REHABILITATION OF CEREBRAL PALSY &

MOTOR DELAY

:

BY

DR. ABDEL MOETY AFIFI

MD. Rheumatology & Rehabilitation

REHABILITATION OF C.P

CEREBRAL PALSY Static encephalopathy(=non progressive) caused by an insult to the

immature brain

REHABILITATION: The process of making the child w/ disability maximally able again

through the application of rehab principles & techniques.

•

REHABILITATION OF C.P

Principles of proper rehabilitation :1. Proper evaluation ( individual treatment ) - to plan a therapy program.to assess

progress. - to add observation to the diagnostic

picture.2. Early treatment( increasing functional

deficits w/ age as secondary effects of spasticity &other primary problems

3. Team work ( global dysfunction )

(A) Clinical evaluation

1. Functional : Postural control Mobility

Primitive reflexes Motor exam

2. Swallowing & dysphagia

3. Communication: Speech/ language Visual

Auditory Mentality

4. Chest 5. Urinary bladder 6. Bowel

7. Self -care activities (ADL) 8. psychosocial

EVALUATION OF CP CHILD

EVALUATION OF CHILD WITH CP.

(B) Imaging

1. Serial X-rays:

Hips (dislocation spastic adductors)

Th-L-Spine (scoliosis, hyperlordosis in spastic CP

kyphoscoliosis in floppy CP)

2. MRI or CT brain (progressive motor deficits ?

tumors, hydrocephalus

ASSESSMENT OF MILESTONES & POSTURAL CONTROL

• Understanding normal development allows to adaptive equipment to assist child in gaining increase the interaction with the environment.

• Sitting balance at age 2 yrs. is an indicator of future walking.

• Observe how much parental support given to child.

child own ability in postural stabilization.

collapse on one side of his body, twist to one

side, tilt & turn to one side.

EVALUATION OF PRIMITIVE REFLEXES

• Can be used as indicator of ambulation• Abnormal response for two of the following seven reflexes

by age 12 month has a poor prognosis for walking this are Should be absent Should be present ATNR parachute reaction STNR foot placement Moro response Neck righting reflex Extensory thrust• Presence of Moro or ATNR, seizures, ability to sit at 12

month indicate ambulation by age of 6 yrs.

MOTOR EXAMINATION

GAIT• Hemiplegia Toe walk• Diplegia Bilateral equinovaras, Knee flexed & in valgus Scissoring• Cerebellar Ataxic

MOTOR EXAMINATION

DEFORMITIES

• Hemiplegia : adducted arm, flexed elbow, wrist & fingers

equinus foot.• Diplegia: adducted hip, flexed knee in valgus, bilateral EV knee height discrepancy indicates hip dislocation.• Quadriplegia: combination scoliosis & hyperlordosis in spastic CP kyphoscoliosis in hypotonic CP

MOTOR EXAMINATIONR.O.M.

• Degree by goniometry:• Limited (= fixed deformity = ms. Contracture)• Not limited (+ deformity = threatening

deformity = muscles imbalance)

ABNORMAL MOVEMENT• Dystonia, ( cervical = spasmodic torticollis )• Chorea & Athetosis• Tremors

MOTOR EXAMINATION

MUSCLE TONE• Spasticity ( = clasp knife ): - generalized or focal - grade 0 (non) - 4 (severe) [Ashworth

scale]• Rigidity ( = lead pipe ) • Hypotonia ( cerebellar )• Combination : the predominant symptoms

will contribute to diagnostic type referred for treatment

MOTOR EXAMINATION

MUSCLE STRENGTHGrade 0 = No contraction detected 1 = Flicker of contraction w/ no movement. 2 = Joint movement possible only with gravity eliminated. 3 = Muscle contraction possible against gravity without resistance. 4= Muscle contraction against gravity & less than normal amount of resistance. 5 = Normal power against gravity and resistance.

MOTOR EXAMINATION

MUSCLE STRENGTHValues of muscles grading: - To determine ambulation with or without

brace ( grade 3 antigravity muscles can ambulate

without brace - Topographic classification for treatment plan ( strengthening exercise for weak muscles ) - Ex. must be low grade and non-fatiguing in

ms.<3/5 -N.B (I) grade drops form muscle power

following tendon lengthening.

SWALLOWING STUDY Values: - To facilitate appropriate position for safe, effective feeding - To increase ability to self feed. Methods: 1. Video fluoroscopic swallowing study - Requires speech - pathologist & radiologist - Patient is given liquid & various consistency of solid food impregnated w/ baruim & folowed by X-ray until be sure safe effective swallowing 2.Fiberoptic evaluation of swallowing ( FEES ) Transnasal endoscopy of hypopharynx to observe foodway & airway before & after( but not during ) the moment of swallowing. 3. EMG, manometry, scintigraphy & U.S: less commonly use.

Assessment of speechSpeech problems :• Dysarthria (oral motor control problems ) : Spastic Hypokinetic (ataxic ) Hyperkinetic (dystonia,chorea)• Aphasia• Language delay (brain pathology, MR,

hearing impairment )

VISUAL ASSESSMENT

• Problems: Strabismus ( imbalance in eye ms. ) Hemianopsia(in dense hemiplegi w/

MCA occlusion)

Blindness ( anoxic cortical vision loss )• Effects: 1. More motor delay 2. Language

delay 3. Abnormal movements ( blindism ) 4. More delayed postural mechanism especially hypotonic CP

AUDIOLOGICAL EVALUATION• Must be early so that important speech development

period not lost. In infant (1-2 d. of birth):

Brain stem auditory evoked response (BAER): Electrodes placed on the child & presenting a stimulus picked up from a computerized system.

A specific wave form response is recorded from the brain stem if stimulus is heard.

Otoacoustic emission testing (OAE): Echo from hair cell of normally functioning cochlea picked by a microphone placed in the middle ear & connected to micro computer.(middle ear pathology is ruled out)

AUDIOLOGICAL EVALUATION

• 6 months children: Behavioral testing in sound treated room• 2-3 years children : Play audiometry done by presenting

auditory stimulus through loud speaker and associate the sound with light or toy

CHEST EVALUATION

Vital Capacity is measured by spirometry

Ventilatory impairment may be caused by:

1. Rib cage abnormalities 2ry. to scoliosis & hyperlordosis (spastic) or kyphoscoliosis (floppy)

2. Respiratory muscle dysfunction (spasticity or hypotonic)

ASSESSMENT OF BLADDER DYSFUNCTION

• Problems: -incontinence,urgency,hesitancy (brain damage,motor

disability, impaired cognition ) -small capacity hypereflexic bladder -detrusor sphincter dyssynergia• Assessment : -Renal function with serial determination of post-voidal

volume -Cytometric evaluation with associated EMG

monitoring of pelvic floor muscle

ASSESSMENT OF BOWEL DYSFUNCTION

• Problems : -Fecal incontinence or defecation

stress ( brain damage, motor disability, impaired cognition,incoordination of anal sphincter or pelvic floor muscle )

-Constipation : exaggerated by immobility & inadequate fluid intake

• Assessment : anorectal manometry

SCOPE OF CP REHAB. 1. Neurodevelopmental training. 2. Motor facilitation approach. 3. Treatment of spasticity. 4. Rehab. of swallowing problems. 5. Rehab. of speech problems. 6. Rehab. of auditory problems. 7. Rehab. of visual problems. 8. Rehab. of chest problems. 9. Rehab. of urinary bladder & bowel

problems.10.Rehab. Of ADL & 11.Psychosocial rehab.

NEURODEVELOPMENTAL TRAINING

EQUIPMENT TRAININGCriteria for selection: 1. to carry out tasks otherwise impossible with his ability.2. appropriate support to participate in social & educational

activities .3. good alignment & correction of abnormal postures4. adjust for child” growth, removal of support with increasing

ability.5. modification for different children in schools & clinics 6. provide additional motor experience in different posture7. Comfort and protect joints & skin.

NEURODEVELOPMENTAL TRAINING

Equipments varieties: 1. Wedges: Abductor W : prevent adduction

deformities

2. Trumble form wedges & trumbles.

3. Large inflatable ball set 4.Crawlers: -platforms on wheels or wedges on wheels -A canavas sling under child” abdomen & supports on casters, straps to hold thighs in flexion.

5. Sitters

NEURODEVELOPMENTAL TRAINING

6. Apparatus for supporting standinga) Prone or supine standers to encourage weight bearing &

standingb) Standing frames adjusting correct alignment: -checked for height so that child does not grasp them w/

abnormal shoulder hunching , excessive elbow flexion & radial deviation of wrist. -supplied w/ strapping to correct flexed hip & knees -feet held at right angles by a board &/or foot place.c) Parallel bars

d) Mirrorse) Stairs with bannisters: very in height. f) Rumps, uneven ground, various floor services for gait training.

NEURODEVELOPMENTAL TRAINING

7.Walking aids Walkers Crutches

Braces & Calipers: Knee gaiters (polyethylene knee moulds)

to keep knee straight abduction parts to keep legs apart.

Elbow gaiters which keep elbow straight for correct arm push & grasp of walkers.

MOTOR FACILITATION APPROACH

1. Bobath Method: inhibition of abnormal tone & posture of released postural reflex while facilitating specific automatic motor response (by special technique of handling) resulting in performance of skilled voluntary movements.

2. Rood Method: Use of peripheral input of cutaneous sensory stimuli (brushing, tapping, icing, heating, pressure, ms. stretch, muscle contraction, joint approximation. or retraction)

Various nerves & sensory receptors are described & classified into types ,location, effect, response, indication.

MOTOR FACILITATION APPROACH

3. Propioceptive Neuromuscular facilitation (Kabat & Knott)

Use of such mechanisms as maximum resistance , quick stretch & spiral diagonal (mass) movements, sensory afferent stimuli (touch, pressure, traction,compression & visual) to facilitate normal mov .

[special techniques: irradiation. stim. of reflexes,reversal(successive induction), relaxation.].

4. Brunstrom Method ( hemiplegia): Produces motion by provoking primitive movement pattern or synergitic pattern as follows :

-Reflex response used initially & later voluntary control

-Control of head & trunk by stim. of TNR, tonic labrinythine R

-Associated reaction : hyperextension of the thumb produces relaxation of finger flexors.

MOTOR FACILITATION APPROACH

5. Motor relearning program of Carr & Shepherd: functional training, practice, repitition, in the performance

of tasks & carry over those motor skills into functional activities.

6. Forced use paradigm (= constraint - induced movements therapy CIMT):

Non hemiplegic limb is restrained in a sling during 90% of waking hrs. to force the patient to use the hemiplegic limb.

The minimum amount of motion in the paretic limb before being enrolled into CIMT protocol is 20 of wrist extension and 10 of extension of 2 fingers at MCP or IPJ.

TREATMENT OF SPASTICITY

Positioning• Avoid prolong sitting (less hip & hamstring

flexion )• Prone lying at night (less hip flexion )• Abduction wedge at night & in wheelchair (less

hip adduction)• AFO splint• Standing frame• Molded thoracolumbar orthosis for early

scoliosis or kyphosis• Total contact support incorporated into a

contoured seating system

Drugs Indication : generalised spacticity to aid in mobility

Types :1. Dantrolene Sodium (Dantrium): Inhibits Ca release in excitation-contraction coupling Used in cerebral form of spacticity Dose: 25- 200mg2. Baclofen (Lioresal ) [ presynaptic inhibition ] Used in spinal form of spasticity Dose :5-40mg3. Diazepam (Valium) [postsynaptic inhibition] Used in spinal form of spasticity Dose :2-30mg

TREATMENT OF SPASTICITY

TREATMENT OF SPASTICITYPHYSIOTHERAPY

PHYSICAL AGENTS

Aim: a. Analgesia b. Ms. Relaxation c. Collagen extensibility

Modalities: 1) Ice 20mins.

2) Heat: Superficial : Dry: I.R. Moist: hot packs

Deep : S.W. U.S

ELECTRIC CURRENTS Aim: Ms. strengthening (galvanic & faradic) .

Analgesia ( TENS, IF)

EXERCISES For spasticity : Passive ROM Stretch (short ms.)

Strengthening (weak ms., antagonist),

resistive > 3/5

For hypotonia : Strengthening ( weak ms) Balance

For athetosis : Training to control simple joint motion

TREATMENT OF SPASTICITY

Nerve/ Motor Point Block

Indications Localized spasticity poorly responsive to drugs or PT,

interfering w/ mobility, bracing, hygiene & causing pain

Contraindication: - Absolute: Allergy Infection Pregnancy - Relative: Coagulopathy Problems: -Loss of motor function of injected ms. -Return of spasticity ( axon sprouting )

TREATMENT OF SPASTICITYNerve/ Motor Point Block

Agents :1- Botulinum toxin(Botox) [inhibits A.C at NMJ] Used in motor point block of UL & LL Antibodies are formed against it2- Phenol [ produce coagulation of axon protein] Used in nerve motor point block Produces sensory dysesthesia.3 - Alcohol [produce coagulation of axon protein] Used in motor point > nerve block Produces hyperaemia & transiant burning

TREATMENT OF SPASTICITY

INTRATHECAL BACLOFEN PUMPIndications: ambulatory or non ambulatory child > 28lbs.w/

spastic diplegia. Method: - Baclofen is delivered via pump implanted S.C.in

abdominal wall & surgically placed in subarachnoid space (CSF) close to its site action ( receptors just 1mm under the surface of spinal cord )

- Start with intrathecal test dose via lumbar puncture to assess baclofen effect over 6-8hs (1grade drops of spasticity)

. Advantage: avoid high dose of oral baclofen. Risk: Infections e.g. meningitis, hypotonia & resp.problem

TREATMENT OF SPASTICIRYSERIAL CASTING

Indications: focal contracture (especially elbows,

knees, ankles ). Method:

• Limb is stretched then casted in a

lengthened position ( can be combined with blocks ) • Changed every few days or weeks to

gradually stretch contracted structures.

TREATMENT OF SPASTICITYBRACES ( = CALIPERS = ORTHOSIS )

Aim: To correct deformity To control athetosis To obtain upright position

Types: AFO: For ankle instability w adequate Q > 3/5 Types: solid ( in ankle clonus ) Klenzak ankle joint w/spring(A,P) w/ stop (A,P) Accessories: varus strap valgus strap KAFO: For correction of knee deform. & instab. HKAFO: For ambulation w/ hip instability . Shoe modification

TREATMENT OF SPASTICITYORTHOPAEDIC SURGERY

1. Spastic equinovarus foot: combination of: a. Achillis tendon lengthening ( equinus def. ) b. Split anterior tibial transfer: Splitting TA tendon

medial half left attached to its origin lateral half tunneled into 3rd cuneiform & cuboid

2. Tight hip adductor: Adductor tenotomy or derotational osteotomy

( + surgical reduction ) 3. Scoliosis: surgical correction in ambulatory child w/ curvature > 45 & vital capacity < 35%

TREATMENT OF SPASTICITY

NEUROSURGERY Dorsal Rhizotomy - Ideal patient: young child (3-8 yrs.) w/ spastic diplegia ambulatory w/ spastic gait. - Method: - Surgical cutting of posterior (sensory) root

to decrease sensory input to spinal cord

reducing muscle tone (but decreases sensation)

- Must be followed by PT & OT - Cutting anterior root produces atrophy &?

ulcer

REHAB OF SWALLOWING PROBLEMS

• Team: speech language specialist, OT, Dietary specialist.

• Items: • Changes in posture & head position during feeding.• Oral motor exercise for the tongue & lips to

increase strength, ROM, velocity, percision.• Use of thickened fluid & soft food in small boluse• Use of alternative feeding routes e.g. nasogastric

tube, gastrotomy or jejunostomy tubes with severe aspiration or caloric need.

REHAB OF SPEECH PROBLEMS

• Team : speech -language pathologist & nurse• Items : 1- oral option : electrolarynx 2 - non oral options : - simple hand writing - gestures - augmentative communication device (simple alphabet & picture

board to sophosticated computer systems 3- treatment of hearing & visual

problems

REHAB OF AUDITORY PROBLEMS

• Team: audiologist, speech therapist, OT • Items: Cochlear implants (for profoundly deaf): to stimulate auditory nerve & provid awareness of

sound Hearing aid :

- Do not help purely central hearing loss. Used for ttt of profound sensorineural hearing loss in infancy & early childhood

REHAB OF AUDITORY PROBLEMS

• Assistive listening device: Voice amplifiers used with or in place of hearing aids. Speaker microphone is connected to the listener’s head set or hearing aid through a wire, FM radio waves or IR light. The signal is amplified and background noise is not picked.

• Compensatory strategies: Hand signs, lip reading, gestures, written communication, speaking clearly at slow speed, visual fire alarms, enrichment of visual & tactile sensory environment, protection of the child”s remaining hearing (use of ear plugs in swimming, ototoxic drugs are avoided)

REHAB OF VISUAL PROBLEMS

• Training of postural reaction (large balls, rolls)

• Use of compensatory stimuli (auditory, tactile, vestibular, propioceptive) for:.

-Training of motor function of child’s life e.g dressing, feeding, bathing, roll over, creeping, crawling (listen to sound, reach to sound, move to sound).

-Training of body image movements enjoyment (hand to hand, hand to mouth, hand to body)

• Mother - child relationship ( kisses, touches, stroking, talking to the baby) is important.

REHAB OF VISUAL PROBLEMS

• Use of vibrating toys, bells & playthings placed for his tummy legs & similar ideas.

• Language development: Important to talk & clearly label the body parts & to encourage the child’s language.

• Visual enhancement (illumination, magnification, altered contrast, glare reduction, expanders of visual field)

• Visual substitution: Recorded talking books,

Computer w/ vebral output,

Braille book.

REHAB. OF CHEST PROBLEMS

• Elimination of air way secretion by manually assisted cough OR mechanical insufflator or exsufflator.

• Respiratory ms. aid by manual force (breathing ex) OR

mechanical ventillatory assistance(hypoxia) • Mouth intermittent positive pressure

ventillation (IPPV) in late stages.

REHAB. OF U.B. PROBLEMS

Timed bladder emptying scheduleRegulation of fluid intake.Use of diapers. Adequate cleaning of perineumFamily education about transfer & dressing

skill .

REHAB. OF BOWEL PROBLEMSA timed toileting schedule for incontinenceUse of dietary fibers, adequate fluid intake,

stool softeners, supp., & enema for constipation.

REHAB OF ADL

• Team : occupational therapist• Items : - provision of self help devices - training in activities of ADL - provision of creative interest - training in suitable work

PSYCHOSOCIAL REHAB

• Team : psychiatrist + social specialist

• Items : - provision of recreational activities

e.g.- special olympics, athletic competition

- horse back riding programs

(recreational & therapeutic )

- computers ( for schools & recreation