Management of cerebral palsy
Over time, the approach to cerebral palsy management has shifted away from narrow attempts to fix individual physical problems – such as spasticity in a particular limb – to making such treatments part of a larger goal of maximizing the person's independence and community engagement.:886 Much of childhood therapy is aimed at improving gait and walking. Approximately 60% of people with CP are able to walk independently or with aids at adulthood. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level, or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.
Because cerebral palsy has "varying severity and complexity" across the lifespan, a multidisciplinary approach for cerebral palsy management is recommended, focusing on "maximising individual function, choice and independence" in line with the International Classification of Functioning, Disability and Health's goals. The team may include a paediatrician, a health visitor, a social worker, a physiotherapist, an orthotist, a speech and language therapist, an occupational therapist, a teacher specialising in helping children with visual impairment, an educational psychologist, an orthopaedic surgeon, a neurologist and a neurosurgeon.
Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents. Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; water therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepines); surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesisers. Many of the therapies used to treat CP have no good evidence base. The treatments with the best evidence are medications (anticonvulsants, botulinum toxin, bisphosphonates, diazepam), therapy (bimanual training, casting, constraint-induced movement therapy, context-focused therapy, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care) and surgery (selective dorsal rhizotomy).
- 1 Lifestyle
- 2 Therapy
- 3 Assistive technology
- 4 Medication
- 5 Surgery
- 6 Others
- 7 Alternative therapy
- 8 Occupational therapy
- 9 Research
- 10 See also
- 11 References
- 12 Further reading
- 13 External links
|This section needs expansion. You can help by adding to it. (February 2017)|
Physical activity is recommended for people with cerebral palsy, particularly in terms of cardiorespiratory endurance, muscle strengthening and reduction of sedentary behaviour. Participating in physical activity can supplement or replace some forms of therapy. Access to exercise can often depend on the caregivers' perception of whether it will benefit the person with CP. Behavioural change methods have been used to promote physical activity among young people with cerebral palsy, but there is no significant evidence for these working. It is difficult to sustain behavioural change in terms of increasing physical activity of children with CP. A normal vaccination schedule should be adhered to, as preventable diseases may take away energy that a person with CP would normally use in day-to-day life.
Physiotherapy (also known as physical therapy) programs are designed to encourage the patient to build a strength base for improved gait and volitional movement, together with stretching programs to limit contractures. Many experts[who?] believe that lifelong physiotherapy is crucial to maintaining muscle tone, bone structure, and prevent dislocation of the joints. Children may find long-term physical therapy boring.
Speech therapy helps control the muscles of the mouth and jaw, and helps improve communication. Just as CP can affect the way a person moves their arms and legs, it can also affect the way they move their mouth, face and head. This can make it hard for the person to breathe; talk clearly; and bite, chew and swallow food. Speech therapy often starts before a child begins school and continues throughout the school years.
Biofeedback is a therapy in which people learn how to control their affected muscles. Biofeedback therapy has been found to significantly improve gait in children with cerebral palsy. Mirror therapy has been used to improve hand function and was found to be "generally effective in enhancing muscle strength, motor speed, muscle activity, and the accuracy of both hands".
Occupational therapy helps adults and children maximise their function, adapt to their limitations and live as independently as possible. A family-centred philosophy is used with children who have CP. Occupational therapists work closely with families in order to address their concerns and priorities for their child. Family centered care is a paradigm that is often used with families with a child with CP. A review of how parents facilitate their child's participation found that parents typically "enable and support performance of meaningful activities" and "enable, change and use the environment", but that there is little written on parents' needs.
CP commonly causes hemiplegia. Those with hemiplegia have limited use of the limbs on one side of the body, and have normal use of the limbs on the other side. People with hemiplegia often adapt by ignoring the limited limbs, and performing nearly all activities with the unaffected limbs, which can lead to increased problems with muscle tone, motor control and range of motion. An emerging technique called constraint-induced movement therapy (CIMT) is designed to address this. In CIMT, the unaffected limbs are constrained, forcing the individual to learn to use the affected limbs. As of 2007[update] there was limited, preliminary evidence that CIMT is effective, but more study is needed before it can be recommended with confidence.
A comparison of bimanual training (BIT) and CIMT found that there was no significant difference between the two in terms of effects. However, bimanual training may be more able to be integrated into a child's daily life, because the goals in bimanual training are more functional. CIMT has some advantages, such as therapists being able to solely focus on the affected arm, and the child having no choice but to use the affected arm in their activities of daily life as their unaffected arm is constrained. In bimanual training, the child may continue to use the unaffected arm to compensate if their therapist or parent does not remind them to use both hands.
However, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Nonspeaking people with CP are often successful availing themselves of augmentative and alternative communication (AAC).
Therapeutic tests for assessing balance do not appear to have good evidence for their reliability and responsiveness. The tests with the strongest evidence are the Trunk Control Measurement Scale and the Level of Sitting Scale (when measuring the ability to maintain balance), Timed Up and Go test (when measuring the ability to achieve balance), and the Segmental Assessment of Trunk Control (when restoring balance).
Assistive technology is commonly used to promote the independence of people with disabilities. Commonly used technologies for people with cerebral palsy can include patient lifts, electric wheelchairs, orthotics, seating systems, mealtime aids (such as large-handled cutlery and slip-resistant mats), mobility aids, standing frames, non-motorised wheelchairs, augmentative and alternative communication and speech-generating devices. Scope has identified 3D printing as an area of promise in being able to print customised orthotics on-demand.
Orthotic devices such as ankle-foot orthoses (AFOs) are often prescribed to achieve the following objectives: correct and/or prevent deformity, provide a base of support, facilitate training in skills, and improve the efficiency of gait. The available evidence suggests that orthoses can have positive effects on all temporal and spatial parameters of gait, i.e. velocity, cadence, step length, stride length, single and double support. AFOs have also been found to reduce energy expenditure. Often children with CP require orthoses, such as casts and splints, to correct or prevent joint abnormalities, stabilize joints, prevent unwanted movement, allow desired movement, and prevent permanent muscle shortening. Orthoses may also make it easier to dress or to maintain hygiene. Lower limb splinting is specifically beneficial in providing a base of support and facilitating walking. It is equally important that the child be able to carry out daily activities and prevent joint deformities.
Children with CP have difficulties with mobility and posture. Occupational therapists often assess and prescribe seating equipment and wheelchairs. An appropriate wheelchair will stabilize the body so the child can use their arms for other activities. Wheelchairs therefore enhance independence.
|This section needs expansion. You can help by adding to it. (February 2017)|
Several kinds of medication have been used to treat the various kinds of cerebral palsy.
Botulinum toxin injections are given into muscles that are spastic or sometimes dystonic, the aim being to reduce the muscle hypertonus that can be painful. A reduction in muscle tone can also facilitate bracing and the use of orthotics. Most often lower extremity muscles are injected. Botulinum toxin is focal treatment, meaning that a limited number of muscles can be injected at the same time. The effect of the toxin is reversible and a reinjection is needed every 4–6 months. In children it decreases spasticity and improve range of motion and thus has become commonly used. Botulin toxin has been used in CP treatment for around two decades and can be recommended for children above the age of two.
Dosages of botulin toxin have been based on expert opinion rather than evidence-based practices. The dosages recommended have recently been reduced to reduce severe side-effects including becoming sensitive to the botulin toxin and developing an allergic response. Higher risks have been noted with children who are at level IV and V on the GMFCS. A review on the treatment of drooling in children with cerebral palsy found that it was not possible to tell whether interventions worked or were safe, including botulin toxin A and benztropine and glycopyrrolate.
Bisphosphonates are used to treat osteoporosis in adults. Osteoporosis is common in children with cerebral palsy, and non-oral bisphosphonates have been used to treat children with a very low bone mass density and a medical history of fragility fracture.
Surgery usually involves one or a combination of:
- Loosening tight muscles and releasing fixed joints, most often performed on the hips, knees, hamstrings, and ankles. In rare cases, this surgery may be used for people with stiffness of their elbows, wrists, hands, and fingers. Selective Percutaneous Myofascial Lengthening (SPML) is one example.
- The insertion of a baclofen pump usually during the stages while a person is a young adult. This is usually placed in the left abdomen. It is a pump that is connected to the spinal cord, whereby it releases doses of baclofen to alleviate continuous muscle flexion. Baclofen is a muscle relaxant and is often given by mouth to people to help counter the effects of spasticity, although this has the side effect of sedating the individual. The pump can be adjusted if muscle tone is worse at certain times of the day or night. The baclofen pump is most appropriate for individuals with chronic, severe stiffness or uncontrolled muscle movement throughout the body. There is a small amount of evidence that baclofen pumps are effective in the short term.
- Straightening abnormal twists of the leg bones, i.e. femur (termed femoral anteversion or antetorsion) and tibia (tibial torsion). This is a secondary complication caused by the spastic muscles generating abnormal forces on the bones, and often results in intoeing (pigeon-toed gait). The surgery is called derotation osteotomy, in which the bone is broken (cut) and then set in the correct alignment.
- Cutting nerves on the limbs most affected by movements and spasms. This procedure, called a rhizotomy ("rhizo" meaning root and "tomy" meaning "a cutting of" from the Greek suffix tomia), reduces spasms and allows more flexibility and control of the affected limbs and joints.
Other surgical procedures are available to try to help with other problems. Those who have serious difficulties with eating may undergo a procedure called a gastrostomy: a hole is cut through the belly skin and into the stomach to allow for a feeding tube. There is no good evidence about the effectiveness or safety of gastrostomy. Gastrostomies are associated with a lower life expectancy, this is probably due to underlying problems with swallowing rather than the procedure itself.
There is debate as to whether hip salvage surgery may reduce pain when the hip has been dislocated. Total hip arthroplasty is recommended for those with a mature skeleton, who are also likely less severely impaired. Because CP is widely heterogeneous in its presentation, surgery should be considered on a case-by-case basis.
Aquatic therapy or hydrotherapy are commonly used therapies for children with CP, but evidence for their effectiveness is mixed. Potential benefits of aquatic therapy is that children might find it more interesting than exercising on land, and they can try different kinds of movement such as jumping or skipping with less impact on their joints. While aquatic exercise is feasible and has low risk of adverse effects, the dose required to make a difference to gross motor skills is unclear.
Hip surveillance is the term for monitoring a child with CP who is at risk of hip dislocation to try to prevent dislocation from happening. The modern definition of cerebral palsy includes secondary skeletal effects on the child. The Gross Motor Function Classification System is a good indicator of hip issues, and more commonly occurs in children with spastic tetraplegia or spastic quadriplegia, but it is difficult to tell what type of CP a child has at the age where hip displacement might first become an issue (sometimes at 2 years old, but more commonly between 3 and 4 years old). Children are assessed for the risk of hip displacement using radiography.
Music therapy has been used in CP to motivate or relax children, or used as auditory feedback. Playing percussion instruments has been used as part of groupwork in therapy. Piano lessons may be beneficial in CP rehabilitation, however more research is needed.
While there is great interest in using video game rehabilitation with children with cerebral palsy, it is difficult to compare outcomes between studies, and therefore to reach evidence-based conclusions on its effectiveness. Because video gaming is popular, it may help children's motivation to continue with the therapy. There is moderate evidence for improvements with balance and motor skills in children and teens, but it is not recommended as an effective therapy.
There has not been much research into the use of alternative medicine to treat cerebral palsy. Acupuncture has been used as a treatment for cerebral palsy since at least the 1980s, but as of 2009, there have been no Cochrane reviews of the effectiveness of acupuncture in the management of cerebral palsy. In Traditional Chinese Medicine, cerebral palsy is often covered in the traditional diagnosis of "5 delayed syndrome". Dolphin-assisted therapy, Adeli suits, and hyperbaric oxygen therapy have been criticised as being alternative medicine and contrary to the practice of evidence-based medicine.
Hyperbaric oxygen therapy (HBOT), in which pressurised oxygen is inhaled inside a hyperbaric chamber, has been studied under the theory that improving oxygen availability to damaged brain cells can reactivate some of them to function normally. HBOT results in no significant difference from that of pressurised room air, however, and some children undergoing HBOT may experience adverse events such as seizures and the need for ear pressure equalisation tubes.
Patterning is a controversial form of alternative therapy for people with CP. The method is promoted by The Institutes for the Achievement of Human Potential (IAHP), a Philadelphia nonprofit organisation, but has been criticised by the American Academy of Pediatrics.
Conductive education (CE) was developed in Hungary from 1945 based on the work of András Pető. It is a unified system of rehabilitation for people with neurological disorders including cerebral palsy, Parkinson's disease and multiple sclerosis, amongst other conditions. It is theorised to improve mobility, self-esteem, stamina and independence as well as daily living skills and social skills. The conductor is the professional who delivers CE in partnership with parents and children. Skills learned during CE should be applied to everyday life and can help to develop age-appropriate cognitive, social and emotional skills. It is available at specialised centres.
Occupational therapists may use neuro-developmental techniques to promote normal movement and posture and to inhibit abnormal movement and posture. Specific techniques include joint compression and stretching to provide sensory-motor input and to guide motor output. Neurodevelopmental treatment, despite being commonly used as a therapy for children with CP, has not been found to have strong evidence for its use.
||This section needs to be updated. (February 2017)|
Occupational Therapy (OT) enables individuals with cerebral palsy to participate in activities of daily living that are meaningful to them. A family-centred philosophy is used with children who have CP. Occupational therapists work closely with families in order to address their concerns and priorities for their child. Occupational therapists may address issues relating to sensory, cognitive, or motor impairments resulting from CP that affect the child's participation in self-care, productivity, or leisure. Parent counselling is also an important aspect of occupational therapy treatment with regard to optimizing the parent's skills in caring for and playing with their child to support improvement of their child's abilities to do things. The occupational therapist typically assesses the child to identify abilities and difficulties, and environmental conditions, such as physical and cultural influences, that affect participation in daily activities. Occupational therapists may also recommend changes to the play space, changes to the structure of the room or building, and seating and positioning techniques to allow the child to play and learn effectively.
Effect of sensory and perceptual impairments
Children with CP may experience decreased sensation or a limited understanding of how the brain interprets what it sees. Occupational therapists may plan and implement sensory-perceptual-motor (SPM) training for children with CP who have sensory impairments so that they learn to take in, understand, plan and produce organized behaviour. The SPM training improves the daily, functional abilities of people with CP. Occupational therapists may also use verbal instructions and supplementary visual input, such as visual cues, to help children with CP learn and carry out activities.
For children with CP with limited movement and sensation, the risk of pressure sores increases. Pressure sores often occur on bony parts of the body. For example, pressure sores may occur when a child has limited feeling and movement of their lower body and uses a wheelchair; the tailbone bears weight when seated and can become vulnerable to pressure sores. The occupational therapist can educate the child, family, and caregivers about how to prevent pressure sores by monitoring the skin for areas of irritation, changing positions frequently, or using a tilt-in-space wheelchair.
Effect of cognitive and perceptual impairments
OT can address cognitive and perceptual disabilities, especially of the visual-motor area. For children with CP who have difficulty remembering the order and organization of self-care tasks in the morning, an occupational therapist can construct a morning routine schedule with reminders. An occupational therapist may analyze the steps involved in a task to break down an activity into simpler tasks. For example, dressing can be broken down into smaller, manageable steps. This can be done by having a caregiver lay out the clothing in order so the child knows what needs to be put on first.
Effect of motor impairments
The effect of motor impairments is significant for children with CP because it affects the ability to walk, propel a wheelchair, maintain hygiene, access the community and interact with other people. Occupational therapists address motor impairments in a variety of ways and makes use of various techniques, depending on the child’s needs and goals. The occupational therapist may help the child with gross motor rehabilitation, or whole body and limb movements, through repetitive activities. If the child has muscle weakness, progressive resistance exercises can improve muscular strength and endurance. Fine motor rehabilitation, or small, specific movements, such as threading the eye of a needle, can be implemented to improve finger movement and control.
For children with difficulties speaking, an occupational therapist may liaise with a speech therapist, carry out assessments, provide education and prescribe adaptive equipment. Adaptive equipment may include picture boards to help with communication and computers that respond to voice.
Occupational therapists can help the child promote use of a neglected arm through techniques such as constraint-induced movement therapy (CIMT), which forces use of the unused arm by placing the other arm in a sling, cast or oversized mitt.
Another OT technique that may be used is neuromuscular facilitation techniques, which involves physically moving and stretching the muscles to improve function so that the child can participate in activities.
Spasticity is a common problem experienced by people with cerebral palsy. It can cause pain and loss of sleep, impair function in activities of daily living, and cause unnecessary complications. Spasticity is measured with the Ashworth scale. Occupational therapy targeting spasticity aims to lengthen the overactive muscles.
OT role with factors influencing participation
Barriers to participation for children with CP include difficulty accessing the community. This includes difficulty accessing buildings and using transportation. Occupational therapists may work with developers to ensure new homes are accessible to all people. Also, occupational therapists often help people apply for government and non-profit funding to provide assistive devices, such as special computer programs or wheelchairs, to children with CP. Availability of transportation services can be limited for children with CP because of many factors, such as difficulties fitting wheelchairs into vehicles and dependency on public transit schedules. Therefore, the occupational therapists may also be involved in education and referral regarding accessible vehicles and funding.
Occupational therapists address the community and environmental factors that affect participation in leisure activities by educating children with CP, their families, and others on available options and adaptive ways to engage in leisure activities of interest. Prejudice of others toward disability can also be a barrier to participation for children with CP with respect to leisure activities. One way occupational therapists can address this barrier is to teach the child to educate others on CP – thus reducing stigma and enhancing participation. Finally, occupational therapists take children’s preferences into consideration in terms of cosmetic appearance when prescribing or fabricating adaptive equipment and splints. This is important as appearance may affect the child’s compliance with assistive devices, as well as their self-confidence, which may impact participation. In addition to providing dedicated occupational therapy to such children, some non-profit organizations viz. Spastic Society of Gurgaon are providing comprehensive assistance which includes designing of child specific assisting devices to such children for making their lives more meaningful by enabling them to be self-reliant to the best possible extent.
|This section needs expansion. You can help by adding to it. (February 2017)|
Stem cell therapy is being studied as a treatment. A potential treatment for some forms of cerebral palsy may be deep brain stimulation.As of 2016[update] it is thought that research in genetics and genomics, teratology, and developmental neuroscience is going to yield greater understanding of cerebral palsy.
- Disease management (health)
- Management of depression
- Pain management
- Quality of life (healthcare)
- Novak, Iona; Mcintyre, Sarah; Morgan, Catherine; Campbell, Lanie; Dark, Leigha; Morton, Natalie; Stumbles, Elise; Wilson, Salli-Ann; Goldsmith, Shona (October 2013). "A systematic review of interventions for children with cerebral palsy: state of the evidence". Developmental Medicine & Child Neurology. 55 (10): 885–910. doi:10.1111/dmcn.12246. PMID 23962350.
- McGinley, Jennifer L.; Pogrebnoy, Dina; Morgan, Prue (2014). "Mobility in Ambulant Adults with Cerebral Palsy — Challenges for the Future". In Švraka, Emira. Cerebral Palsy - Challenges for the Future. doi:10.5772/58344. ISBN 978-953-51-1234-1.
- Trabacca, Antonio; Vespino, Teresa; Di Liddo, Antonella; Russo, Luigi (September 2016). "Multidisciplinary rehabilitation for patients with cerebral palsy: improving long-term care". Journal of Multidisciplinary Healthcare. 9: 455–462. doi:10.2147/JMDH.S88782. PMC .
- National Guideline Alliance (UK) (January 2017). Cerebral Palsy in Under 25s: Assessment and Management (PDF). London: National Institute for Health and Care Excellence (UK). ISBN 978-1-4731-2272-7. Retrieved 5 February 2017.
- "Cerebral palsy - Treatment". www.nhs.uk. NHS Choices. Retrieved 6 February 2017.
- Verschuren, Olaf; Peterson, Mark D; Balemans, Astrid C J; Hurvitz, Edward A (August 2016). "Exercise and physical activity recommendations for people with cerebral palsy". Developmental Medicine & Child Neurology. 58 (8): 798–808. doi:10.1111/dmcn.13053. PMC . PMID 26853808.
- Heller, Tamar; Ying, Gui-shuang; Rimmer, James H.; Marks, Beth A. (May 2002). "Determinants of Exercise in Adults with Cerebral Palsy". Public Health Nursing. 19 (3): 223–231. doi:10.1046/j.0737-1209.2002.19311.x., as cited in Kent, Ruth M. (2012). "Cerebral palsy". In Barnes, Michael; Good, David. Neurological Rehabilitation Handbook of Clinical Neurology. Oxford: Elsevier Science. pp. 443–459. ISBN 9780444595843.
- Reedman, Sarah; Boyd, Roslyn N; Sakzewski, Leanne (March 2017). "The efficacy of interventions to increase physical activity participation of children with cerebral palsy: a systematic review and meta-analysis". Developmental Medicine & Child Neurology. doi:10.1111/dmcn.13413. PMID 28318009.
- Bloemen, Manon; Van Wely, Leontien; Mollema, Jurgen; Dallmeijer, Annet; de Groot, Janke (March 2017). "Evidence for increasing physical activity in children with physical disabilities: a systematic review". Developmental Medicine & Child Neurology. doi:10.1111/dmcn.13422. PMID 28374442.
- Stanton, Marion (2012). "Special Considerations". Understanding cerebral palsy : a guide for parents and professionals. London: Jessica Kingsley Publishers. p. 70. ISBN 9781849050609.
- Ravi, D.K.; Kumar, N.; Singhi, P. (September 2016). "Effectiveness of virtual reality rehabilitation for children and adolescents with cerebral palsy: an updated evidence-based systematic review". Physiotherapy. doi:10.1016/j.physio.2016.08.004. PMID 28109566.
- Pennington L, Goldbart J, Marshall J (2004). Pennington L, ed. "Speech and language therapy to improve the communication skills of children with cerebral palsy". Cochrane Database of Systematic Reviews (2): CD003466. doi:10.1002/14651858.CD003466.pub2. PMID 15106204.
- Dursun, E; Dursun, N; Alican, D (21 January 2004). "Effects of biofeedback treatment on gait in children with cerebral palsy.". Disability and Rehabilitation. 26 (2): 116–20. doi:10.1080/09638280310001629679. PMID 14668149.
- Park, Eom-ji; Baek, Soon-hyung; Park, Soohee (2016). "Systematic review of the effects of mirror therapy in children with cerebral palsy". Journal of Physical Therapy Science. 28 (11): 3227–3231. doi:10.1589/jpts.28.3227. PMC . PMID 27942154.
- Macgregor R, Campbell R, Gladden MH, Tennant N, Young D (2007). "Effects of massage on the mechanical behaviour of muscles in adolescents with spastic diplegia: a pilot study". Developmental Medicine & Child Neurology. 49 (3): 187–191. doi:10.1111/j.1469-8749.2007.00187.x. PMID 17355474.
- Zhou, Joanne; Butler, Erin E.; Rose, Jessica (17 March 2017). "Neurologic Correlates of Gait Abnormalities in Cerebral Palsy: Implications for Treatment". Frontiers in Human Neuroscience. 11. doi:10.3389/fnhum.2017.00103. PMC . PMID 28367118.
- Hansen, Ruth A.; Atchison, Ben (2000). Conditions in occupational therapy: effect on occupational performance. Hagerstown, MD: Lippincott Williams & Wilkins. ISBN 0-683-30417-8.
- Crepeau, Elizabeth Blesedell; Willard, Helen S.; Spackman, Clare S.; Neistadt, Maureen E. (1998). Willard and Spackman's occupational therapy. Philadelphia: Lippincott-Raven Publishers. ISBN 0-397-55192-4.
- Mulligan, Shelley (2003). Occupational therapy evaluation for children : a pocket guide. Philadelphia: Lippincott Williams & Wilkins. ISBN 9780781731638.
- Piškur, Barbara; Beurskens, Anna JHM; Jongmans, Marian J; Ketelaar, Marjolijn; Norton, Meghan; Frings, Christina A; Hemmingsson, Helena; Smeets, Rob JEM (8 November 2012). "Parents' actions, challenges, and needs while enabling participation of children with a physical disability: a scoping review". BMC Pediatrics. 12 (1). doi:10.1186/1471-2431-12-177. PMC . PMID 23137074.
- Hoare, BJ.; Wasiak, J.; Imms, C.; Carey, L. (2007). "Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy.". Cochrane Database Syst Rev (2): CD004149. doi:10.1002/14651858.CD004149.pub2. PMID 17443542.
- Dong, Vicky An-Qin; Tung, Ivy Hsi-Hsuan; Siu, Hester Wai-Yi; Fong, Kenneth Nai-Kuen (4 September 2012). "Studies comparing the efficacy of constraint-induced movement therapy and bimanual training in children with unilateral cerebral palsy: A systematic review". Developmental Neurorehabilitation. 16 (2): 133–143. doi:10.3109/17518423.2012.702136. PMID 22946588.
- Clarke, Michael; Price, Katie (2012). "Augmentative and alternative communication for children with cerebral palsy". Paediatrics and Child Health. 22 (9): 367–71. doi:10.1016/j.paed.2012.03.002.
- Saether, Rannei; Helbostad, Jorunn L; Riphagen, Ingrid I; Vik, Torstein (November 2013). "Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review". Developmental Medicine & Child Neurology. 55 (11): 988–999. doi:10.1111/dmcn.12162. PMID 23679987.
- "Assistive Technology, Mobility and Customised Seating | Cerebral Palsy Alliance". www.cerebralpalsy.org.au. Cerebral Palsy Alliance. Retrieved 5 February 2017.
- "Disability Innovations: How 3D printing will make orthotics smarter, faster and cheaper". Scope's Blog. Scope. 3 March 2015. Retrieved 5 February 2017.
- Condie DN, Meadows CB. Conclusions and recommendations. In: Condie DN, Meadows CB, eds. Report of a Consensus Conference on the Lower Limb Orthotic Management of Cerebral Palsy. Copenhagen: International Society of Prosthetics & Orthotics; 1995:15-19
- Ross, K; Bowers, R (2009). "A review of the effectiveness of lower limb orthoses used in cerebral palsy". Recent developments in healthcare for cerebral palsy : implications and opportunities for orthotics : report of an ISPO conference held at Wolfson College, Oxford, 8-11 September 2008. Copenhagen: International Society for Prosthetics and Orthotics (ISPO). pp. 235–297. ISBN 87-89809-28-9.
- Balaban B, Yasar E, Dal U, Yazicioglu K, Mohur H, Kalyon TA (2007). "The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy". Disability and Rehabilitation. 29 (2): 139–144. doi:10.1080/17483100600876740. PMID 17373095.
- Autti-Rämö I, Suoranta J, Anttila H, Malmivaara A, Mäkelä M (2006). "Effectiveness of upper and lower limb casting and orthoses in children with cerebral palsy: an overview of review articles". American Journal of Physical Medicine & Rehabilitation. 85 (1): 89–103. PMID 16357554.
- Boyd RN, Morris ME, Graham HK (2001). "Management of upper limb dysfunction in children with cerebral palsy: a systematic review". European Journal of Neurology. 8 (Suppl 5): 150–66. PMID 11851744.
- Gormley, Mark E. (2001). "Treatment of neuromuscular and musculoskeletal problems in cerebral palsy". Pediatric Rehabilitation. 4 (1): 5–16. doi:10.1080/13638490151068393. PMID 11330850.
- Miller F, Bachrach SJ, Bachrach SJ. Cerebral palsy: A complete guide for caregiving. : Johns Hopkins University Press; 1995.[page needed]
- Steultjens, Esther MJ; Dekker, Joost; Bouter, Lex M; van de Nes, Jos CM; Lambregts, Brigitte LM; van den Ende, Cornelia HM (February 2004). "Occupational therapy for children with cerebral palsy: a systematic review". Clinical Rehabilitation. 18 (1): 1–14. doi:10.1191/0269215504cr697oa.
- Švraka, Emira (2014). "Cerebral Palsy and Accessible Housing". In Švraka, Emira. Cerebral Palsy - Challenges for the Future. doi:10.5772/56983. ISBN 978-953-51-1234-1.
- Blake, Sharon F; Logan, Stuart; Humphreys, Ginny; Matthews, Justin; Rogers, Morwenna; Thompson-Coon, Joanna; Wyatt, Katrina; Morris, Christopher (2 November 2015). "Sleep positioning systems for children with cerebral palsy". Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd009257.pub2. PMID 26524348.
- Norton, Neil S. (2007). "Cerebral Palsy". XPharm: The Comprehensive Pharmacology Reference. New York: Elsevier. pp. 1–5. doi:10.1016/B978-008055232-3.60641-5. ISBN 978-0-08-055232-3.
- Heinen F, Desloovere K, Schroeder AS, et al. (January 2010). "The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy". Eur. J. Paediatr. Neurol. 14 (1): 45–66. doi:10.1016/j.ejpn.2009.09.005. PMID 19914110.
- Apkon SD, Cassidy D (2010). "Safety considerations in the use of botulinum toxins in children with cerebral palsy". PM & R. 2 (4): 282–4. doi:10.1016/j.pmrj.2010.02.006. PMID 20430330.
- Strobl, Walter; Theologis, Tim; Brunner, Reinald; Kocer, Serdar; Viehweger, Elke; Pascual-Pascual, Ignacio; Placzek, Richard (11 May 2015). "Best Clinical Practice in Botulinum Toxin Treatment for Children with Cerebral Palsy". Toxins. 7 (5): 1629–1648. doi:10.3390/toxins7051629. PMC . PMID 25969944.
- Walshe, M; Smith, M; Pennington, L (14 November 2012). "Interventions for drooling in children with cerebral palsy.". The Cochrane database of systematic reviews. 11: CD008624. doi:10.1002/14651858.CD008624.pub3. PMID 23152263.
- Boyce, Alison M.; Tosi, Laura L.; Paul, Scott M. (May 2014). "Bisphosphonate Treatment for Children With Disabling Conditions". PM&R. 6 (5): 427–436. doi:10.1016/j.pmrj.2013.10.009. PMC . PMID 24368091.
- Hasnat, Monika J; Rice, James E (13 November 2015). "Intrathecal baclofen for treating spasticity in children with cerebral palsy.". The Cochrane database of systematic reviews (11). doi:10.1002/14651858.CD004552.pub2. PMID 26563961.
- "Cerebral Palsy: Hope Through Research". National Institute of Neurological Disorders and Stroke (U.S.). NIH Publication No. 13-159. August 2013. Retrieved 2014-01-23.
- Schejbalová A (2006). "[Derotational subtrochanteric osteotomy of the femur in cerebral palsy patients]". Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca (in Czech). 73 (5): 334–9. PMID 17140515.
- Farmer JP, Sabbagh AJ (2007). "Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy". Child's Nervous System. 23 (9): 991–1002. doi:10.1007/s00381-007-0398-2. PMID 17643249.
- Carraro, Elena; Zeme, Sergio; Ticcinelli, Valentina; Massaroni, Carlo; Santin, Michela; Peretta, Paola; Martinuzzi, Andrea; Trevisi, Enrico (November 2014). "Multidimensional outcome measure of selective dorsal rhizotomy in spastic cerebral palsy". European Journal of Paediatric Neurology. 18 (6): 704–713. doi:10.1016/j.ejpn.2014.06.003. PMID 24954890.
- Gantasala, S.; Sullivan, PB.; Thomas, AG. (2013). "Gastrostomy feeding versus oral feeding alone for children with cerebral palsy.". Cochrane Database Syst Rev. 7: CD003943. doi:10.1002/14651858.CD003943.pub3. PMID 23900969.
- de Souza, Rafael Carboni; Mansano, Marcelo Valentim; Bovo, Miguel; Yamada, Helder Henzo; Rancan, Daniela Regina; Fucs, Patricia Maria de Moraes Barros; Svartman, Celso; de Assumpção, Rodrigo Montezuma César (May 2015). "Hip salvage surgery in cerebral palsy cases: a systematic review". Revista Brasileira de Ortopedia (English Edition). 50 (3): 254–259. doi:10.1016/j.rboe.2015.06.003. PMC . PMID 26229926.
- Saquetto, M; Carvalho, V; Silva, C; Conceição, C; Gomes-Neto, M (June 2015). "The effects of whole body vibration on mobility and balance in children with cerebral palsy: a systematic review with meta-analysis.". Journal of musculoskeletal & neuronal interactions. 15 (2): 137–144. PMC . PMID 26032205.
- Franki, I; Desloovere, K; Cat, J; Feys, H; Molenaers, G; Calders, P; Vanderstraeten, G; Himpens, E; Broeck, C (2012). "The evidence-base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy: A systematic review using the ICF as a framework". Journal of Rehabilitation Medicine. 44 (5): 396–405. doi:10.2340/16501977-0984.
- Roostaei, Meysam; Baharlouei, Hamzeh; Azadi, Hamidreza; Fragala-Pinkham, Maria A. (14 December 2016). "Effects of Aquatic Intervention on Gross Motor Skills in Children with Cerebral Palsy: A Systematic Review". Physical & Occupational Therapy In Pediatrics: 1–20. doi:10.1080/01942638.2016.1247938.
- Wynter, Meredith; Gibson, Noula; Willoughby, Kate L; Love, Sarah; Kentish, Megan; Thomason, Pam; Graham, H Kerr (September 2015). "Australian hip surveillance guidelines for children with cerebral palsy: 5-year review". Developmental Medicine & Child Neurology. 57 (9): 808–820. doi:10.1111/dmcn.12754.
- Johari, Ratna; Maheshwari, Shalin; Thomason, Pam; Khot, Abhay (23 January 2016). "Musculoskeletal Evaluation of Children with Cerebral Palsy". The Indian Journal of Pediatrics. 83 (11): 1280–1288. doi:10.1007/s12098-015-1999-5.
- Robb, J. E.; Hägglund, G. (18 August 2013). "Hip surveillance and management of the displaced hip in cerebral palsy". Journal of Children's Orthopaedics. 7 (5): 407–413. doi:10.1007/s11832-013-0515-6.
- Alves-Pinto, Ana; Turova, Varvara; Blumenstein, Tobias; Lampe, Renée (2016). "The Case for Musical Instrument Training in Cerebral Palsy for Neurorehabilitation". Neural Plasticity. 2016: 1–9. doi:10.1155/2016/1072301. PMC . PMID 27867664.
- Bonnechère, B.; Jansen, B.; Omelina, L.; Degelaen, M.; Wermenbol, V.; Rooze, M.; Van Sint Jan, S. (August 2014). "Can serious games be incorporated with conventional treatment of children with cerebral palsy? A review". Research in Developmental Disabilities. 35 (8): 1899–1913. doi:10.1016/j.ridd.2014.04.016.
- Gunel, Mintaze Kerem; Kara, Ozgun Kaya; Ozal, Cemil; Turker, Duygu (2014). "Virtual Reality in Rehabilitation of Children with Cerebral Palsy". In Švraka, Emira. Cerebral Palsy - Challenges for the Future. doi:10.5772/57486. ISBN 978-953-51-1234-1.
- OPPENHEIM, WILLIAM L (October 2009). "Complementary and alternative methods in cerebral palsy". Developmental Medicine & Child Neurology. 51: 122–129. doi:10.1111/j.1469-8749.2009.03424.x.
- Wong, Virginia; Wen-xiong, Chen (2006). "Is Acupuncture Useful for Cerebral Palsy? What Evidence Do We Have?". In Fong, Helen D. Trends in Cerebral Palsy Research. New York: Nova Science Publishers. pp. 139–165. ISBN 9781594544484.
- Weisleder, Pedro (January 2010). "Unethical Prescriptions: Alternative Therapies for Children With Cerebral Palsy". Clinical Pediatrics. 49 (1): 7–11. doi:10.1177/0009922809340438.
- McDonagh MS, Morgan D, Carson S, Russman BS (2007). "Systematic review of hyperbaric oxygen therapy for cerebral palsy: the state of the evidence". Dev Med Child Neurol. 49 (12): 942–947. doi:10.1111/j.1469-8749.2007.00942.x. PMID 18039243.
- American Academy of Pediatrics. Committee on Children with Disabilities (1999). "The treatment of neurologically impaired children using patterning". Pediatrics. 104 (5): 1149–1151. doi:10.1542/peds.104.5.1149. PMID 10545565.
- Whalen, Cara N.; Case-Smith, Jane (29 November 2011). "Therapeutic Effects of Horseback Riding Therapy on Gross Motor Function in Children with Cerebral Palsy: A Systematic Review". Physical & Occupational Therapy In Pediatrics. 32 (3): 229–242. doi:10.3109/01942638.2011.619251.
- Tseng, Sung-Hui; Chen, Hung-Chou; Tam, Ka-Wai (26 May 2012). "Systematic review and meta-analysis of the effect of equine assisted activities and therapies on gross motor outcome in children with cerebral palsy". Disability and Rehabilitation. 35 (2): 89–99. doi:10.3109/09638288.2012.687033.
- Sakzewski, L.; Ziviani, J.; Boyd, R. N. (23 December 2013). "Efficacy of Upper Limb Therapies for Unilateral Cerebral Palsy: A Meta-analysis". PEDIATRICS. 133 (1): e175–e204. doi:10.1542/peds.2013-0675.
- Mulligan S, Neistadt ME. Occupational therapy evaluation for children: a pocket guide. : Lippincott Williams & Wilkins; 2003.
- Neistadt ME. Occupational therapy evaluation for adults: a pocket guide. : Lippincott Williams & Wilkins; 2000.
- Guidetti S, Söderback I. Description of self-care training in occupational therapy: case studies of five Kenyan children with cerebral palsy. OCCUP THER INT 2001 03;8(1):34-48.
- Bumin G, Kayihan H. Effectiveness of two different sensory-integration programmes for children with spastic diplegic cerebral palsy. Disabil.Rehabil. 2001 06/15;23(9):394-399.
- Chin TYP, Duncan JA, Johnstone BR, Kerr Graham H. Management of the upper limb in cerebral palsy. Journal of Pediatric Orthopaedics B 2005;14(6):389.
- Anttila H, Suoranta J, Malmivaara A, Mäkelä M, Autti-Rämö I (2008). "Effectiveness of physiotherapy and conductive education interventions in children with cerebral palsy: a focused review". American Journal of Physical Medicine & Rehabilitation. 87 (6): 478–501. doi:10.1097/PHM.0b013e318174ebed. PMID 18496250.
- Morris C. Orthotic management of children with cerebral palsy. JPO: Journal of Prosthetics and Orthotics 2002;14(4):150.
- Canadian Association of Occupational Therapists position statement: universal design and occupational therapy. Can.J.Occup.Ther. 2003 06;70(3):187-188.
- Shamsoddini A, Amirsalari S, Hollisaz MT, Rahimnia A, Khatibi-Aghda A (2014). "Management of spasticity in children with cerebral palsy". Iranian Journal of Pediatrics. 24 (4): 345–51. PMC . PMID 25755853.
- Imms C. Children with cerebral palsy participate: a review of the literature. Disabil.Rehabil. 2008 11/30;30(24):1867-1884.
- Specht J, King G, Brown E, Foris C. The importance of leisure in the lives of persons with congenital physical disabilities. Am.J.Occup.Ther. 2002 2002;56(4):436-445.
- Ringaert L. Universal design and occupational therapy. Occupational therapy now 2002;4:28-30.
- Wittman PP, Velde BP. Occupational therapy in the community: What, why, and how. Occup.Ther.Health Care 2001;13(3-4):1-5.
- Bruce MA, Borg B. Psychosocial frames of reference: core for occupation-based practice. : Slack Incorporated; 2002.
- Norton K. Transportation Options for People with Disabilities. 2002-2010; Available at: http://gfstrong.vch.ca/programs/spinal/docs/Transportation%20Blue.ppt. Accessed April 12, 2010.[dead link]
- Bennet, L; Tan, S; Van den Heuij, L; Derrick, M; Groenendaal, F; van Bel, F; Juul, S; Back, SA; Northington, F; Robertson, NJ; Mallard, C; Gunn, AJ (May 2012). "Cell therapy for neonatal hypoxia-ischemia and cerebral palsy.". Annals of Neurology. 71 (5): 589–600. doi:10.1002/ana.22670. PMID 22522476.
- Koy, A; Hellmich, M; Pauls, KAM; Marks, W; Lin, J-P; Fricke, O; Timmermann, L (May 2013). "Effects of deep brain stimulation in dyskinetic cerebral palsy: A meta-analysis.". Movement Disorders. 28 (5): 647–654. doi:10.1002/mds.25339. PMID 23408442.
- Nelson KB, Blair E (2015). "Prenatal Factors in Singletons with Cerebral Palsy Born at or near Term". The New England Journal of Medicine. 373 (10): 946–53. doi:10.1056/NEJMra1505261. PMID 26332549.
- Lungu C, Hirtz D, Damiano D, Gross P, Mink JW (2016). "Report of a workshop on research gaps in the treatment of cerebral palsy". Neurology. 87 (12): 1293–8. doi:10.1212/WNL.0000000000003116. PMC . PMID 27558377.
- Dodd, Karen J.; Imms, Christine; Taylor, Nicholas F., eds. (2010). Physiotherapy and occupational therapy for people with cerebral palsy: a problem-based approach to assessment and management. London: Mac Keith Press. ISBN 978-1-908316-11-0.
- Smith, Martin; Kurian, Manju A. (September 2016). "The medical management of cerebral palsy". Paediatrics and Child Health. 26 (9): 378–382. doi:10.1016/j.paed.2016.04.013.
|Wikibooks has a book on the topic of: Exercise as it relates to Disease/Functional Strength Training in Children with Cerebral Palsy|