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COMPLEMENTARY
AND ALTERNATIVE
FOR CEREBRAL PALSY
THERAPIES
Gregory S. Liptak*
University of Rochester Medical Center, Rochester, New York
The optimal practice of medicine includes integrating individual clinical expertise with the best available clinical evidence from systematic research. This article reviews nine treatment modalities used for children who
have cerebral palsy (CP), including hyperbaric oxygen, the Adeli Suit, patterning, electrical stimulation, conductive education, equine-assisted therapy, craniosacral therapy, Feldenkrais therapy, and acupuncture. Unfortunately, these modalities have different degrees of published evidence to
support or refute their effectiveness. Uncontrolled and controlled trials of
hippotherapy have shown benecial effects on body structures and functioning. Studies of acupuncture are promising, but more studies are required before specic recommendations can be made. Most studies of
patterning have been negative and its use cannot be recommended. However, for the other interventions, such as hyperbaric oxygen, more evidence
is required before recommendations can be made. The individual with CP
and his or her family have a right to full disclosure of all possible treatment
options and whatever knowledge currently is available regarding these
2005 Wiley-Liss, Inc.
therapies.
MRDD Research Reviews 2005;11:156 163.
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Table 1.
Therapy
Theory/Benets
Adverse Effects
Evidence
Comments
Hyperbaric
oxygen
Ear trauma,
pneumothorax, re
and explosions
Adeli suit
Resistance across
muscles can improve
strength, posture, and
coordination
Patterning
Results of uncontrolled
studies are inconsistent;
controlled trials show no
benets
Cannot be recommended
Electrical
stimulation
Threshold
electrical
stimulation
Functional
neuromuscular
stimulation
Conductive
education
Hippotherapy
Craniosacral
therapy
Feldenkrais
Acupuncture
None known
None known
Forgotten needles,
pain, bruising, and
infection
Conductive education is
implemented in many
different ways making
generalizations from a
single program difcult
Horseback riding also
increases social
participation
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Fig. 1. Two children enjoying equine assisted therapy. Photos are courtesy of Rong-Ju Cherng,
National Cheng Kung University, Taiwan. [Color gure can be viewed in the online issue, which is
available at www.interscience.wiley.com.]
though many studies have shown improvements with NDT, except for maternal responsiveness, the most credible
studies were unable to document a difference between children treated with
NDT and those treated with other interventions.
CEREBRAL PALSY
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THERAPEUTIC ELECTRICAL
STIMULATION
Several types of electrical stimulation have been used to treat children who
have CP [Kerr et al., 2004]. In neuromuscular electrical stimulation, electrical
current actually elicits muscle contrac159
EQUINE-ASSISTED THERAPY
(HIPPOTHERAPY)
Therapeutic horseback riding has
been used with children who have disabilities since the 1950s when it was used
primarily for children who had polio.
Recently, it has become increasingly
popular with children who have CP.
Theoretically, riding astride a horse can
improve posture, balance, and overall
function by mobilizing the pelvis, lumbar
spine, and hip joints, decreasing muscle
tone, improving head and trunk postural
control, and developing equilibrium reactions in the trunk [Sterba et al., 2002].
A number of studies without comparison groups [Bertoti, 1988; MacPhail
et al., 1998; McGibbon et al., 1998;
Sterba et al., 2002; Winchester et al.,
2002; Casady and Nichols-Larsen, 2004]
have shown benecial effects from horseback riding in children with CP. For
example, Sterba et al. [2002] had 17 children ride for 1 hour per week for 18
weeks. Improvements were noted in specic aspects of the GMFM score, specif-
CRANIOSACRAL THERAPY
Craniosacral therapy is based on
the theory that a cranial rhythm exists
and is linked with movements in the
sacrum through mechanical forces transmitted through the dura of the spinal
cord. Therapy is used to remove impediments to the ow of cerebrospinal uid
within the cranium and spinal cord. A
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nervous system that is free of impingement would allow more normal function
[Boon, 2004]. Using light touch, the
practitioner can feel the rate, amplitude,
symmetry, and quality of the rhythm.
Light corrective pressure is applied to
various points along the craniosacral axis
to reestablish a normal, symmetrical pattern of impulses throughout the system.
This would allow more efcient functioning of the entire nervous system
throughout the body.
No peer-reviewed articles on the
use of craniosacral therapy in individuals
with CP were found. However, several
articles questioning the basis of craniosacral therapy have been published. Green
et al. [1999] reviewed published articles
and found insufcient evidence to support the premise of craniosacral therapy.
Norton [1996] had six examiners who
were osteopathic physicians with extensive training and experience in cranial
osteopathy examine nine healthy volunteers. He found that, when pairs of examiners documented the cranial and sacral rhythms of a subject simultaneously,
their ndings did not agree. He concluded that, although the ndings of this
study supported predictions of the tissue
pressure model for cranial rhythm, they
did not support the concept of craniosacral interaction. In a more recent review
of published studies, Hartman and Norton [2002] concluded that little scientic
basis for any aspect of cranial osteopathy
(including craniosacral therapy) existed.
They noted that the only publication
purporting to show diagnostic reliability
with sufcient detail to permit evaluation
was awed and stood alone against ve
reports that showed interobserver reliabilities of essentially zero. They also
concluded that there was no scientic
evidence of treatment efcacy. No published studies are available on the use of
craniosacral therapy in CP. Available
studies in the peer-reviewed litearature
question its foundations.
FELDENKRAIS METHOD
The Feldenkrais Method is an intervention using gentle change of position and directed attention to relax muscles to improve movement, posture, and
functioning. It is designed to increase
range of motion and to improve exibility and coordination [Feldenkrais Educational Foundation of North America,
2004].
No studies of the use of this
method in individuals with CP were
identied. The method has been studied
in uncontrolled trials in individuals
with conditions such as bromyalgia
MRDD RESEARCH REVIEWS
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Fig. 2. School-aged girl receiving acupuncture and the device used to supply the electrical
current. Photo courtesy of Professor Virginia Wong, Division of Neurodevelopmental Paediatrics,
Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary
Hospital. [Color gure can be viewed in the online issue, which is available at www.interscience.
wiley.com.]
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In an intent-to-treat study of 10
children who had drooling, Wong et al.
[2001] provided acupuncture to the
tongue over 30 sessions. Blinded observers found statistically signicant improvements in drooling in those children undergoing active treatment. Sun et al.
[2004] conducted a randomized trial of
acupuncture of the tongue in 33 children
with CP. They argued that, because the
tongue is close to the brainstem and cerebellum, stimulating acupoints in the
tongue could affect the neural pathways
and improve motor function. The mean
GMFM score in the treated group increased from 78.9 to 83.0. These improvements were statistically signicant
in the treatment compared to the control
group. Three subscores improved on the
PEDI in the treated group but not in the
control group. Thus, uncontrolled studies have shown improvements in several
areas; two controlled trials also showed
improvements.
CONCLUSIONS
The optimal practice of medicine includes integrating individual clinical expertise with the best available clinical evidence
from systematic research. The care of patients should be based, to the greatest extent possible, on evidence. This means that
sound evidence exists that 1) the therapy
recommended is effective in reducing morbidity, 2) the benets outweigh the risks, 3)
the cost of the treatment is reasonable compared to its expected benets, and 4) the
recommended therapy is practical, acceptable, and feasible.
These guidelines apply to therapy
whether conventional or complementary. In fact, Fontanarosa and Lundberg
[1998] have argued that, There is no
alternative medicine. There is only scientically proven, evidence-based medicine supported by solid data or unproven
medicine, for which scientic evidence is
lacking. Whether a therapeutic practice is
Eastern or Western, is unconventional or mainstream, or involves mind
body techniques or molecular genetics is
largely irrelevant except for historical
purposes and cultural interest.
Sometimes, advocates of complementary and alternative medicine adopt a
counterculture that is adversarial or even
hostile to traditional medicine. Despite
that, it is important to integrate complementary and alternative medicine with
conventional medicine. The individual
with CP and his or her family have a
right to full disclosure of all possible
treatment options. Failure to inform
them of alternatives encourages them to
use these therapies without informing the
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