Alternative Therapy
The use of complementary and alternative medicine (CAM) in cerebral palsy is not uncommon. CAM has been defined by The American Academy of Pediatrics as “strategies that have not met the standards of clinical effectiveness, either through randomized controlled clinical trials or through the consensus of the biomedical community (195)” and by the National Center for Complementary and Alternative Medicine “as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional Western medicine (196).” It is not surprising that caregivers would be attracted to therapies that promise significant functional improvement when traditional medicine may appear to have little to offer.
CAM is more commonly used in children with chronic diseases such as CP despite lack of substantiating evidence (197). CAM is often used in addition to orthodox medicine, but often its use is not discussed with the child's treating physician secondary to a feared negative response (197). Several studies have documented increased use of CAM in children placed in higher GMFCS categories (198,199). One study found that 56% of families surveyed had utilized at least one CAM therapy for their child with CP (198). The most commonly utilized therapies were massage therapy (25%) and aquatherapy (25%). The most significant predictors of use were the child's age (younger), lack of independent mobility, and parental use of CAM (198). Other CAM therapies utilized by children with CP include conductive education, patterning, hyperbaric oxygen therapy, Adeli suit therapy, acupuncture, craniosacral therapy, chiropractic manipulation, and many others (Table 8.3).Hyperbaric Oxygen Therapy (HBOT)
Proponents of HBOT propose that “dormant areas” can be found surrounding injured areas in the brains of children with CP and that high levels of oxygen in the brain reactivate, or “wake up,” the cells of this dormant area (200).
Delivery of hyperbaric oxygen typically consists of treatments with pressures of 1.5 to 1.75 atmospheres for one hour per session, sometimes as often as five to six times per week, for up to 40 treatment sessions in a phase of treatment. A blinded, randomized, controlled clinical trial of 111 children with cerebral palsy compared treatment with hyperbaric oxygen at 1.75 atmospheres with a control group that received air at a pressure of 1.3 atmospheres (201). Both groups demonstrated significant functional improvements, but no differences were found between the groups. While some authors have argued that this demonstrates the value of elevated oxygen, even at minimal levels (202), others argue that the effect demonstrates a “powerful clinical trials effect (203),” with the effect primarily due to highly motivated parents spending many hours with the children in an intensive setting, knowing that developmental outcomes would be evaluated (200). A systematic review of the evidence revealed that there is inadequate evidence to establish a significant benefit of HBOT or for identifying potential adverse effects of HBOT in children with CP (204).Conductive Education (CE)
CE is a combined therapeutic and pedagogic program for children with CP developed by the Hungarian child neurologist Andras Peto in the 1940s that has been given increased attention in Western countries in recent years with the main elements being task- oriented learning within highly structured programs; facilitating and commenting on motor actions by rhythmic intending, for example, rhythmic speaking or singing; integration of manual abilities into the context of activities of daily living; and child-oriented group settings to facilitate psychosocial learning to increase the level of participation (205). In this program, the “conductor” is trained in special education and therapy and administers the conductive education program. As CE has spread from Hungary to other countries, it has been packaged in an array of delivery models, making it difficult to ascertain specific criteria that define CE as a program (206).
The use of adaptive equipment such as splints, walkers, and wheelchairs in the classroom is generally discouraged (200). An American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) Treatment Outcomes Committee Evidence Report was conducted to evaluate the current state of evidence regarding CE and found that the present literature base does not provide conclusive evidence either in support of or against CE as an intervention strategy, primarily due to the limited number of studies and their weak quality (206).Adeli Suit Therapy (AST)
AST was introduced in 1991 and incorporates a prototype of a device developed in Russia in the late 1960s to maintain neuromuscular fitness during weightlessness experienced by cosmonauts. The treatment is based upon three principles: the effect of the suit (working against resistance loads, increased proprioception, and realignment), intensive daily physical therapy for one month, and active motor participation by the patient (207). The suit consists of a vest, shorts, knee pads, and specially connected shoes; pieces of the suit are connected by hooks, rings, and elastic bands that are adjusted to optimally position limbs and joints. The bungeelike cords are adjusted by therapists to mimic normal flexor and extensor patterns of major muscle groups in an attempt to correct abnormal muscle alignment (208). The theory is that once the body is in proper alignment, aggressive movement therapy can be performed that will reeducate the brain to recognize correct movement of the muscles (208). It is also felt that deep pressure at the joints improves the sensory and proprioceptive information at that joint, enhances the vestibular system, and improves coordination (200). Treatment is typically given at a higher intensity, at one to two hours per day, multiple times per week, for a four- to six-week period. One randomized, controlled, clinical trial compared the efficacy of AST in children with CP to neurodevelopment treatment (NDT) (207).
Both groups received the same intensity of treatment, totaling 20 sessions in four weeks, and were evaluated with the GMFM-668.3
Summary of Selected Complementary and Alternative Treatments for Cerebral Palsy
| THERAPY | THEORY/BENEFITS | ADVERSE EFFECTS | EVIDENCE | COMMENTS |
| Hyperbaric oxygen | Awakens dormant brain tissue surrounding the original injury | Ear trauma, pneumothorax, fire and explosions | Uncontrolled studies show improvements in the treated children. Controlled study showed improvement in Treated and controls | More evidence is required before recommendations can be made; eg, what is the role of increased pressure without supplemental oxygen? |
| Adeli suit | Resistance across muscles can improve strength, posture, and coordination | Discomfort from suit; expense for intensive therapy and for travel to centers that prescribe the suit | No conclusive evidence either in support of or against the use of the Adeli suit | |
| Patterning | Passively repeating steps in normal development can overcome brain injuries | Time, energy, and expenses required for treatment | Results of uncontrolled studies are inconsistent; controlled trials show no benefits | Cannot be recommended |
| Electrical stimulation | More evidence is required before recommendations can be made | |||
| Threshold electrical stimulation | Increased blood flow from electrical current will lead to stronger muscles | Expense for unit; generally safe | Some uncontrolled trials show subjective improvements; controlled trials are inconclusive | |
| Functional neuromuscular stimulation | Increased muscle contraction will improve strength and function | Expense; infection from needles; discomfort | Evidence somewhat more positive than for threshold stimulation but still inconclusive | |
| Conductive education | Problems with motor skills are problems of learning; new abilities are created out of teaching | None known | Uncontrolled trials show benefit; controlled trials are mixed | Conductive education is implemented in many different ways making generalizations from a single program difficult |
| Hippotherapy | Riding a horse can improve muscle tone, head and trunk control, mobility in the pelvis, and equilibrium | Trauma from a fall; allergies | Uncontrolled and controlled trials show beneficial effects on body structures and functioning | Horseback riding also increases social participation |
| Craniosacral therapy | Therapy is used to remove impediments to the flow of cerebrospinal fluid within the crainum and spinal cord | None known | No studies showing efficacy in CP; some question the basis of the intervention | |
| Feldenkrais | Change of position and directed attention can relax muscles, improve movement, posture, and functioning | None known | No studies showing efficacy in CP; studies in other conditions are equivocal | |
| Acupuncture | Acupuncture can help to restore the normal flow of Qi, or energy | Forgotten needles, pain, bruising, and infection | Uncontrolled studies show improvements in several areas; two controlled trials also showed improvements | Appears promising, but more studies are required before specific recommendations can be made |
| Source: Reprinted from Mental Retardation and Developmental Disabilites Research Reviews, Volume 11, No. 2, G. Liptak, page 158, copyright 2005, with permission from Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc. | ||||
at baseline, after one month of AST or NDT therapy and again nine months later after they had returned to their baseline therapies. When administered with equal intensity, the AST did not show superior motor skills retention in comparison with NDT (207).
Additional Therapies
Patterning (Doman Delacatto method), hippotherapy, craniosacral therapy, Feldenkrais, and acupuncture are additional CAM therapies that are sought out by parents of children with CP. In regards to patterning, the American Academy of Pediatrics concluded that “patterning treatment continues to offer no special merit, [and] that the claims of its advocates remain unproved... (209)” There are a few uncontrolled and controlled studies revealing improvements in GMFM scores as well as other benefits in regard to decreasing muscle tone, improving head and trunk postural control, and developing equilibrium reactions in the trunk from hippotherapy (210-212). No published studies are available on the use of craniosacral therapy or the Feldenkrais method in children with CP. Most studies published in English regarding acupuncture are uncontrolled and primarily case series.
The American Academy of Pediatrics Committee on Children with Disabilities published recommendations for counseling families on CAM, which includes the following: maintaining a scientific perspective, providing balanced advice about therapeutic options, guarding against bias, and establishing and maintaining a trusting relationship with families (195). Ethically, families have the right to use alternative medicine therapies for their children as a matter of autonomy, but they also have the duty not to harm their children (213). The care of patients should be based, to the greatest extent possible, on existing sound evidence revealing that the therapy recommended is effective in reducing morbidity; the benefits outweigh the risks; the cost of the treatment is reasonable compared to its expected benefits; and the recommended therapy is practical, acceptable and feasible (200).