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CEREBRALPALSY

� DR. ARVIND TOMAR� ASSO. PROF.� DEP. MGPC

� It is defined as a group of disordersresulting from permanent nonprogressive cerebral dysfunctiondeveloping before maturation of CNSaffecting the locomotor system

� Non curable , life long condition� Maybe congenital or acquiredResults in paralysis , weakness, incoordination or abnormal movement

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� The incidence of CP is about 2 per 1000 livebirths

� The incidence is higher in males than infemales

� Other associated problems include◦ Mental disadvantage (IQ < 50): 31%◦ Active seizures: 21%◦ Mental disadvantage (IQ < 50) and not walking:

20%◦ Blindness: 11%

incoordination or abnormal movement◦ Blindness: 11%

Prenatal (70%) Haemorrhage / bleeding High or low BP� Prenatal (70%)� Peri-natal (5-10%)� Post natal

� Haemorrhage / bleeding� Infections� Environmental factors� Rh incompatibility� Diabetesduring pregnancy� Genetic causes� Maternal jaundice

� High or low BP� Breech delivery� Trauma i.e forceps or vacuum

delivery� Rapid delivery� Low birth weight� Coagulopathy

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� Brain damage secondary to cerebralhemorrhage

� Trauma� Head injury� Motor vehicle accidents� Seizures� Meningitis� Encephalitis

� Depending on tone or movementpatterns◦ Spastic◦ Athetoid/ dyskinetic◦ Ataxic◦ Flaccid/ Hypotonic◦ Mixed

It is the most common type of CP, It is mixed muscle tone It is caused by damage to� It is the most common type of CP,occurring in 70% to 80% of all cases.

� The cerebral cortex is affected� Moreover, spastic CP accompanies any

of the other types of CP in 30% of allcases

� It can be monoplegia, diplegia,triplegia, hemiplegia or quadriplegia.

� It is mixed muscle tone� Often show involuntary motions� The damage occurs to extrapyramidal motor

system & pyramidal tract� It occurs in 10% to 20% of all cases� In newborn infants, high bilirubin levels in

blood, if left untreated, can lead to braindamage in certain areas (kernicterus).

� This may also lead to Athetoid CP

� It is caused by damage tocerebellum

� They are least common types ofCP, occurring only in 10% of all cases

� Some of these individuals havehypotonia and tremors

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� Hypotonic CP have musculature that islimb, and can move only a little or not atall (Floppy child)

� The location of damage is wide spread inthe CNS

� Although physical therapy is usuallyattempted to strengthen muscles it is notalways fundamentally effective.

� Signs & symptoms of spastic CP isseen with any other type of CP◦ Most commonly mixed with Athetoid

� Abnormal behaviour� Poor eye contact� Poor sleep� Irritability� Poor sucking� Tongue retraction� Poor head control� Abnormal tone� Scissoring gait

� Routine check up for mother during pregnabeneficial for the mother & the foetus Starts in the immediate neonatal� Posture and balance problems

� Loss of control and coordination� Abnormal tone� Abnormal strength� Abnormal reflexes� Persistent motor delay� Cognitive defect

Routine check up for mother during pregnabeneficial for the mother & the foetus

� Health education◦ Diet advice (avoid tobacco & alcohol)◦ Exercise on prescription◦ Sleep & working habitsClinical examination1. Breast condition2. Height of uterus

� Starts in the immediate neonatalperiod & during the first two years◦ To find biochemical defects◦ Hearing & visual problems

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� The diagnosis of CP depends onpatient's history & on the basis ofsignificant delay in gross & fine motorfunction, with abnormalities in tone,posture, & movement on neurologicalexamination.

� Once diagnosed with CP, furtherdiagnostic tests are optional.

� MRI is preferred over CT scan due todiagnosticyield & safety.

� The CT scan or MRI also revealstreatable conditions, such ashydrocephalus, AVM, subdural hematomasetc.

� Diagnosis, classification, & treatment areoften based on abnormalities in tone

� Medical� Surgical� Rehabilitative

diagnostic tests are optional.

� Dorsal rhizotomy reduces spasticitySubjective Examination:� Common medicines used are antispasmodics.

They relax tight muscles and reduce muscle spasm like:- Diazepam, baclofen, etc.

� If child gets epileptic seizures then anti epileptic medicines such as phenytoin, carbamazepine, valprolate

� Dystonic CP or CP with involuntary movements may need anti cholinergic drugs like carbidopa- levodopa, glycopyrrolate

� Dorsal rhizotomy reduces spasticity� Joint & Tendon release most often performed on

hips, knees, & ankles.� The insertion of a baclofen pump usually during

young adolescence.◦ usually placed in left abdomen - a pump that is

connected to spinal cord,◦ sends bits of Baclofen to relax muscle

� Bony correction E.g. femur (termed femoralanteversion or antetorsion) & tibia (tibial torsion).

� Subjective Examination:◦ Obtained from parents especially mother

or from relatives and through case-sheet.◦ General details includes� Name� Age & Sex� Address� When did the mother first noticed the

dysfunctions◦ Siblings having same type of symptoms

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� History◦ Review of complications of pregnancy &

delivery, birth weight, gestation, anyneonatal & perinatal difficulties,feeding problems, and other health-related problems◦ Developmental milestones

� Prenatal History◦ Age of mother◦ Consanguity marriage◦ Any drugs taken during pregnancy◦ Any trauma & stress◦ Any addiction – smoking or alcoholism◦ History of TORCH infection◦ History of previous abortions, still born or death

after birth◦ Multiple pregnancies◦ Status & cast of the mother

� Perinatal History◦ Place of delivery◦ History preterm or post-term delivery◦ History of asphyxia at birth◦ History of prolonged labour pain◦ Type of delivery (Forceps, vacuum

delivery)◦ Presentation of child (Breech)◦ Condition of mother at the time of

delivery◦ Status & cast of the mother delivery

Postnatal History Behaviour of the child Other observations� Postnatal History◦ Delayed birth cry◦ Weightof the child at birth◦ History of trauma to brain during the first 2 years of life◦ History of neonatal

meningitis, jaundice, hypoglycemia, Hydrocephalus orMicrocephaly

◦ Nutritional habits of the child (malnutrition), Feeding difficulties◦ Any medical, surgical or physiotherapy treatment taken before◦ What treatment was used?◦ Was the treatment effective or not?◦ What was the ability level of child at that time?◦ What obstructs the child from progress?

� Behaviour of the child◦ Whether child is alert, irritable or fearful in the

session orduring particular activities◦ Child becomes fatigued easily or not during activity◦ What motivates his action – particular situation,

person or special plaything� Communication of the child◦ With the parents◦ Whether child initiates or responds with gestures,

sounds, hand or finger pointing, eye pointing or useswords and speech

� Other observations◦ Involuntary movements◦ Deformities & contracture◦ Scar may be present◦ Trophic changes may also be seen due to

poor positioning◦ Postural faults◦ Gait abnormalities◦ Use of external appliances

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◦ Position of the child� Which position does the child prefer to be in?� Can child get into that position on his own or

with help?� With assistance, child makes any effort to go in

that position� Symmetry of the child (actively or passively

maintained)� If involuntary movements present, then in which

positions these movements are decreased orincreased

◦ Postural control & alignment� How much parental support is given� Proper & equal weight bearing� If the child’s center of gravity appears to be

unusually high, resulting in floating legs andpoor ability to raise head against gravity

� Fear of fall in child due to poor balance

◦ Use of limbs & hands� Limb patterns in changing or going into position

as well as using them in position◦ Attitudes of limbs during playing & in all

positions� Whether one or both hands are used, type of

grasp and release� Accuracy of reach and hand actions� Any involuntary movements, tremors or

spasms, which interfere with actions, areincreased spasms, which interfere with actions, arepresent

◦ Sensory aspects ◦ Deformities Sensory Assessment◦ Sensory aspects� Observe child’s use of vision, hearing, of

touch, smell and temperature in relevant tasks� Does child enjoys particular sensations� Whether child enjoys being moved or having

position changed◦ Form of Locomotion� How child is carried� Any use of wheelchair or walking aids� Which daily activities motivates child to

roll, creep, crawl, bottom shuffle or walk

◦ Deformities� Any part of body, which remains in particular position in all

postures & in the movements� The positional preferences typically seen in spastic cerebral

palsies are for mid positions of body –� In the UL� Shoulder protraction or retraction, adduction and internal rotation,

Elbow flexion, Forearm pronation, Wrist & Fingers flexion� In the LL� Hip semi-flexion, internal rotation and adduction, Knee semi-flexion,

Ankle plantar flexion, Foot pronation or supination, Toes flexion� Athetoid or dystonic posturing usually incorporates

extremes of movement such as total flexion or extension� Windswept Deformity of hip – One hip flexed, abducted and

externally rotated; other hip flexed, adducted and internallyrotated and in danger of posterior dislocation

� Sensory Assessment◦ It is difficult to assess sensation in

babies and young children with severemultiple impairments.◦ If any hearing or visual or psychological

abnormalities are present thenassessment done by specialist is required

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� Motor integrity◦ Abnormalities of tone� Spasticity, hypotonicity, dystonia etc◦ Muscular weakness◦ Loss of voluntary control◦ Decreased co ordination

� Reflex integrity◦ Abnormal DTR◦ Abnormal Superficial reflexes◦ Abnormal primitive reflexes may be

persistent� Extensor thrust, gallant reflex etc

� ROM & flexibility◦ Decreased in the ROM of the involved

limbs◦ Tightness & contracture in hip

adductors, hamstrings, calf are verycommon

Developmental milestones 10 to 11 months Creeps 13 months Feeds self with spoonDevelopmental milestones� Age Developmental Milestones

Social smileHead holdingSits with supportSits without supportReaches out for bright object & gets itTransfers object from one hand to otherStarts imitating coughCrawls

� 4 to 6 weeks� 3 months� 6 months� 7 months� 5 to 6 months� 6 to 7 months� 6 to 7 months� 8 to 10 months

� 10 to 11 months� 9 months� 12 months� 10 to 11 months� 13 months� 12 months� 13 months� 15 to 18 months

CreepsStanding holding furnitureWalks holding furnitureStands without supportWalks without much of a supportSays one word with meaningSays three words with meaningJoints 2 or 3 words into sentence

� 13 months� 15 to 18 months� 15 to 18 months� 24 months� 24 months� 3 to 4 years� 2 years� 3 years� 3 years� 3 years

Feeds self with spoonClimbs stairTakes shoes and socks offPuts shoes and socks onTakes some clothes offDresses self fullyDry by dayDry by nightKnows full name and sexRides tricycle

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GOALS OBJECTIVES OF REHAB.

� Improve mobility

� Prevent deformity

� Educate the parents

� Teach daily living skills� Social integration

� Teach the child to use his remaining potential

� Teach the child functional movement � Gain muscle strength

� Decrease spasticity� Improve joint alignment

� To set reasonable expectations� Do the exercises at home

� Have the child participate in daily living activities

� Provide community and social support

� Family education� Handling & care� Promote infant & parent interaction� Encourage development of functional

skills & play� Promote sensory motor development� Establishhead & neck control� Attain & maintain upright position

Facilitate sensory-motordevelopment (body image)

� Reaching, rolling, sitting, crawling &transitional movements like standing &pre walking are facilitated◦ Promotes spatial perception, body awareness

& mobility, facilitate play, social interaction& exploration of environment

� Use of equipments that facilitatesfunction when impairment is preventingdevelopment E.g. sitting on adaptedchair

� Attain & maintain upright position development E.g. sitting on adaptedchair

Practice midline play, reach for� Practice midline play, reach forfeet, suck on fingers

� Do not give too many stimuli at once� Carefully introduce different surfaces

for child to roll on, creep, crawl, & walkon with bare feet

� Always give child time to experiencetactile & auditory stimuli & let him reach& find out about himself wheneverpossible

Facilitatingmotordevelopment

Postural stability of the head when Acceptance of prone position.development� Postural stability of the head when◦ lying prone (0-3 months)◦ on forearms (3 months)◦ on hands and on hands and knees (6

months),◦ during crawling, half-kneeling hand

support (9-11 months)◦ in the bear-walk (12 months) in normal

developmental levels.

� Acceptance of prone position.◦ Accustom child to prone� on soft surfaces, sponge rubber, inflatable

mattress, in warm water, over large softball, over your lap

� rock and sway a baby held in pronesuspension.

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� Postural stability of the shoulder girdle◦ weight on forearms (3 months),◦ on hands (6 months),◦ on hands & knees & arms held stretched forward

along the ground to hold a toy at 5-6 months alsoinclude postural stability.

� Pivot prone with arms held extended in airactivates stabilizers (8-10 months).

� Maintenance of half-kneeling lean or uprightkneeling (lean on hands) or grasp a support -9-12 months stimulates shoulder girdlestability

� Postural stability of pelvis◦ On knees with hips at right angles (4

months)◦ on elbows & knees & on hands and knees

(4-6 months),◦ on half-kneeling and upright kneeling

with support (9-12 months) in normalmotor levels.

Maintaining anupright position� Use of adapted chairs & standing

frame� Use of orthosis can be delayed until

some voluntary movement is gained� Sitting on swiss ball, vestibular board

etc can be given to improvechallengesstability motor levels.

Main aim is to reduce the primary � Ambulatory children with CP have� Main aim is to reduce the primaryimpairments & prevent thesecondary impairments

� Creating demands in both concentric& eccentric work◦ Transitional movements against gravity,

ball gymnastics etc.� If a child has some voluntary control

in muscle group, capacity forstrengthening exists

� Use of electrical stimulation orby strengthening withinsynergistic movement patterns

� Ambulatory children with CP havecapacity to strengthenmuscles, although poor isolated controlor inadequate length

� To participate in a strength-trainingprogram, child must be able tocomprehend & to consistently producea maximal or near-maximal effort

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� Positioning in anti synergistic pattern� Stretching of tight structures� MFR� ROM exercise� Rhythmic rotations� Splinting & serial casting� Dorsal rhizotomy� Botox injection

� ROM exercise� Maintain length of muscle by

regular stretching & splinting◦ Prolonged stretching of 6 hours a day with

the threshold at which the muscle beganto resist a stretch

� Strengthening exercise of primemovers of a joint

� Serial Casting techniques� Orthosis & night splints� Lycra splinting & taping techniques◦ Skin reactions should be

carefully assessed� Allignment of the body in a variety

of positions in which they canoptimally function, travel & sleep� Botox injection movers of a joint optimally function, travel & sleep

Exercise should be intensive, challenging &

Improve ambulatorycapacity� Weight bearing,

Play is the primary productive activity of� Exercise should be intensive, challenging &meaningful & involve integration of skillsinto function

� Movement should be goal oriented & interestingto maintain motivation◦ Kicking a soccer ball

� Feedback is important & feedforward isalso considered

� CIMT also improves function in hemiplegic CP� Oromotor rehabilitation should also be provided

� Weight bearing,promoting dissociation, & improvingbalance

� Walkers & crutches may be used◦ Posterior walkers encourages more upright

posture during gait� Treadmill training or body weight

support treadmill training� Adapted tricycle, wheelchair

or motorized wheelchair may improvemobility in more disabled

� Play is the primary productive activity ofchildren it should be motivating &pleasurable

� Motivates social skills, perceptionconceptual, intellectual & language skills

� Appropriate toys & play methodsshould be suggested

� Parents should encourage to let childrenenjoy their typical play activities s/arolling downhill or getting dirty

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� Ankle foot orthoses� Knee ankle foot orthoses� Hip abduction orthoses� Thoracolumbosacral orthoses� Supramalleolar orthoses� Foot orthoses� Hand splints

1. REFLEX THEORY ( Sherrington 1906)•Movement is controlled by stimulus –response.•Reflexes are basis for movement - Reflexes are combined into actions that create behavior.

•CLINICAL IMPLICATIONS-Use sensory input to control motor output-Stimulate good reflexes-Inhibit undesirable (primitive) reflexes-Rely heavily on Feedback

2. DYNAMIC SYSTEM THEORY� Movement emerges to control degrees of freedom.� Patterns of movements self-organize within the characteristics of environmental

conditions and the existing body systems of the individual.� Functional synergies are developed naturally through practice and experience and

help solve the problem of coordinating multiple muscles and joint movements at once.

� De-emphasize commands from CNS in controlling movement and emphasize physical explanations for movement.

� CLINICAL IMPLICATIONS� Movement is an emergent property from the interaction of

multiple elements.� Understand the physical & dynamic properties of the body - i.e.

Velocity- important for dynamics of movement. May be good to encourage faster movement in patients to produce momentum and therefore help weak patients move with greater ease.and therefore help weak patients move with greater ease.

2. HIERRARCHIAL THEORY� Cortical centers control movement in a top-down

manner throughout the nervous system.

3. MOTOR PROGRAM THEORY� Adaptive, exible motor programs (MPs) and

generalized motor programs (GMPs) exist to

4.ECOLOGICAL THEORY� The person, the task, and the environment interact to in uence motor behavior and

learning. The interaction of the person with any given environment provides perceptual information used to control movement.manner throughout the nervous system.

� Closed-loop Mode: Sensory feedback is needed and used to control the movement.

� Voluntary movementts initiated by “Will” (higher levels). Reflexive movements dominate only after CNS damage

CLINICAL IMPLICATION� Identify & prevent primitive reflexes� Reduce hyperactive stretch� Normalize tone� Facilitate “normal” movement patterns� Developmental Sequence� Recapitulation

generalized motor programs (GMPs) exist to control actions that have common characteristics.

� Higher-level Motor Programs - Store rules for generating movements.

CLINICAL IMPLICATIONS� Abnormal Movement - Not just reflexive, also including

abnormalities in central pattern generators or higher level motor programs.

� Help patients relearn the correct rules for action� Retrain movements important to functional task� Do not just reeducate muscles in isolation

perceptual information used to control movement.� The motivation to solve problems to accomplish a desired movement task goal

facilitates learning.CLINICAL IMPLICATIONHelp patient explore multiple ways in achieving functional task → Discovering best solution for patient, given the set of limitations

5.SYSTEM THEORY� Multiple body systems overlap to activate synergies for the production of movements

that are organized around functional goals.� Considers interaction of the person with the environment.� Goal-directed Behavior - Task OrientatedCLINICAL IMPLICATION- identifiable ,functional task

- modify environment context

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