What is the recommended rehabilitation approach for a pediatric patient with cerebral palsy?

Rehabilitation Approach for Cerebral Palsy

Children with cerebral palsy should receive immediate, intensive, task-specific motor interventions—specifically constraint-induced movement therapy (CIMT) for hemiplegia or Goals-Activity-Motor Enrichment (GAME) for all CP subtypes—delivered primarily in home-based settings, as delaying treatment causes progressively irreversible modifications to muscle and bone growth. 1, 2

Timing: Start Immediately Upon Diagnosis

• Begin rehabilitation the moment CP is diagnosed or strongly suspected, even using an interim diagnosis of "high risk of CP" when certainty is lacking 1, 2
• Early intervention harnesses maximal neuroplasticity—infants who don't actively use their motor cortex risk losing cortical connections and dedicated function 2
• Delaying intervention allows harmful, progressively harder-to-reverse modifications to muscle and bone 1, 2

Core Intervention Characteristics

Task-specific, motor training-based approaches are the foundation:

• CIMT for hemiplegic CP: Constrains the unaffected limb to force use of the affected side 1, 2
• GAME for all CP subtypes: Goals-Activity-Motor Enrichment targeting individualized functional goals 1, 2
• Interventions must incorporate child-initiated movement, task-specific practice, environmental adaptations, repetitive exercises, and age-appropriate activities 2

Home-based delivery is superior to clinic-based therapy for both motor and cognitive outcomes 1, 2

Intensity and Dosing

• Therapy should be intensive and enriched, with functional intensive programs showing effectiveness even in older (11-19 years) and more severely affected children (GMFCS I-IV) 3
• One effective model: 6-7 hours daily of functional therapy for 15 days, with improvements retained at 3-month follow-up 3
• Moderate evidence supports goal-directed/functional training and gait training to improve gait speed 4

Specific Motor Interventions by Function

For gross motor function and gait:

• Mobility and gait training, cycling, backward gait, and treadmill training 5
• Core stability exercises and slackline training improve balance and coordination 6
• Sit-to-stand exercise programs target functional transitions 6

For upper extremity function:

• Bimanual therapy has moderate evidence for improving manual performance 4, 5
• CIMT shows moderate evidence for upper limb recovery 4

For overall function:

• Stretching and resistance exercises improve strength, though evidence is conflicting 6, 4
• Increase daily physical activity and counter sedentary behavior 5

Complementary Approaches

These may supplement (not replace) task-oriented programs:

• Virtual reality, action-observation therapy 5
• Hydrotherapy and hippotherapy 5
• Horse riding and biking 6

Critical Pitfall to Avoid

Neurodevelopmental therapy (NDT) is ineffective and should not be used 4

Prevention of Secondary Complications

Hip surveillance protocol:

• Obtain anteroposterior pelvic radiographs every 6-12 months starting at age 12 months, as hip displacement affects 28% of children with CP 1, 2

Orthotic management:

• Prescribe ankle-foot orthosis (AFO) immediately for foot drop in hemiplegic CP to improve gait mechanics and prevent contractures 1

Pain management:

• Implement preemptive analgesia for all procedural pain—untreated procedural pain elevates risk for long-term neuropathic pain, and 75% of children with CP experience chronic pain 1, 2

Multidisciplinary Team Structure

Essential team members include:

• Pediatric neurologist, pediatrician, orthopedic surgeon 1, 2
• Physical therapist, occupational therapist 1, 2
• Psychologist and education specialist 1, 2

Coordination between educational and clinic settings increases therapy minutes and improves outcomes 7

Family-Centered Care

• Provide immediate counseling and goal-setting with parents at intervention start to reduce depression and anger 1
• Screen parental mental health routinely, as 1 in 4 children have behavior disorders that compound parental stress 1
• Offer attachment support and facilitate parent-infant interactions 1

Monitoring and Adjustment

• Individualize rehabilitation plans based on GMFCS level—children in levels IV-V require more intensive services than level I 7
• Update plans regularly based on developmental milestone progress 2
• Interventions should focus moderately to greatly on primary impairments, secondary impairments, activity, and structured play; moderately on environmental modifications and equipment 7

Expected Outcomes

With appropriate early intervention and comprehensive management:

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