Twenty years ago, strength training in children with cerebral palsy was discouraged, as it was assumed that it would increase spasticity (tight/stiff muscles and the inability to control them). However, this was not supported by the results of earlier studies, which showed that strength training can actually improve lower-limb muscle strength in children with CP, without increasing spasticity. Current research supports that intermittent bursts of intensive therapy during development is beneficial to children for them to learn and re-learn movements.
Research shows that time and duration of these bursts can vary and be effective from as little as 45 minutes per session up to three hours per session, and can range from two weeks to 16 weeks. Shorter sessions do not allow for body preparation prior to active functional strength and neuromuscular re-education type activities. While typical, traditional therapies ranging from 45-60 minutes, one to two days per week address these issues, an intensive program has shown to build on current skills and takes clients to another level of function toward independence.
In 2001, UCP of Greater Cleveland launched a pilot program titled “Steps to Independence.” This new integrated therapy approach was targeted at muscle strengthening, which is needed to accomplish functional tasks. This program is based on a Polish treatment/physical therapy model. UCP integrated this unique therapy model with a team approach, including both physical and occupational therapists working together. This team approach is designed to look at the body as a whole, developing a unique and individualized program for each child. The Steps to Independence program was constructed to improve gross motor, fine motor and self-help (independent) skills. Each child is also provided with an individualized Home Program designed for their specific needs and goals.
There are times when these intensive bursts can be highly beneficial, especially before and post-surgery, after spasticity management, and when a client wishes to acquire a new skill. Before implementing an intensive therapy program for an individual, certain barriers should be considered such as schedule (for both therapy and the home program), as well as financial and family support. Fatigue can be an issue early on in the process, but it has been shown to improve as endurance increases throughout the intensive program.
Today, a typical Steps to Independence session is two and a half hours long, three times per week, for four weeks. Each session is comprised of a warm-up and strengthening exercises, followed by working on functional tasks. The warm-up is designed to get the body ready for several hours of work. This includes sensory integration (deep pressure, vestibular, proprioception and vibration), massage, myofascial release, stretching, donning any garments or any external supports typically used for alignment, as well as body awareness. The Universal Exercise Unit (UEU) is one of the major pieces of equipment that is utilized to work on strengthening exercises. It includes a SPIDER unit and Pulley System. The SPIDER uses a belt and bungee system that allows a child to work on balance, coordination and function. The SPIDER provides partial body weight support to allow a child to perform movements that they otherwise would not be able to do, or adds resistance for strengthening while doing a functional task. In the Pulley System, a child works on strengthening by using weights and pulleys, allowing the therapist(s) to isolate specific muscle groups. After strengthening, a child is ready to work on functional tasks such as gait training, stair climbing, sitting, standing, fine motor activities, activities of daily living and communication skills. Other modalities are also used throughout the session.
While the initial idea behind intensive therapy was to improve strength and improve functional outcomes, therapists and families have reported other benefits such as increased confidence, clearer speech, improved eye contact, improved sleep, overall wellness and the development of new friendships. In teenage clients there is sometimes a transitional component that works toward a client’s job training and endurance to complete tasks, as well as assistive technology to build skills which can be incorporated in the community setting.
- Posted by Guest Bloggers Cynthia L. Marks and Diane Karban, LeafBridge Physical Therapy Assistants (PTA) at UCP of Greater Cleveland