Therapy Management of the Child with Cerebral Palsy: an Overview
Cerebral palsy (CP) is the most common physical disability of childhood with a prevalence of 2.5–3.6 cases per 1000 live births (Christensen et al., Dev Med Child Neurol 56:59–65, 2014). CP is defined as a nonprogressive injury to the developing fetal or infant brain that results in movement and posture impairments, activity limitations, and participation restrictions (Rosenbaum et al. 2007). Although the brain injury in CP is nonprogressive, the impairments and limitations may become more severe with growth and often require services from multiple health professionals.
Clinical management of children with CP requires a collaborative inter-professional team approach to address the multiple health, function, and mobility problems that occur during the child’s lifetime (Chan and Miller 2014; Aisen et al. 2011). The team includes medical and rehabilitation health professionals to address the primary and secondary conditions associated with CP. The medical providers consist of primary care physicians and specialty providers including developmental pediatricians, orthopedic surgeons, neurologists, and pediatric physiatrists. The rehabilitation providers include physical therapists (PTs), occupational therapists (OTs), speech and language pathologists (SLPs), orthotists, biomedical engineers, and experts in adaptive equipment and assistive devices.
This section on Therapy Management of the Child with CP contains 40 chapters which provide evidence on the roles of rehabilitation professionals in the care of children with CP. We use the International Classification of Functioning, Impairment, Disability, and Health (ICF) model to provide a framework for the subsections and chapter topics to ensure that multiple components of health and function are included (WHO 2001). World Health Organization, Geneva, 2001). This section focuses on promoting family-centered care by expanding health care beyond impairments and limitations to include child and family goals and participation in the context of personal and environmental factors (Rosenbaum and Stewart, 2004; Rosenbaum and Gorter, 2011).
KeywordsCerebral palsy Physical therapy Inter-professional Management ICF Model Lifespan approaches
Family-centered approaches evolve into patient-centered approaches as the child or adolescent with CP becomes the adult with CP. Health professionals who provide care for children and adolescents with CP are reminded that our roles include supporting our patients to ensure a smooth transition to adult health and rehabilitation services that meet their needs and continue to promote health, function, and participation (Lennon et al. 2018).
Neuromotor impairments are a primary issue for children with CP (Aisen et al. 2011). These impairments lead to secondary musculoskeletal conditions and mobility limitations, which often require orthopedic surgery and physical therapy (Chan and Miller 2014; O’Neil et al. 2006). CP is the most prevalent pediatric diagnosis for which physical therapy services are provided (Hayes et al. 1999). Other impairments and functional limitations associated with CP include sensation, vision, perception, cognition, communication, feeding, and behavior, which require the expertise and services of other members of the inter-professional team health team (Rosenbaum et al. 2007).
The Second Edition of Dr. Freeman Miller’s Medical Text: Cerebral Palsy
Various etiologies of CP or CP-like conditions and description of common pathologies in major body systems
2: Medical management
Systems and specific medical concerns for children with CP and information on growth, development, and health status for these children
3: Orthopedic management
Central nervous system insults associated with CP and the impact on the neuromuscular and musculoskeletal systems including a review of spasticity
4: Therapy management
Roles of PTs, OTs, and SLPs to reduce body function and structure impairments, activity limitations, and participation restrictions, optimize child function, and achieve child and family goals
Therapy Management in the Child with Cerebral Palsy
This Executive Summary provides an overview of section “Therapy Management in the Child with Cerebral Palsy.” We have used the ICF model to provide the framework for the subsections and chapters included in this “Therapy Section” (WHO 2001). The goal of this section is to provide the reader with widely accepted evidence to support and inform clinical practice for the rehabilitation health professionals (PTs, OTs, SLPs). We hope that inclusion of this expanded “Therapy Section” in the Cerebral Palsy text will provide the rehabilitation professionals and medical and orthopedic specialists with a better understanding of rehabilitation services and encourage continued collaboration to promote the child’s health and function and to enhance child and family engagement and participation.
The “Therapy Section” is divided into 6 subsections and 40 chapters with more than 76 authors who are experts in their fields of physical or occupational therapy or speech and language pathology. Our authors represent clinical, research, and academic settings, and they have shared their expertise in the specific topics they write about in the therapy management of children and youth with CP. Many authors included case descriptions in their chapters to provide examples of clinical approaches to integrate the current evidence into practice.
Introduction: Expert Opinion
In subsection “Introduction: Expert Opinion” we invited three leaders and experts (a PT, OT, and SLP) to provide us with an overview and their expert opinion on the current evidence to optimize child health and function from each therapy profession. We invited these leaders to provide their perspectives on the “state of the science and clinical practice” in each area of therapy. It is common for therapists from all three specialty areas to be part of the inter-professional team and to contribute to the plan of care for a child with CP and his/her family. Therefore, we are thankful to Carole and Katherine Bevans their her chapter on “Physical Therapy Elements in the Management of the Child with Cerebral Palsy,” Laura Vogle for her chapter on “Occupational Therapy Elements in the Management of the Child with Cerebral Palsy,” and Mary Jo Hidecker for her chapter on “Communication, Speech, Language, and Hearing Practice Elements in the Management of the Child with Cerebral Palsy.”
Life Span Approaches and Environmental Settings
In this subsection, we have invited leaders (PTs, OTs, SLPs) in specific areas of expertise in the care of children with CP. We asked these authors to provide us with information on roles of therapy during specific ages or developmental periods in a child’s life. This subsection includes chapters on the specific settings where services may be provided, based on the child’s age and/or ability, and resources that may be used to augment therapy, based on a child’s developmental level. The ICF model identifies the “personal and social environments” as key in providing protective factors or reducing risk factors for individuals with disabilities. Rehabilitation therapists consider the age and developmental level of the child with CP as well as the environment in which they receive services and match interventions to specific needs and settings to optimize function. For example, infants born preterm are often admitted to a neonatal intensive care unit (NICU) where they may receive therapy services. Rachel Unanue Rose’s chapter describes “Therapies in Newborn and Pediatric Intensive Care Units for Neurologic at Risk Infants.” Young children who may be at risk for or who may have developmental disabilities or a diagnosis of CP may receive therapy services in the Early Intervention setting. Alyssa LaForme-Fiss and Lynn Jeffries describe “Early Intervention Services for Young Children with Cerebral Palsy.” Young children with mobility restrictions may benefit from fun and innovative devices to promote social and community participation. An example of such devices can be seen in the “Go Baby Go!” program in which physical therapists design toy-like mobility devices and robots to provide children with opportunities to engage with their environments. Cole Galloway and team provide evidence on the effectiveness of this and other clinical innovations in their chapter on “Innovative Approaches to Promote Mobility in Children with Cerebral Palsy in the Community.” Children and youth often require focused therapy interventions in conjunction with hospitalizations to address medical and surgical needs and functional goals. Children with CP may require therapy services in the hospital setting or in the outpatient clinic to increase dose (frequency, intensity, duration) and/or to focus on reducing specific body structure and functions impairments to promote activity and participation and to optimize health and function. Karen Josefyk and Allison Menard provide an overview of this model in their chapter on “Outpatient-Based Therapy Services for Children and Youth with Cerebral Palsy.” Additionally, children may need ongoing therapy services in the school setting to optimize educational experience through direct interventions, consultation, or monitoring to help adapt the environment and evaluate students for assistive devices as needed to increase participation. Laurie Ray and Susan Effgen provide an overview of school-based therapy in the United States in their chapter “School-Based Therapy Services for Youth with Cerebral Palsy: Individuals with Disabilities Education Act (IDEA) – Part B: Individual Education Program.” All children should have opportunities for active recreation and play outside of the school day. Therefore, it is important that rehabilitation therapists have resources for children with CP and their families to help them find community recreation programs to promote health, mobility, and socialization through active play and recreation. Maria Fragala-Pinkham and Jennifer Miros describe “Community Resources: Sports and Active Recreation for Individuals with Cerebral Palsy.” As youth with CP ages into young adulthood, it is critical for the rehabilitation therapist to consider the needs and to help find the resources for the young adult with CP to continue to receive therapy services to optimize health and function. Mary Gannotti and David Frumberg provide an overview of “Clinical Therapy Services for Adults with Cerebral Palsy.” Finally, this section ends with a discussion on the importance of social supports and vocational services for the adult with CP. It is important for the rehabilitation therapist to support the family and youth with CP so that there is a smooth transition for success as an adult with CP. The rehabilitation therapist should be familiar with health and other resources and provide families with recommendations to help in this transition. Margo Orlin and Susan Tachau share important resources that are available in the United States to support the adult with CP in their chapter “Community Engagement for Adults with Cerebral Palsy.”
Body Structure and Functions
This subsection includes information on the ICF model personal dimension of body structure and functions impairments that often occur in children and youth with CP. We have invited clinical and research leaders in the field of rehabilitation therapy to provide evidence on the pathophysiology of common impairments and evidence on effective interventions to reduce impairments to promote function. Postural control is often compromised in children with CP who have brain lesions in the cerebellum. Postural control will differ in children with CP based on the location and severity of the injury, and different intervention approaches may be indicated, with a focus on different body segments for specific strategies to promote postural control and balance. Sandra Saavedra and Adam Goodworth provide more detail in their chapter “Postural Control in Children and Youth with Cerebral Palsy.” The ability to dissociate the use of body segments (upper or lower extremities, head, and trunk) in functional tasks and to modulate movement to perform motor tasks successfully may be a challenge when motor control is compromised. In the chapter on “Motor Control in Children and Youth with Cerebral Palsy,” Eileen Fowler and Theresa Sukal-Moulton provide evidence on motor control impairments and methods to measure selective motor control. In this chapter, the authors frame intervention strategies with a recognition of specific motor control impairments in youth with CP. Hippotherapy is a unique approach to improve postural control in children and youth with CP. In the chapter “Hippotherapy for Children and Youth with Cerebral Palsy,” Annette Willgens and Ellen Erdman provide the rationale for hippotherapy as a therapeutic strategy and approaches in designing an intervention and measuring effectiveness. Children and youth with CP have secondary conditions such as muscle weakness and decreased muscular endurance and power. Noelle Moreau provides evidence on the changes in muscle morphology in youth with CP and effective interventions to promote muscle strength, endurance, and power in her chapter on “Muscle Strength in Children and Youth with Cerebral Palsy.” Aquatic interventions are used to promote aerobic performance and capacity in children and youth with CP. The chapter “Aquatic Therapy for Children and Youth with Cerebral Palsy” by Deborah Thorpe and Emily Paul includes information and evidence on the effectiveness of aquatic interventions to promote fitness and function in youth with CP and intervention strategies to optimize outcomes. In “Functional Electrical Stimulation (FES) Interventions for Children and Youth with Cerebral Palsy,” authors Sam Lee, Ahad Behboodi, James Alesi, and Henry Wright describe the modality designed to elicit motor output and promote motor learning in contexts of common daily functions. FES practice and research in CP has focused on walking therapies, and this chapter reports on some early and positive results. Astrid Balemans and Eline Bolster provide an overview on the state of aerobic and anaerobic fitness in children and youth with CP in “Aerobic/Anaerobic Fitness in Children and Youth with Cerebral Palsy.” Although the neuromotor insult has no direct effect on cardiorespiratory function, the inactive lifestyles associated with limited mobility function can affect physical fitness levels. Monitoring, maintaining, and improving aerobic and anaerobic fitness is an essential component of rehabilitation in children and youth with CP to allow participation in physical activity with peers and prevent health decline when aging. The chapter “Flexibility in Children and Youth with Cerebral Palsy” by Catie Christensen reviews the contributing factors to poor flexibility in children with CP, namely, spasticity, increased passive muscle stiffness, and soft tissue contracture. It is important for therapists to recognize that improved flexibility does not consistently lead to improvements in activity level or function; however, combining interventions to enhance flexibility with physical or occupational therapy may improve activity level outcomes more than isolated interventions. This subsection “Body Structure and Functions” closes with a chapter on “Postsurgical Therapy for the Individual with Cerebral Palsy” by authors Karen Turner-Bare, Betsy Mullan, Nicole Needles, and Danielle Stapleton. When orthopedic surgery is performed to reduce musculoskeletal deformities for the child with CP, postsurgical therapy should be implemented to ensure successful outcomes. This chapter describes the settings, processes, and goals of therapy in these special circumstances.
Activity and Participation
The subsection on the ICF dimensions and the effectiveness of various physical and occupational therapy and speech and language pathology interventions to address activity limitations and participation restrictions. The nine chapters in this subsection focus on therapy-specific topics to improve activity and participation. In the chapter on “Fine Motor Development in Children and Youth with CP,” Susan Duff and Aviva Wolf review the development of neural integrity and typical and atypical prehension patterns in children with and without unilateral CP. The authors describe characteristics of upper extremity function including muscle activation, anticipatory control, and selective motor control. The authors discuss effective interventions to improve hand and upper extremity function to promote activity and participation in children with unilateral CP. In the chapter, “Functional Mobility and Gait in Children and Youth with CP,” Pam Thomason focuses on the effects of CP on mobility and gait, with specific attention to activity limitations and participation restrictions. The author discusses the effect of various intervention strategies on mobility and gait, including botulinum toxin A (BoNT-A) injections and oral medications to reduce spasticity, muscle strengthening interventions, and select orthopedic surgeries. Hubertus J. A. van Hedel and Andreas Meyer-Heim provide an in-depth review on the effectiveness of robot-assisted gait training (RAGT) to promote physiological gait patterns in youth with CP in their chapter “Robotic Gait Training for Children and Youth with CP.” The authors discuss the evidence to date on using different levels and variations of dose-dependency, task specificity and patient engagement in RAGT. The authors provide a comprehensive overview of different equipment and technology used in RAGT and the clinical structure and organization needed in RAGT research and clinical services. Although RAGT is becoming more popular in rehabilitation, the authors indicate that more evidence is needed to gain a more clear understanding of the effectiveness of this approach in promoting and improving gait in children and youth with CP. Ann Tokay Harrington reviews treadmill intervention effectiveness in “Treadmill Training for Children and Youth with Cerebral Palsy.” In this chapter the author discusses the advantages of treadmill training (multiple repetitions in a session, stepping without forward propulsion, availability of different treadmill devices, and a safe gait training environment for youth with CP). She points out that despite the potential for improved gait, there is a need for more research on intervention strategies and effectiveness of treadmill training on improving activity and participation in youth with CP. In the chapter on “Functional ADL Training for Children and Youth with Cerebral Palsy,” Faithe Kalisperis, Kathleen Miller-Skomorucha, and Jason Beaman, PT, discuss the unique challenges that children and youth with CP face when learning activity of daily living (ADL) skills such as dressing, feeding, toileting, and participating in daily tasks. Success in ADLs is impacted by the child’s impairments and limitations, environmental factors, comorbidities, and cognitive abilities. The authors discuss the clinician’s role in completing a comprehensive evaluation to understand a child’s ADL performance and capacity. Also, the authors indicate the importance of including child and family goals to guide goal setting and interventions. Ann-Christin Eliasson and Andrew Gordon discuss the effectiveness of “Constrained Induced Movement Therapy (CIMT) for Children and Youth with Hemiplegic (Unilateral) CP.” In this chapter the authors review the important aspects to consider when implementing CIMT in the clinic. They review various CIMT intervention models, discuss supporting evidence, and present the evidence on the efficacy of this intervention. They suggest that CIMT may be considered an intensive complement to usual therapy care. Beth Mineo, in her chapter titled “Communication in Children and Youth with Cerebral Palsy,” describes current practices for evaluating communication skills in children with CP. The author discusses that it is critically important to identify and remove or reduce potential barriers to the development of oral speech and receptive, expressive, and reciprocal language in the young child with CP. Additionally, the author describes how SLPs address early literacy skills for young children with articulation disorders. Kathleen Benson, Kristin Capone, Kim Duch, and Christine Palmer-Casey wrote the chapter on “Mobility Supports in Educational Curriculum for Children and Youth with Cerebral Palsy.” In this chapter the authors discuss how the goal of mobility interventions in schools promote access and participation for students (youth with CP) in the school environment. The school-based therapist focuses on interventions to help students achieve academic goals and promote task-oriented outcomes. They present case studies to illustrate the role of the physical therapist and mobility supports in school settings. The final chapter in subsection “Activity and Participation” focuses on using active video games (AVGs) to promote activity and participation in active leisure for youth with CP. In this chapter, “Gaming Technologies for Children and Youth with Cerebral Palsy,” Torey Gilbertson, Lin-Ya Hsu, Sally Westcott McCoy, and Margaret O’Neil discuss how virtual reality and active video games (VR/AVGs) have become more accessible and flexible for use in clinic, community, and home environments. The authors suggest that more evidence is needed to support the effectiveness of VR/AVGs on improving motor ability, activity, and participation. However, there are some small, published pilot studies suggesting that VR/AVGs may be effective to increase motor activity in youth with CP. This technology, especially flexible custom platform games, may prove beneficial in promoting activity and participation in youth with CP.
Adaptive Technology and Supports
Instead of a focus on specific personal dimensions of the ICF model, section concentrates on environmental elements critical to enhancing function in the various settings in which children and youth with CP conduct their daily lives (home, school, and community). It is important for rehabilitation therapists to have up-to-date knowledge and resources about the voluminous options available to children and families who wish to pursue adaptive technologies to help optimize the child’s function. While it would be impossible to cover all of the commercially available technology, this subsection provides the reader with a comprehensive overview of the most valuable adaptive technology in common use for children and youth with CP. Maria Jones’ chapter describes “Wheeled Mobility Options and Indications for Children and Youth with Cerebral Palsy.” Children with CP often experience mobility limitations that prevent them from exploring their environments and participating in activities with typically developing peers. Identifying appropriate wheeled mobility options for children with little or no walking ability is critical to opening access to the child’s world. Maria’s chapter includes elements of wheelchair evaluation, recommendations, and training necessary for successful manual and power wheelchair mobility. The next chapter in the section “Adaptive Technology and Supports” provide concise synopses of adaptive technology to improve standing and walking skills, address positioning needs, and enhance independence in daily living skills. Mary Bolton and Maureen Donohoe describe “Ambulatory Assistive Devices for Children and Youth with Cerebral Palsy.” Children with CP often require supportive equipment to stand and walk. Understanding the child’s mobility potential based on Gross Motor Function Classification System (GMFCS) and environmental needs helps to guide the prescription and progression of assistive standing and walking devices as the child grows and as motor skills or environmental demands change. In most cases, families rely on the physical therapist for knowledge and expertise in guiding decisions and establishing practices to optimize the child’s ambulatory potential. Elizabeth Koczur, Denise Peischl, and Carrie Strine describe “Seating and Positioning Approaches for Children and Youth with Cerebral Palsy.” There are countless options available to provide support and optimize seated posture for children with CP. The chapter breaks down the options into basic categories and describes the evaluation of needs and prescription of components and accessories. The goals of well-aligned seated positioning are to minimize musculoskeletal impediments, provide comfort, and support participation in activities within the child’s school, home, and community environments. Maureen Donohoe and Patricia Hove describe “Activities of Daily Living Supports for Persons with Cerebral Palsy.” The ability to participate independently in activities of daily living (ADL) for the individual who has CP determines opportunity for lifelong independence. This chapter addresses the key activities of (1) feeding, (2) dressing, (3) hygiene, and (4) home access, with strategies of management from basic tool use, to minor adaptations, to high technology. Although not all persons with CP will gain full independence, any level of performance by an active participant can help reduce reliance on others and support self-determination. This chapter provides the reader with a guide for selection of devices and progression of skills toward maximizing function in adulthood. Subsection “Adaptive Technology and Supports” includes two chapters on orthotic intervention in children and youth with CP. David Hudson, Heather Michalowski, and Freeman Miller discuss “Lower Extremity Orthoses for Children and Youth with Cerebral Palsy.” Lower extremity orthotic treatment is ubiquitous for children with cerebral palsy. Orthoses are prescribed with the goal of improving standing and walking function of the child. In growing children, management of orthoses requires frequent changes or modifications. To be effective, orthotic devices need to be strong, lightweight, and comfortable to wear. Their prescription should be to manage a specific impairment and needs to delineate the specifications of the device, the wearing dose, and the potential complications. This chapter defines treatment of common biomechanical problems in youth with CP using lower extremities orthotic interventions. Tracy Shank and Charles Cericola discuss “Upper Extremities Orthotics for Children and Youth with Cerebral Palsy.” Children with CP or similar neurologic conditions present with a variety of soft tissue problems, joint instabilities, and postoperative needs of the upper limb. This chapter reviews techniques for evaluating the need for and fabricating orthosis for the child with abnormal muscle tone. The chapter addresses postoperative orthoses, common contracture management orthoses, functional orthoses, and motor reeducation orthoses. Material and design recommendations are made, as well as strategies to evaluate effectiveness. Mary Jo Cooley Hidecker describes “Augmentative and Alternative Communication for Cerebral Palsy.” Augmentative and alternative communication (AAC) augments or replaces communication for individuals with CP who otherwise cannot achieve communication with familiar and unfamiliar partners in everyday environments. This chapter describes unaided and aided AAC methods. Aided AAC includes speech-generating devices (SGD) to supplement or replace speech. The appropriately prescribed and utilized AAC system interacts with the individual’s body structure and functions to achieve desired communication activities and support participation at home and in the community. AAC is used regardless of age or cognitive ability and supports understanding of, as well as expression of communication. This chapter describes the interdisciplinary evaluation and intervention needed to support the broad AAC goal of ensuring that individuals with communication impairments can participate in all life situations.
Complementary Therapy Approaches
Finally, we have included the section “Complementary Therapy Approaches”. Complementary approaches are usually not yet accepted by mainstream clinical practice (Lynoe 1992). This subsection consists of two chapters. The first chapter “Complementary Therapy Approaches for Children and Youth with Cerebral Palsy” by Roberta (Robbie) O’Shea and Gina Siconolfi-Morris provides an overview of several complementary approaches sometimes used in the therapy management of children with CP including therapeutic garments, therapeutic taping, yoga, Pilates, myofascial release, Conductive Education, patterning, Feldenkrais, Votja, medical marijuana, and craniosacral therapy.
Overall, evidence on the effectiveness of complementary approaches in the management of CP is limited (Rosenbaum 2003; Liptak 2005; Oppenheim 2009). Despite low levels of evidence, one study found that over a third (35.5%) of families with children with CP use complementary and alternative medicine (CAM) in the care of their children (Samdup et al. 2006). Reasons for using CAM include improving quality of life, assisting traditional medicine, and relief of symptoms (Hurvitz et al. 2003). Medical providers and families (caregivers and youth with CP) should be well-informed and engage in meaningful discussions when considering complementary therapies to help the child with CP. Care should be used when recommending complementary therapies given the limited evidence on effectiveness of these approaches.
The second chapter in section “Complementary Therapy Approaches” is “Neurodevelopmental Treatment Clinical Practice Model’s Role in the Management of Children with CP” written by Faithe R. Kalisperis, Jeanne-Marie Shanline, and Jane Styer-Acevedo. Neurodevelopmental treatment (NDT) is a holistic clinical approach that uses current evidence to inform therapeutic handling skills to promote functional mobility in children with CP. There is a continued debate as to whether NDT is a complementary or mainstream approach to therapy management of CP. We do not have a position in this debate; however, we put this chapter in the complementary approach subsection because it seemed to fit best here. In NDT the therapist uses “key points of control” to facilitate movement to reduce impairments, increase activity, and promote participation. This therapeutic handling is used to aid the child’s movement, to redirect ineffective movements, and to teach movements that are efficient and lead to improved function. The child’s strengths and needs are considered in the design of a well-sequenced treatment plan that is functional, fun, efficient, effective, and collaborative.
We understand that the information in the Therapy Section is not exhaustive but we are confident that current evidence and research is presented to support clinical decision making in the care of children with CP and their families. We hope this information is useful to clinicians and researchers. And we hope it contributes to the information exchange and collaboration among the members of the interprofessional team to best serve children with CP and their families.
We are very grateful to more than 76 authors who contributed their time and expertise to this Therapy Management Section. These authors are committed to improving the lives of children and youth with CP and to moving their professions forward in the use of evidence-based practice approaches. They have an abundance of clinical, research, and academic experience, and we are grateful to them for sharing it with us. In addition to the information and review of evidence that they contributed in this section, the authors also provided case descriptions in their chapters to support the clinician in implementation of current evidence into practice to improve outcomes for children and youth with CP and their families. Again, for that we are very grateful.
We would be remiss if we did not extend our gratitude to Dr. Freeman Miller and Dr. Steven Bachrach for the opportunity to work with them as editors of this section on Therapy Management of the Child with CP. We are very thankful for the invitation and the mentorship we have received in this process. Dr. Miller and Dr. Bachrach have demonstrated to so many in health and rehabilitation services for children with CP that collaboration, evidence-based practice, and authentic family-centered care are the keys to success to optimize health, function, and participation. In their directing the CP Program at Nemours/AI duPont Hospital for Children in Wilmington, Delaware, they have taught us valuable lessons and shown us how to achieve positive outcomes for so many children and youth with CP and their families. Thanks for all you do and thanks for inviting us along in this journey!
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