Early Diagnosis and Interventional Therapy in Cerebral Palsy: An Interdisciplinary Age-Focused Approach (Pediatric Habilitation)

366 Pages·2000·3.03 MB·English

ThepreviouseditionwaspublishedasEarlyDiagnosisandTherapyinCerebralPalsy:
APrimeronInfantDevelopmentalProblems,SecondEdition,RevisedandExpandedby
AlfredL.ScherzerandIngridTscharnuter.
ISBN:0-8247-6006-9
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Preface to the Third Edition
HowsurprisingtorecallthatthefirsteditionofEarlyDiagnosisandTherapyin
Cerebral Palsy was published in 1982. With the tools then available, clinical
focus on diagnosis of the very young child seems, in retrospect, more a hope
than a serious endeavor. Yet the volume was well received and led to a second
edition in 1990. The interim changes reflected more experience with the very
young child, and a shift in focus, away from the older established schools of
therapy toward more activist, invasive treatments.
Preparing the third edition has revealed truly remarkable changes. These
changesarereflectedinaslightrevisionofthetitle.Fundamentalresearchatthe
molecular and cellular levels has advanced our understanding of mechanisms
involved in etiology and epidemiology. Developmental neurology has extended
ourunderstanding ofnormalandabnormalbehavioroftheearly preterminfant.
Screeningandassessmenthavebecomemoresophisticated,withanexponential
increaseinthenumberofstandardizedinstruments.Thedevelopmentalscreening
and evaluation process has matured considerably, with the availability of very
sensitiveneuroradiologictools.Theaccumulationofclinicalexperiencewiththe
veryyoungchildhasenabledamoredirectedapproachtoinfantdifferentialdiag-
nosis.
Interventionaltherapyhasalsomovedforward in manynewanddifferent
directions. Therapy has become oriented more toward a dynamical systems ap-
proach,emphasizingfunctionalchange,andmaintainingphysiologicalcondition-
ing. Advances in the use of botulinum toxin, intrathecal baclofen, and selective
dorsal rhizotomy to reduce spasticity have taken center stage, without uniform
iii
iv Prefacetothe ThirdEdition
criteriaforeitherindividualorsequentialapplication,orclearevidenceoflong-
termeffects.Cerebralpalsyhasincreasinglyfounditselfaprimetargetforalter-
native treatments during this era.
Perhaps the most startling innovation in the decade since the last edition
hasbeenadvancesinresearch.Outcomesresearch,includinganindicationofthe
strengthofevidence,hasemergedinthisperiod,andhasjustbeguntoinfluence
the field of cerebral palsy.
This third edition reflects these dramatic changes. We focus on the infant
from birth to three years in order to highlight specific concerns about diagnosis
and treatment in this group. This approach provides a model for dealing with
older age group categories as well. It is apparent that an understanding of how
to deal most effectively with the individual with cerebral palsy can best be ap-
proached through consideration of the options for the specific age group in-
volved.
The authors comprise a truly interdisciplinary group that has worked to
preparethisvolumeinmuchthesamecollaborativewaythattheywouldtotreat
aninfant withcerebral palsy. Weallfeel itisa privilege tobring forwardthese
important changes in the field at the start of a new century.
Alfred L. Scherzer
Preface to the Second Edition
The first edition of Early Diagnosis and Therapy in Cerebral Palsy, issued in
1982, sought to fill a major need for professionals in bringing together in one
source comprehensive information regarding diagnosis and management of the
veryyoungchildwithcerebralpalsy.Atthesametime,wehopedtodemonstrate
howthisframeworkmightserveequallyindevelopingprogramsforothertypes
of nonprogressive deficits with similar needs. That we succeeded in filling this
gapiswellillustratedbythewideuseofthistextovertheyearsanditscontinued
demand by a variety of professionals.
Intheyearssincetheoriginalissue,therehavebeenmanynewandexciting
developments in the field. Among these of major interest are new approaches
to early screening and identification, refinements in concepts and approaches to
therapy, considerations of alternative surgical approaches to treatment, and an
explosion in early intervention strategies increasingly based more on an educa-
tional than on a traditional medical model.
Clearlythetimehascometoincorporatethesedevelopmentsintothistext
whichhasfoundmuch favorwithourcolleagues. Wethereforetakepleasurein
bringing forth this second edition with the hope that it will continue to fill the
needsofthosedevotedtothecareofthehandicappedchildinthisever-changing
field.
Alfred L. Scherzer
Ingrid Tscharnuter
v

Preface to the First Edition
Untilrelativelyrecentyears,cerebralpalsywasprimarilyofprofessionalinterest
toalimitednumberofspecialistsdealingwithspecificaspectsoftreatment,such
as orthopedics and neurology. Indeed, these are the specialties which initially
shapeditsdefinitionandscope,datingfromthedaysofLittleandFreud.Children
cametoattentionlate,whensignificantlimitationsindevelopmentandmilestones
were noted, or severe orthopedic deficits were apparent. Intervention was fre-
quentlyconcernedwithstaticneurologicassessment,andtreatmentoftenexclu-
sively focused upon orthopedic surgery or a form of limited individual muscle
therapy. The approach was to deal with the specific functional deficits as they
appeared.
A much broader concept has subsequently emerged with the awareness
that cerebral palsy represents a major multidisciplinary developmental disorder
inwhichtimelyinterventionbyavarietyofspecialtiesisessential,andacoordi-
nated, directed approach is required. In addition, traditional therapy involving
individual muscle training has given way—mostly through clinical work with
cerebral palsy—to a more comprehensive and dynamic approach of movement
educationwhichemphasizesthesensorimotordualityandisthereforeconducive
tolearningnewmotorskills.Clinicalexperiencewithcerebralpalsyhasalsopro-
motedanexpansionintheunderstandingofsensorimotordevelopment.Today,ab-
normalmotorbehaviortypicallyassociatedwithcerebralpalsyisseenastheout-
comeofalongprocessofpostural compensationstounderlyingdeficits,suchas
abnormalposturaltonusorpoorintegrationofposturalreflexes.Whileearlyand
primaryposturalcompensationsconsistofmoresubtledeviationsfromthenorm,
motorskillsbuildingonthesedeviantpatternsbecomemoreandmoreabnormal.
vii
viii PrefacetotheFirstEdition
Newerknowledgeconcerninginfantdevelopmentandrecognitionofearly
common findings among infants with nonprogressive central nervous system
deficits has now placed cerebral palsy within the spectrum of major develop-
mental disabilities. In fact, its early identification and management presently
serve as a model for other types of multiply handicapping conditions.
Recent perinatal management and neonatal intensive care technologies
havefurtherinfluencedtheoutlookforthechildwithpotentialdisability.Children
are now surviving who until recently had an abysmal prognosis. Evidence indi-
catesareduction,aswell,indegreeofdisability,althoughanincreaseinseverity
issuggestedespeciallyamongthosehigh-riskandlow-birth-weightinfantswho
formerlydidnotsurvive.Itseemslikelythatchronicdevelopmentaldisordersin
children are destined to be a major and increasing concern for pediatrics of the
future.
It is in this setting that the concepts of early diagnosis and intervention
have taken root and a sizable literature has emerged. Current data are clinically
supportive of early intervention and the notion is intuitively appealing on the
basis of developmental theory. An explosive interest has been generated in this
field,yetthereisapaucityofsourcesavailableforcomprehensivereferenceand
documentation.
The present text attempts to fill this gap by putting into perspective the
evolution of cerebral palsy from a narrow focus as an orthopedic disability to a
broadly conceived developmental disorder. The emphasis is on the process of
developmentaldiagnosis,andcurrentclinicalapproachestoevaluation,manage-
ment,andtreatmentaredetailed.Theneedforcontinuous,systematic,andstan-
dardizedre-evaluationisstressed.Suggestionsaremadefordevelopingresearch
methodswhichwillultimatelyleadtoestablishingtheeffectivenessofanygiven
treatment approach.
It is hoped that the text will provide a useful guide for those who deal
withawidevarietyofdevelopmentaldisabilitiesinyoungchildren.Considerable
emphasis is placed on identifying early patterns of postural maladjustments so
thattheycanbecorrectedasfaraspossiblebeforeleadingtomoresevereabnor-
malities. Its focus is to provide a more uniform and standardized approach to
diagnosisandtreatment.Onlyinthiswaywillitbepossibletoobjectivelyevalu-
ateandguideindividualtherapyactivities.Ultimately,thiswillgreatlyaidinthe
muchneededquestforresearchmethodologiesandfirmdataconcerningtheearly
intervention process.
Alfred L. Scherzer
Ingrid Tscharnuter
Contents
Preface to the Third Edition iii
Preface to the Second Edition v
Preface to the First Edition vii
Contributors xi
1. History, Definition, and Classification of Cerebral Palsy 1
Alfred L. Scherzer
2. Trends in Etiology and Epidemiology of Cerebral Palsy: Impact of
Improved Survival of Very Low-Birth-Weight Infants 27
Vidya Bhushan Gupta
3. Diagnostic Approach to the Infant 49
Alfred L. Scherzer
4. Management and Treatment Planning for the Abnormally
Developing Child 95
Alfred L. Scherzer
5. Historical Perspective to Current Practice: Habilitative Services 121
Margaret J. Barry
ix
x Contents
6. Clinical Assessment of the Infant 139
Gay L. Girolami, Diane Fritts Ryan, and Judy M. Gardner
7. The Written Assessment, Treatment Planning, and Intervention
Strategies 185
Gay L. Girolami, Judy M. Gardner, and Diane Fritts Ryan
8. Treatment Implementation, Reassessment, and Documentation 207
Gay L. Girolami, Diane Fritts Ryan, and Judy M. Gardner
9. Assessment and Treatment Planning: A Case Study 229
Gay L. Girolami, Diane Fritts Ryan, and Judy M. Gardner
10. Research in Cerebral Palsy: Yesterday and Today 267
Charlene Butler
11. Evidence Tables and Reviews of Treatment Outcomes 285
Charlene Butler
12. Future Perspective on Cerebral Palsy 331
Alfred L. Scherzer, Charlene Butler, Vidya Bhushan Gupta,
Margaret J. Barry, Gay L. Girolami, Diane Fritts Ryan,
and Judy M. Gardner
Index 347