OMT and cerebral palsy: A patient-centered approach

I thought I knew everything there was to know about cerebral palsy going into my first year of medical school. After all, my younger brother, Alex, has cerebral palsy (CP). How could I not? I accompanied him to his appointments, helped my parents bathe, feed and dress him and even went to school with him in my younger years. We are only eleven months apart in age and we were practically inseparable.

But it wasn’t until a few months into my medical education that I realized I wasn’t an expert in the medical aspects of CP; I was experienced in caring for and loving someone with CP. While studying osteopathic principles and practice, I found osteopathic manipulative medicine was an incredible means of blending my two worlds.

I recently spoke with Blaise Langan, DO, a third-year physical medicine and rehabilitation resident at UT Health in San Antonio. He uses osteopathic manipulative treatment (OMT) regularly when he sees his patients who have CP.

Dr. Langan and I are both passionate about caring for the disabled community; we hope to encourage our osteopathic peers and colleagues to be confident and prepared to make a difference in the quality of life of people with CP. Below, in this edited interview, Dr. Langan shares his approach to managing some of the most common CP complications.

My brother struggled to maintain regular bowel movements without medical intervention, most frequently constipation. What would be your approach to treating constipation in someone with CP?

OMT has a large role to play in managing constipation not only in CP, but in all patients. For me, I always start with a three-step process. First, I start superficially, treating any myofascial tension that I can find. Then, I move on to the chief sympathetic ganglia of the gastrointestinal tract. I treat these with one hand on the anterior portion of the patient’s abdomen and one on the posterior. I use both hands to balance and treat the ganglion itself and any nearby myofascial restrictions.

Finally, I move onto visceral techniques to the colon itself: tracing my way from the cecum through the large intestinal tract to the rectum. As always, it is important to rule out any type of bowel obstruction or other red flags before treating with OMT. Additionally, be sure to plan your treatment around any tubes, implants or stomata.

When many people think of CP, the first thing that comes to their mind is spasticity. What is the role of OMT in treating this?

OMT could be very helpful in this area, but OMT will never completely eliminate contractures. However, the goal for treatment should be to achieve a level of functional spasticity, a state that can improve a patient’s ability to perform activities of daily living and reduce caregiver burden.

Start by noting your patient’s baseline function; ask the patient and/or caregiver about any activities that might be challenging. Generally, I stay away from muscle energy, HVLA and articulatory techniques around contractures, as these can be difficult or dangerous to perform.

Indirect techniques such as balanced ligamentous tension, soft tissue kneading and myofascial release are safer alternatives for patients with CP. Still’s technique can be very useful in patients with limited participation, as three to five seconds of hold can be much easier to manage than the longer times required for counterstrain.

As my brother aged, it became increasingly difficult to maintain his autonomic stability. It was agonizing watching him suffer with bouts of extreme sympathetic overdrive and failure. How would you go about treating autonomics as a supplement to medical management for patients with CP?

Autonomics is something that is often ignored, but it can yield some of the greatest benefits for patients. Something as simple as suboccipital release, rib raising or sacral rocking can have a large effect. However, these techniques often need to be adapted or modified in patients with CP, as laying still for prolonged periods of time is often difficult. By adjusting your hand position to have one hand treating and the other stabilizing the area being treated, one can get better results as the patient moves around.

Overall, the most important thing to remember is patience. Sometimes it may take several treatments to see results, but the most important thing to establish in the first visit or two is trust. As patients gain trust in you and your treatments, they will be able to relax and accept treatment more readily. Five minutes may be all they can tolerate at first, but you can increase duration over time.

Remember, as patients age, their needs will change. Significant life events such as puberty can change their presentation and the area of their body that needs the most attention. Be mindful of changes in all autonomically regulated body systems as a result of shifts in the hormonal balance.

What kind of cranial manipulation do you use in practice? Given the site of injury, it seems logical that cranial somatic dysfunctions could follow.

Absolutely! Commonly, CP causes a baseline elevation in the cranial rhythm that can lead to chronic somatic dysfunction for patients. The goal of treatment should be to calm and maintain a normal rhythm. In my experience, vault hold is often ineffective. An anterior-posterior hold offers more control.

Especially when performing cranial treatments, it is important to utilize caregivers. They can often provide support by holding the patient’s hand, saying calming words or playing the patient’s favorite music or show.

What are some tips in determining when/how often to use OMT for your patients with CP?

As we know, not all patients with CP are the same. It may take a few sessions to diagnose and treat your patient accordingly. It might be beneficial to break treatments into smaller, more frequent doses; however, be mindful of social determinants of health. Does your patient have accessible, affordable and reliable transportation to get to your office? If not, dosing more frequently might not be possible for these patients. With this population comes a great deal of structure, but also the need for creativity and open-mindedness in your treatment approach.

What are your final thoughts on treating CP patients with OMT?

The list of complications of CP that can be managed with OMT does not end here. I recommend using the information in this article as scaffolding when treating your next patient with CP. With a non-progressive spectrum disease such as this, it is important to think outside the box. Patients with CP can undoubtedly benefit from regular targeted OMT.

Related reading:

5 popular fad diets and how to advise your patients on them

How to make treatment decisions while considering the cost of care