pain when possible (untreated pain elevates long-term neuropathic pain risk)
• Provide preemptive analgesia for necessary procedures
• Use pharmacological therapy and environmental interventions for ongoing pain 1

Neurological Complications

Epilepsy management (affects 1 in 4): 1

• Standard antiepileptic pharmacological management 1

Sleep disorders (affects 1 in 5): 1

• Specialist assessment and early treatment before secondary academic/behavioral problems emerge
• Sleep hygiene and parental education
• Spasticity management
• Melatonin 2.5-10 mg
• Gabapentin 5 mg/kg 1

Other Complications

Sialorrhea (affects 1 in 5): 1

• Botulinum toxin A
• Benztropine mesylate
• Glycopyrrolate 1

Vision impairment (affects 1 in 10): 1

• Early assessment of visual function in first 48 hours of life
• Infants with abnormal vision at term-equivalent age require immediate intervention and reassessment at 3 months 1

Bladder control problems (affects 1 in 4): 1

• Medical investigations (abnormal anatomical findings are common)
• Standard toilet training over extended duration 1

Multidisciplinary Team Structure

Essential team members: 3, 4, 5

• Pediatric neurologist
• Pediatrician
• Orthopedic surgeon
• Physical therapist
• Occupational therapist
• Speech-language pathologist
• Psychologist
• Education specialist

Family involvement is non-negotiable: 3, 5

• Active parental participation from birth improves outcomes
• Family-centered approach addresses parental guilt and supports coping
• Parents should be involved in goal-setting and decision-making 4

Long-Term Monitoring

Children with CP require lifelong surveillance: 1

• Individualized rehabilitation plans updated regularly based on developmental milestone progress
• Annual reviews at minimum 1
• Children may "grow into their disability" as demands increase with age
• Ongoing and emerging rehabilitation needs throughout growth and development 1

Critical Pitfalls to Avoid

Do not wait for definitive diagnosis before starting intervention - begin as soon as CP is suspected to maximize neuroplasticity window. 1, 6

Do not use passive therapies - child-initiated, active movement is essential for motor cortex activation and cortical connection preservation. 1

Do not neglect comorbidities - comprehensive management of pain, sleep, vision, and other complications is as important as motor rehabilitation. 1

Do not underestimate parental mental health needs - parental depression and anxiety directly impact rehabilitation success and child outcomes. 1

Expected Outcomes

With appropriate early intervention and comprehensive management: 6

• 2 in 3 individuals with CP will walk
• 3 in 4 will talk
• 1 in 2 will have normal intelligence