I recently received a very good email from a parent asking about why I… and many others… seem to talk more about CP than about spasticity. She wants to know is there any hope for reducing spasticity? The short answer is yes. The problem is that reducing tone is an on-going problem that requires a coordinated approach. Unfortunately, this is rarely done.
In my view, the first issue is a confusion of terminology. Cerebral palsy and spasticity are not the same thing. Cerebral palsy is a disorder caused by brain damage in an immature brain. Spasticity is a part of the complex signs and symptoms caused by the brain damage. This distinction is important because some of the treatments that are available aim to treat the underlying brain problem by encouraging neuroplasticity…making new connections. Some examples are Constraint Induced Movement Therapy (CIMT), the Anat Baniel method, Neurodevelopmental Therapy (Bobath/NDT) and a wide variety of Sensorimotor Integration techniques. EMG Triggered Stimulation (ETS or EMG+Stim) is a newer technology that allows the child to “find” new brain pathways, often in minutes. Each of these therapies works from a different theoretical background, but all of them are working to reprogram the child’s learned abnormal movement pattern into a more normal movement pattern. The goal is to teach the child how to move in a more normal fashion. There are other methods of treatment that also have the goal of improving the brain and over the years, I have found that there are regional and personal preferences amongst physical and occupational therapists.
Whatever the method used, if the brain re-wires into a more normal circuitry with a how to therapy, it seems obvious that spasticity will reduce. If in fact, after a treatment session, many children will move more easily. But it rarely lasts for long. The effect wears off and the child tightens up again. The mother who wrote me had tried Botox injections several times and was able to report that her four-year-old child had a much better potential of walking under the effect of Botox. The injection temporarily decreased her child’s spasticity, which allowed easier movement. However, as soon as the Botox wore off, she was back to square one.
I believe parents need to learn how to differentiate between treatments that teach a child how to do an activity in a different way and techniques and therapies that allow the child to move differently. Both types of treatment are necessary, but most times parents and therapists tend to focus on the most recent therapies and often neglect the basic requirement to maintain alignment until the child stops growing. Treatments that maintain alignment are the treatments and techniques that allow more normal movement and growth. A key difference between an adult with a stroke and a child with hemiplegia is the child has a growing body and any tone change will distort growth. Here is a reality check…None of the how to therapies work as well as they could if we allow the body to distort. It is not an either/or situation.
I am going to write more on this important topic in the coming weeks. In the meantime, try making a list of your child’s therapies that allow better movements and therapies that teach how to move differently.
Interesting. My son doesn’t have much spasticity but more like highly variable tone — high tone when excited, low tone when not, etc.
Anyway, I’m a little confused about what you’re saying here and maybe you can illuminate this point in future posts. Are you saying that, for example, one needs to treat children with spasticity with both, say, Botox and ABM in order to get max benefit? Botox releases the muscles and then ABM can teach a new way of interacting with the muscles in order to lessen the need for Botox in future?
Response from Dr Pape: The first step is to provide the needed postural support so that the child can learn a new task. With variable tone, you need to use the supports most of the time, to hold him up when he is floppy and control the tendency to tip toe when he is excited. The goal is normal alignment. If the child needs serial casting and/or Botox to attain neutral alignment, that comes first. Then you can use ABM or many other treatment techniques to teach new skills. But trying to teach a new skill in bad alignment is counterproductive.
What a great summary. You’ve made such a complex issue so simple and practical. Thanks very much
Hi Dr Pape,
If you have not done so already, you should look into ABR Therapy.
I am, like you a physician, and I have a child with cerebral palsy ( GMFSC 4). We have been doing ABR for the past three years and with these gentle non-invasive tissue stimulation techniques we have completely remodeled my child’s structure. No Botox or surgery required. Her overall tone and spasticity is less, she now has neck control and is starting to sit. I hold the physical exam of a patient in high regard and I always rate a doctor on how well and thoroughly they do this. The ABR physical exam is something to note. Especially because it allows for early diagnosis. As you know, this is an issue with CP.
If you had a chance, please look into it. I find it really sad that more parents don’t know about this because it really works. They have strong group in North America and I am also co-ordinating some research activities with them.
If you would like, I am hapoy to share the recent outcomes of the study they presented in San Diego this year.
Thank you for everything you do for our children,
Thank you Erika. I am aware of the ABR method and feel it is one of the excellent therapies that are available.I am very pleased that it is working so well for you. Unfortunately, like many other programs that have gone before, some of the practitioners tell parents that this is the ONLY treatment or technique that should be used. I disagree with this message, as in over 40 years of working with children with CP, I have never seen a child who has reached their maximum potential using only one approach. Espousing only one approach may be necessary in a single intervention research trial, but this approach should not be applied to the overall management of the individual child.
Karen, I was surprised to note that you do not mention Selective Dorsal Rhyzotomy, a procedure that can eliminate spasticity. I would be interested to know why you have not included it in this post.
Dear Leigh, Thank you for your question.The point of this post was to differentiate between therapies that teach a child “how to” do an particular action and therapies the “allow to” do the function. The child needs both, but some practitioners of “how to” therapies tell parents to only use their technique. In my experience, this is wrong. The Selective Dorsal Rhizotomy is an evidence-based intervention for spasticity that works well in appropriately selected children. But, experience shows that it works better if the child is in good shape before the surgery and has both intensive strengthening and gait re-training post surgery. This is rarely available in North America….I have heard from families that have even travelled overseas to get the training they need post-operatively.I believe we have to provide more intensive training programs for children, but this will require a lot of pressure from empowered parents that ask questions and demand more… Keep up the good work.