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As part of Shirley Ryan AbilityLab’s regular “Ask the Expert” series, community members submit questions via social media to the hospital’s clinicians and researchers. The latest featured expert, Sarah Lock, MS, PT, DPT, PCS, offers her knowledge about cerebral palsy (CP), therapeutic interventions for CP and the importance of early detection.
Sarah is a pediatric physical therapist with extensive experience working with children from infancy through adolescence. She specializes in early identification and intervention strategies, with a particular focus on the early detection of CP. She works with Shirley Ryan AbilityLab’s Cerebral Palsy Center of Excellence and is one of the lead physical therapists in the hospital’s Early Motor Development Clinic.
Sarah shared her insights in the following Q&A (which has been edited for length and clarity), as well as in a video on Instagram.
First, how did you get into pediatric physical therapy, specifically in working with kids with CP?
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I have always had an interest in working with kids. After I graduated from school, I sought out opportunities to work in pediatric clinics. When I moved to Chicago, I knew Shirley Ryan AbilityLab was the top rehabilitation hospital in the country and I thought, “Where better?”
I became interested in CP, and specifically in early intervention in CP, when I realized that’s where I could have the biggest impact — and when I really started to see what these kids are capable of achieving from an early age.
What is CP, and how is it caused?
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CP is the most common motor disorder in children in the United States. It affects about 1 in every 345 children.
CP can impact your movement, your muscle tone and your postural control. It’s caused by damage to the brain that happens just slightly before birth, during the birth process or shortly thereafter.
What is the Early Motor Development Clinic at Shirley Ryan AbilityLab?
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Our Early Motor Development Clinic was established to support children who are at high risk for neuromotor delay. We monitor their development in an effort to provide an early diagnosis of CP if it is indicated. Our clinic includes a group of physical therapists, occupational therapists, physiatrists and nurses who all work together to establish a CP diagnosis and link children up with resources as soon as possible.
Why is therapy so important for babies who have CP?
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Physical, occupational and speech-language therapy are all extremely important for children with CP, and especially babies up to age 3.
The first few years of life are an incredibly neuroplastic time for individuals with CP, when the brain is malleable. During this time, even if there is damage to part of the brain, we're able to tap into the rest of the brain to lay down new pathways — and to help patients learn how to explore and engage with their environment through whatever means possible.
What types of assessments are done when screening little ones for CP?
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We use a number of standardized tests in order to establish a diagnosis of CP in young infants.
In infants under 5 months, we review MRI results. We also consider their neurological system with the use of the Hammersmith Infant Neurological Exam (HINE), which is a standard neurological examination used to identify infants with a high probability of CP. Many of our clinicians are certified in performing the General Movements Assessment, a non-invasive assessment to detect neurological impairments. Finally, we use the Test of Infant Motor Performance (TIMP) to look at their gross motor skills.
In infants who are more than 5 months, we consider MRI results and the HINE again. We also use a parent-report measure called the Developmental Assessment of Young Children, Second Edition (DAYC-2) and look at responses in both the gross and fine motor sections. Lastly, the Alberta Infant Motor Scale (AIMS) provides an observational assessment of gross motor skills.
What motor milestones should we focus on for a child with CP under age 3?
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I like to look at children with developmental differences on a completely different spectrum than I would for a typically developing child. A lot of these children are born extremely early. We know they have injuries to their brain.
For me, the big thing is providing kids with CP with opportunities to develop skills in their own way — and for them to gain independence and explore their environment regardless of what it looks like. Yes, we work on rolling, we work on tummy time, we work on sitting and we work on standing, but what that looks like in each individual child can vary a lot.
As another example, crawling on hands and knees is an extremely difficult skill, especially for someone with hemiplegia (paralysis of one side of the body) or quadriplegia (paralysis of all four limbs). For these kids, working on walking may be more important and more practical, and we can provide them with opportunities to walk with a supportive device.
I consider both strength and function. I never say, “We need to develop this skill before another skill.” I like to work on everything at once and also find what the child really, really enjoys doing. That's always a really important piece of it.
When do you start introducing assistive technology, such as mobility aids, for kids with CP?
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We can introduce assistive technology as soon as possible and as soon as appropriate. There is a concept I live by called “on-time mobility,” which means that an intervention can be provided at the age when typically developing children begin to initiate movement.
For children with CP, sometimes it's harder for them to stand up or to get into upright positions, so it is our job to figure out how to create the environment to allow them to have success with these activities.
Providing a child with CP with a stander at 9 months old (when babies typically start to stand), or with a gait trainer at 10 to 12 months old (when their peers may be up and moving) or even with a wheelchair, can be incredibly impactful. They then find a love for mobility and movement in a way that's really age appropriate for them.
How old should a patient be to use botulinum toxin for spasticity?
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The discussion of when to consider using botulinum toxin in children with CP, especially those with spastic CP, should start fairly early in the course of care — especially if range of motion and spasticity are a concern for the child. Spasticity is a disruption of typical muscle tone due to an injury to the nerves that start in the brain and innervate muscles. Due to this disruption, when a muscle is stretched quickly, it tightens or resists more than it should. The faster the movement, the stronger the muscle resistance. Spasticity can be associated with increased muscle stiffness and reduced ability to selectively control muscles, which impacts function.
The FDA has approved the use of botulinum toxin in children 2 years and up. Before age 2, we use different interventions, such as braces or standers for strengthening, to help control and limit joint contractures and other adverse effects of spasticity on a young child's development.
Finally, what's your “why?”
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I love this one! My “why,” or my reason for doing what I do, is the children and families I get to work with. Having the opportunity to empower parents, celebrate the successes of their infants, let them know that it's going to be OK, and show them what their children are capable of is truly the most rewarding opportunity that one could ever ask for.
