Hai-Jing Wang,Qian Yan

1Tianjin University of Sport,Tianjin,China.2Shandong College of Physical Education,China.

Introduction

Cerebral palsy(CP)is a syndrome characterized by restricted activity which is caused by a non-progressive brain injury and developmental defect during conception that begins in infancy.It causes speed-dependent hyper excitable stretch reflexes and abnormally high muscle tone.The main sign is movement dysfunction and abnormalposture,usually accompanied by mental retardation, speech disorders, epilepsy, perceptual disorders,communication disorders,abnormal behavior,and secondary musculoskeletalproblems [1].The international incidence rate is 0.15-0.4%,while the incidence of CP in China is 1.8-4.0% [2-3].The dyskinesiaand postureabnormality caused by CP seriously affects patients’ability of daily activities and social participation,resulting in the decline of their quality of life.It places a heavy medical burden on the patient’s family and society as a whole.

At present,methods of functional exercise,physical therapy,medicine,and nutrition are mainly adopted for treatment of CP in children at home and abroad[4].However,in the past few years,plentiful evidence has shown that the efficacy of drugs,surgery,and therapies used over the previous decades is limited[5].The use of more appropriate comprehensive treatment that involves improving the quality oflife to increasing social participation is helpful and meaningful for children with CP and their carers.By referring to the domestic and international literature and guidelines,we compared the advantages and disadvantages of various treatments,providing a reference for patients with cerebral palsy to help choose treatment methods and a new idea for research on the treatment of cerebral palsy.

Rehabilitation

The methods of rehabilitation mainly include motor therapy,homework therapy,physical factor therapy,and sensory integration therapy.The brain develops most rapidly and has the strongest compensatory capacity before the age of 2 year-old;brain structure and function in this period has strong plasticity and recombination ability [6].Therefore,early intervention and early treatmentofchildren with cerebralpalsy isvery necessary.

Motor therapy

Activity limitation and posture abnormality are the most serious problems of children with CP;muscle tone and jointactivity areimportantparts thataffectbody movement function in children[7].Motor therapy is based on motor control, motor learning, and neurophysiology,and is guided by the theories of brain plasticity,biomechanics,and behavior,forming the various types of effective motor therapy.In the various types of CP treatments,motor therapy is most effective,mainly comprising:(1)Bobath technology:it acts mainly by inhibiting abnormal posture,promoting the normal development of posture,and provides recovery methods to treat patients with central nerve damage by controlling the key point,reflex inhibition,promote posture reflexes,sensory stimulation,and attaches great importance to the overall treatment of children as the main method.Ma Xiuwei highlighted that Bobath technology is suitable for children aged 0-3 years,including inhibitive techniques,accelerative techniques,and sensory stimulation[6].(2)Vojta technology:it induces systemic,coordinated reflex belly crawling and reflexive turning to improve the motor function of children through compression stimulation to a certain part of the body.(3)Rood technology:it starts with inducing reflex activity and combines a developmental mode to enhance the motor responses of children.This can be divided into two types,inhibitive manipulation and accelerative manipulation.Accelerative manipulation is mainly used to increase the muscle tone and sensation of children,while inhibitive manipulation is mainly used to reduce the abnormal muscle tone of children.(4)Peto method:it refers to improving or restoring the function ofdisabled people through education that is centered around the needs of children.Children are guided and encouraged to solve problems by themselves and their functional independence should be restored asfaraspossiblethrough treatmentand educational promotion and gradual academic progress,emphasizing teamwork to promote functional independence in children as much as possible.(5)Suspended motion therapy:Huang P et al.proved the application of suspended motion training on the basis of conventional exercise therapy with open and closed chain exercises can significantly improve the pelvic motor function of children with CP,effectively reducing muscle tone and improving gross motor function[8].The core muscle group is the muscle group responsible for maintaining thestability ofthespine and pelvis.Therefore,through core muscle group training,the rough movement and posture control of children with CP can be improved and involuntary movement is reduced.(6)Riding therapy:riding therapy,a new treatment method developed in recent years,has also achieved good therapeutic effect.Tang Jiu demonstrated that the gait of a horse is precise and steady,with rhythmic and repetitive characteristics.This is similar to the characteristics of the rhythmic regularity of the human gait.The rhythmicity of horse movements can reduce the muscle tone of children with CP.The regularity of the movement patterns and interactive activities provide physical,mental,sensory perception,social interaction,and behavior disorder rehabilitation to children with CP[9].Moreover,horse riding has the function of spreading the legs,which can stretch the adductor muscle group of children and reduce the muscle tension of the adductor muscle.Horse riding therapy can also enhancechildren's love,courage,patience,and confidence such that children feel happy and excited.Ionatamishviliet al.also proved that therapeutic riding was more effective than therapeutic exercise[10].Although therapeutic exercise has positive effects,it is significantly less effective than equestrian therapy.Thus,horse riding therapy is an original and appropriate treatment for children with CP as it promotes the formation of new motor skills closest to those in healthy individuals,reduces spasmodic disorders and hyperactivity,and ensures eventual utilization of the plasticity of the child’s brain.But this treatment is dangerous and requires guarantees of the child's safety.(7)Motion relearn technology:sports and learning methods are based on the ability of healthy people to fully recognize movement skills.Through the analysis of children with CP and motion dysfunction related to various abnormal motor performances that are problematic or specifically designing and guiding the patient’s practice of sports missing certain components and functional activities actively, brain function reconstruction can be promoted,allowing patients to achieve movement skills as close as possible to those seen in healthy people.(8)Rehabilitation robot:the therapeutic effect of rehabilitation robots on children with CP hasbeen recognized in recentyears[11-12].Rehabilitation robots can continuously correctthe abnormal movement patterns and then input the correct movement patterns and sensations.Using the brain's plasticity helps patients to restore as close as possible to normal movement patterns.In addition,rehabilitation robot intelligence spasm models can effectively improve walking in patients with convulsions.

Homework therapy

Homework therapy refers to the process of evaluating,treating,and training children with CP by designing treatment content as homework and applying the targeted and selected work activity.It mainly includes children's daily living ability,sensory perception ability,learning ability,fine motor function training of the hands,and daily auxiliary equipment making and using,among others.By adopting the methods that are easily accepted by children,such as selected games and recreational activities,the children are encouraged to master the skills of the activities of daily living,improving their learning ability, independence in family life, and social participation ability.It can also improve verbal communication ability,as well as reduce loneliness and encourage emotionaladjustment.Cao GZetal.highlighted that virtual scene technology has played a role in the treatment of children with CP.It increases interest in rehabilitation exercise by putting children in a virtual environment,using computer graphics technology,making rehabilitation exercises and games together,reducing the boringness of rehabilitation treatment,so as to arouse the enthusiasm of children in rehabilitation training[13].In addition,by phase picking technology,children can see the virtual image directly and refer to image movements,making the rehabilitation exercises of children more scientific and targeted and allowing children to complete rehabilitation treatment plans more actively.Chen YPetal.pointed outthatwhen robot-assisted treatmentwascombined with virtual scenario technology,children using trunk band training had better training effects in preventing compensatory exercise during training[14].Park CJet al.reported that mirror therapy has a positive effect on hand muscle strength,movement speed,muscle activity,and hand matching in children with CP[15].Mirror-mediated therapy is based on activation of the mirror neuron system[16].

Sensory integration therapy

Sensory integration therapy refers to individual organisms in the environment,use their sense organs of different modalities(including vision,hearing,taste,smell,touch,vestibular sense, and proprioception), obtaining information from the environment that enters the brain.Thebrain obtainstheinformation,processing and integrating it as part of an adaptive response.The role of this method is to develop and perform normal adaptive behavioral responses and improve functional capability[17].Children with CP usually have sensory integration disorders.Appropriate motor responses to vestibular,somatic,and tactile stimuli are used to enhance the integration function of the brain and improve balance and coordination in children.

Physical factor therapy

Physical factor therapy is also an important physical method for CP.Appropriate electric stimulation is used in children with CP to promote muscle contraction to prevent muscle atrophy.Using the plasticity of brain combined with feedback therapy can allow children to actively learn muscle control,such as in relaxation training or contraction training.Wen YQet al.proved the effectiveness of hydrotherapy and functional training for children with spasmodic CP.The results showed that the spasm index of children was significantly improved by hydrotherapy,and the effects of hydrotherapy on the human body mainly included temperature stimulation and mechanical compression stimulation[18].Hydrotherapy and other physiotherapy methods using thermodynamic factors can be used to treat CP,relieving tension in children.In recent years,the treatment of systemic vibration of children with CP by using physical factors has attracted people's attention[19-20].It acts on the neuromuscular skeletal system of children with CP through using a specified mechanical vibration frequency and vibration amplitude that can effectively relieve gastrocnemius spasm in children with spastic CP.This improves the gross motor ability and daily living ability of children.

Speech training

Children with CP are associated with a certain amount of language dysfunction, with the main clinical manifestations comprising dysarthria and retardation of linguistic development.Treatment of dysarthria children focuses on improving respiratory frequency and the flexibility of facial muscles in basic social interaction by training the speech production respiratory system(thoracic and abdominal respiration)and tuning system(lips,tongue,teeth,jaw,soft palate,etc.),and performing basic speech motor function stimulation.The focus of treatment for children with language delay requires parents to patiently tell stories,play games,etc.to stimulate the child’s desire to express their ideas.Jie SL confirmed thatthe combination of low-frequency transcranial magnetic stimulation and speech training was used to treat language dysfunction in children with CP,which can not only enhance the treatment effect of children with CP-related speech disorder,butalso effectively improve the quality of life of children with CP-related speech disorder[21].

Psychological behavior therapy

The psychological behavioral problems of children with CP cannot be ignored,and most of them are associated with autistic tendencies and attention deficit hyperactivity disorder.In addition,there are emotional disorders.For children with CP who have behavioral abnormalities or cognitive impairment,different psychological treatments should be given according to the different conditions of the patients.Healthy living environment,increased communication with children of the same age,and should be treatment as soon as possible.N.I.Ionatamishviliet al.also proved that horse riding therapy is a unique way of encouraging children to overcome difficulties and improve their psychophysical state,expand their horizons,and develop a sense of pride and victory over the disease[10].Therefore,it helps eliminate the sense of inferiority in children.Physical and psychological rehabilitation of all types in children with CP is beneficial.Therefore,horse riding therapy can be used as an effective method of psychological rehabilitation of children.

Rehabilitation of deglutition function

This item aims to improve the coordination of swallowing muscle movement and strength of oral,facial,and tongue muscles in children with CP.Oral disorder devices are mainly used for lip and tongue flexibility training,and mouth,face,and tongue strength training.Pharyngeal dysfunction mainly focuseson voice training.By improving the respiratory control ability,reducing the risk of aspiration and choking,the children can eat safely and effectively and meet their own nutritional needs.In recent years,Wei BYet al.proved that the treatment of children with CP with dysphagia using neuromuscular electrical stimulation combined with functional deglutition training is more effective than simple functional deglutition training[22].

Application of orthopedic devices

The application of orthopedic appliances in the rehabilitation of CP is mainly used to limit abnormal joint activities,improve the stability of the body,assist in reducing muscle spasms,and stretching the spastic muscle.In particular,children with spasmodic CP often have major problems in their lower limbs,such as hip adduction,ankle contracture,heel tendon shortening leading to touchdown failure,and scoliosis.Skeletal muscle deformities need to be corrected with the help of an orthotic.Manuela Get al.demonstrated that the use of ankle-foot orthotics can significantly reduce the extent of abnormal gait patterns in children with CP[23].At present,commonly used orthopedic appliances mainly include ICB orthotic insole,ankle orthosis,and spine orthosis.The choice of the orthopedic device should be made according to the size ofthe child'sbody,emphasizing its comfort and practicality.

Home environment reconstruction

The purpose of home environment reconstruction is to alleviate difficulties in the family life of children with CP,reducing the possibility of falling and dependence on family life ofchildren with CP,enhancing their self-confidence and ability to participate in life,and improving their safety in sports.This make take the form of barrier-free passageways,toilets with an armrest,use of thicker chopsticks and spoon that are easier for the child to grasp,and use of protective mats on furniture to break the child’s fall.

Drug therapy

Drug therapy has a rapid therapeutic effect on nerve tissue and is often used in the clinical treatment of CP.The main drugs are preventive drugs,neurotrophic drugs,and drugs to reduce muscle tension.

Preventive drugs

Prenatal magnesium sulfate alone can prevent CP in premature infants.The drug can be used to prevent CP in premature infants less than 34 weeks of gestational age[24].

Neurotrophic drugs

Ganglioside,mecobalamin,mouse nerve growth factor,and other drugs have certain functions in nourishing brain cells and nerves,and promoting synaptic connections and myelin development.

Muscle relaxant drugs

(1) Baclofen: baclofen can inhibit abnormal single-synaptic extensor and multi-synaptic flexor activity,reduce substance P levels,and weaken pain perception,and is effective for children with dysfunction caused by abnormal muscle tone,thus improving symptoms of CP.(2)Botulinum toxin A(BTX-a):since 1993,BTX-a has been used in reducing spasms in patients with CP.It can selectively decrease muscle tension in spastic muscles,re-establishing the balance between agonist and antagonistmusclepowers,to adjustthe effectof abnormal posture,improving the movement function[25].BTX-a utilizes its neurotoxin to impair the properties of the biological nervous system[26].Botulinum produces localparalysisby blocking presynaptic release of acetylcholine in the neuromuscular junction,relieving muscle spasm and reducing muscle tension,thereby reducing lower limb spasm and improving the gait of patients with CP[27].However,the chemical denervation of BTX-a is reversible,such that treatment usually only has a temporary effect,lasting three to four months[28].Maria Fet al.proved that BTX-a was most suitable for children with CP aged 4-6 years and had significant therapeutic effect on gastrocnemius muscle spasm[29].

Stem cell therapy

Stem cells are primitive and unspecialized cells.Human umbilical cord mesenchymal stem cells(UC-MSC)are a type of cell with the characteristics of remarkable self-renewal and multi-lineage differentiation.The human umbilical cord is rich in mesenchymal stem cells,which are relatively immature in comparison with bone marrow mesenchymal stem cells.Traditionally,the therapeutic potential of stem cells has focused on tissue repair and regeneration because of their ability to differentiate into multiple cell types.UC-MSC has strong biological activity and differentiation ability.It is worth noting that both chemical and neurotrophic factors can induce the differentiation ofUC-MSC into neuralstem cells.UC-MSC can also differentiate into oligodendrocytes progenitor cells,secrete various nerve growth factors,such as vascular endothelial growth factor,neurotrophic factor derived from the glial cell line,brain-derived neurotrophic factor,and promote axonal growth[30].Differentiated UC-MSC shows not only the morphology and phenotype of oligodendrocyte precursors,but also their corresponding functions.Forraz and McGuckin selected children with CP aged from 2 to 12 years old and utilized autologous cord blood stem cells(extracted at birth and preserved and injected into the children)[31].They were followed up for more than 1 year,and it was found that the motor indicators of the children improved without any obvious adverse reactions.Dong HJet al.used UC-MSC in the treatment of children with CP;the patients received UC-MSC transplantation three times[32].After three consecutive cell transplants,the patient's brain and limb strength were significantly improved,and motor function and verbal expression were enhanced.However,the effect of this method on the IQ of children with CP is notobvious.Xinet al.showed that mesenchymal stem cells exosomes(MSC-EXO)derived from mesenchymal stem cells can repair the damage caused by the abnormalbrain tissue environment following ischemia and promote the repair of nerve cells through the high expression of mir-133b(messenger no.133 on micro ribonucleic acid)contained in themselves[33].Using a mouse stroke model study[34],it was found that intravenous injection of MSC-EXO promoted neurite remodeling,nerve regeneration and vascular regeneration,thus promoting the recovery of nerve function. The MSC-EXO from bone marrow mesenchymal stem cells was injected into the vitreous body of mice with optic nerve injury.MSC-EXO could migrate from the vitreous body to the ganglion layer,promoting the survival of receptor cells(retinal ganglion cells)and regeneration of axons[33].These results indicate that UC-MSC transplantation for CP is very promising.

Surgical treatment of neurosurgery

Surgical treatment,mainly based on the type of spastic CP,is administered to improve muscle tone and correcting deformities.By relieving muscle spasm and correcting deformities caused by uncoordinated muscle tension or shortened tendons,it plays a supplementary role in rehabilitation treatment.The therapeutic mechanism is to selectively cut off the afferent Iα fibers of the muscle spindle and then block the spinal cord reflex loop to relieve muscle spasm and prevent recurrence.It has been demonstrated that decreased muscle tone does not affect motor function[36].Seung YLet al.studied the effect of tendon surgery around the knee on the ankle motion of patients with CP.The postoperative knee motion of children improved,but knee surgery may affect ankle activity[37].In addition,gait exercises in children made external surgical intervention unnecessary.In addition,since knee and ankle movementsare interrelated,surgeons should be aware of potential changes in the ankle after knee surgery.Surgical methods mainly include selective dorsal root amputation and peripheral selective partial amputation.Generally,the ideal age for surgery is between 4 and 6 years for children when considering lower limb surgery and between 6 and 8 years for children when considering upper limb surgery[36].In addition,postoperative rehabilitation training isan important part of successful treatment.Rehabilitation training should be continued.However,due to the appearance of BTX-a and various orthopedic braces,surgical selection should be cautious.

Treatment of complications

The complications of CP mainly include epilepsy,pain,nutritional disorders,respiratory system infection,urinary system infection,joint contracture,osteoporosis,and paresthesia.Some children with CP may even die from infection,malnutrition,or epilepsy.Therefore,in order to improve motor function in children,multidisciplinary participation is needed and related complications need to highly valued.Complications in children should be prevented and pain should be alleviated as much as possible through health education,a combination of physical and medical treatment,active lifestyle advocacy,and time pressure relief.

Conclusion

The impact of CP on human beings is enormous,and the quality of life of children with CP should concern the wholeofsociety.Compared with theseverity of symptoms,current treatment approaches are limited and,in many ways,underdeveloped.However,it is believed that with the performance of various studies,people will have a better understanding of the treatments of CP,and the rapid development of auxiliary treatment equipment will also provide more breakthroughs in the treatment of the sequelae of CP.

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