CEREBRAL PALSY

TYPES
-Spastic-w/ stiff & contracted muscles, jerky movements diplegia(affected: 2 UE or 2 LE), quadriplegia (affected:4 limbs);hemiplegia(affected: half of body) ,monoplegia(1 limb affected, UE or LE), triplegia (affected:2 LE and 1 UE or 2 UE and 1 LE) -Ataxic-muscles are too weak, shaky & unsteady movements. -Athetoid-slow writhing movements

4 TYPES OF BRAIN DAMAGE THAT CAUSE ITS CHARACTERISTICS 1. Damage to the white matter of the brain Periventicular Leukomalacia (PVL)- white matter of the brain that is responsible for transmitting signals inside the brain. 2. Abnormal development of the brain (cerebral dysgenesis) 3. Bleeding in the brain it sometimes caused by head trauma or injury. 4. Brain damage caused by lack of O2 in the brain.

EMBRYONIC & FETAL DEVT.

-it is not detected at this stage -it is not inherited-- acquired or congenital - happens during fetal devt , during or after birth (because of multiple reasons like genetic abnormalities, maternal infections, fever or fetal injury) ACQUIRED CEREBRAL PALSY- if the baby had brain infections such as bacterial meningitis or viral encephalitis, head injury or child abuse CONGENITAL CEREBRAL PALSY- detected until months or years later because of complications RISK FACTORS: (it is not inevitable but it does increase the chance of cerebral palsy) CAUSES OF CP: PRENATAL - Rubella (german measles) -Cytomegalovirus(mild viral infection-herpes) -toxoplasmosis (infection caused by parasite that can be carried in Cat feces or inadequate cooked meat) - Blood Incompatibility- Rh dse-. - incompatibility bet. the blood of the mother and baby -Chorioamnionitis (maternal infections involving the placental Membrane) -UTI (preterm delivery) - Mothers with thyroid abnormalities, mental retardation or seizures -. Exposure to toxic substance- because of inhalation of the mother to substance like methylmercury PERINATAL - Complicated labor and delivery - Asphyxia During Labor and Delivery- lack of oxygen due to breathing problems or a poor oxygen supply. - Breech Presentation- feet or buttocks first during delivery or at the beginning of the delivery - awkward birth position - labor that goes on too long or is too abrupt -interference with the umbilical cor POSTNATAL - Low birth weight & Premature birth- higher risk among babies who weigh less than 5 lbs or less than 37 weeks into pregnancy -Small for Gestational age -Low APGAR SCORE - cerebral infection and febrile convulsions in infancy -Jaundice- their bile builds up bilirubin faster than their livers can break it down. Kernicticus- it kills the brain cells and can cause deafness and CP; a form of brain damage caused by excessive jaundice

PHYSICAL DEVELOPMENT
-Delayed growth and development.- A syndrome called failure to thrive is common in children with moderate-to-severe cerebral palsy, especially those with spastic quadriparesis. -Failure to thrive-use to describe children who lag behind in growth and development. -In babies - this lag usually takes the form of too little weight gain -In young children- it can appear as abnormal shortness. -In teenagers - may be short for their age and may have slow sexual development. -Muscles and Limbs are Shortened - especially noticeable in children with spastic hemiplegia because limbs on the affected side of the body may not grow as quickly or as long as those on the normal side. -Scoliosis, or spine curvature can develop-when the muscles that hold the spine in place become either weak or spastic. In either case, an imbalance of forces pulls the vertebrae out of alignment; can cause pain,interfere with normal posture and internal organ function. -Slender-because these children cant eat normal and has poor nutrition.

MOTOR DEVELOPMENT
*1-2 years old Level I: in and out of sitting ; floor sit with both hands free to manipulate objects; crawl on hands and knees;pull to stand and take steps holding on to furniture; walk between 18 months and 2 years of age without the need for any assistive mobility device. Level II: floor sitting but may need to use their hands for support to maintain balance; creep on their stomach or crawl on hands and knees; pull to stand and take steps holding on to furniture. Level III: maintain floor sitting when the low back is supported; roll and creep forward on their stomachs. Level IV: have head control but trunk support is required for floor sitting; roll to supine and may roll to prone. Level V: Physical impairments limit voluntary control of movement- unable to maintain antigravity head and trunk postures in prone and sitting; require adult assistance to roll. *2-4 years old Level I: floor sit with both hands free to manipulate objects. Movements in and out of floor sitting and standing are performed without adult assistance. Children walk as the preferred method of mobility without the need for any assistive mobility device.

Level II: floor sit but may have difficulty with balance when both hands are free to manipulate objects. Movements in and out of sitting are performed without adult assistance; pull to stand on a stable surface; crawl on hands and knees with a reciprocal pattern, cruise holding onto furniture and walk using an assistive mobility device as preferred methods of mobility. Level III: maintain floor sitting often by "W-sitting" ;require adult assistance to assume sitting; creep on their stomach or crawl on hands and knees (often without reciprocal leg movements) as their primary methods of self mobility; pull to stand on a stable surface and cruise short distances;walk short distances indoors using an assistive mobility device and adult assistance for steering and turning. Level IV: floor sit when placed,;unable to maintain alignment and balance without use of their hands for support; require adaptive equipment for sitting and standing. Self mobility for short distances (within a room) is achieved through rolling, creeping on stomach, or crawling on hands and knees without reciprocal leg movement. Level V: Physical impairments restrict voluntary control of movement and the ability to maintain antigravity head and trunk postures. All areas of motor function are limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment and assistive technology; have no means of independent mobility and are transported. Some children achieve self-mobility using a power wheelchair with extensive adaptations. *4-6 years old Level I: get into ,out of,and sit in a chair without the need for hand support;move from the floor and from chair sitting to standing without the need for objects for support; walk indoors and outdoors, and climb stairs. Emerging ability to run and jump. Level II: sit in a chair with both hands free to manipulate objects; move from the floor to standing and from chair sitting to standing but often require a stable surface to push or pull up on with their arms; walk without the need for any assistive mobility device indoors and for short distances on level surfaces outdoor; climb stairs holding onto a railing but are unable to run or jump. Level III: sit on a regular chair but may require pelvic or trunk support to maximize hand function;move in and out of chair sitting using a stable surface to push on or pull up with their arms; walk with an assistive mobility device on level surfaces and climb stairs with assistance from an adult; frequently are transported when travelling for long distances or outdoors on uneven terrain. Level IV: sit on a chair but need adaptive seating for trunk control and to maximize hand function;move in and out of chair sitting with assistance from an adult or a stable surface to push or pull up on with their arms;may at best walk short distances with a walker and adult supervision but have difficulty turning and maintaining balance on uneven surfaces; transported in the community;achieve self-mobility using a power W/C. Level V: Physical impairments restrict voluntary control of movement and the ability to maintain antigravity head and trunk postures. All areas of motor function are

limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment and assistive technology. Level V: have no means of independent mobility and are transported. Some children achieve self-mobility using a power wheelchair with extensive adaptations. *6-12 years old Level I: walk indoors and outdoors; climb stairs without limitations; perform running and jumping but speed, balance, and coordination are reduced. Level II: walk indoors and outdoors;climb stairs holding onto a railing but experience limitations walking on uneven surfaces and inclines; walking in crowds or confined spaces; have at best only minimal ability to perform gross motor skills such as running and jumping. Level III:; walk indoors or outdoors on a level surface with an assistive mobility device;climb stairs holding onto a railing. Depending on upper limb function, children propel a wheelchair manually or are transported when travelling for long distances or outdoors on uneven terrain. Level IV: maintain levels of function achieved before age 6 or rely more on wheeled mobility at home, school, and in the community; self-mobility using a power W/C. Level V: Physical impairments restrict voluntary control of movement and the ability to maintain antigravity head and trunk postures. All areas of motor function are limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment and assistive technology. At level V, children have no means of independent mobility and are transported. Some children achieve self-mobility using a power wheelchair with extensive adaptations.

REFLEX DEVELOPMENT
Commonly Elicited Reflexes: -Asymmetric Tonic Neck Reflex- dyskinesia -Symmetric Tonic Neck Reflex-dyskinesia -Moro Reflex - dyskinesia -Positive Supporting Reaction-spasticity -Tonic Labyrinthine-spasticity - Palmar Reflex-spasticity -Plantar Reflex -Extensor Thrust Reflex at rest

COGNITIVE DEVELOPMENT
-CP patients have 40% cognitive delay -very distractible -learning disabilities( hemiplegic is more prone to cotical brain injury, next is quadriplegic, then diplegic) -have abnormal touch sensitivity. -mental impairment most common in spastic quadriplegia; 1/3 of population with CP= mild mental impairment; 1/3 = moderate to severe; 1/3 = have normal intellectual functioning.

PERSONALITY DEVELOPMENT
-Mental Retardation -Emotionally Unstable -Behavioral Problems CAUSES OF BEHAVIORAL PROBLEMS

-Frustration-When a child has difficulty completing a task, they become discouraged and angry. - inability to communicate -Attention deficit disorder, or ADD ADD symptoms may include -Be easily distracted, miss details, forget things, and frequently switch from one activity to another -Have difficulty focusing attention on organizing and completing a task or learning something new -Not seem to listen when spoken to -Have difficulty processing information as quickly and accurately as others -Struggle to follow instructions Other behavioral problems: mood swings ,occasional aggression,hair pulling &biting

SOCIAL DEVELOPMENT
- young adults are less socially active, have fewer romantic relationship, may experience social isolation(keep apart from others) and have difficulties in socializing with others. Emotional Problems: distress, frustrated, angry, sad, poor self esteem, negative self-image.

SPEECH & LANGUAGE DEVELOPMENT

-child interactions, baby's language and communicative skills fail to develop -fails to develop a communicative understanding with parents -understanding of language fails to develop -In the absence of an understanding of language, the child also fails to produce language. -In other cases, where some appropriate but incomplete interaction has taken place between parents and baby, a partial understanding of language develops, with little or no production of language. -experiencing sensory distortions - adversely affect the functioning of several structures within the brain, which are responsible for the processing of incoming sensory information from the environment -auditory development - the child's ability to process sound is poor, then his language development will be poor. If his ability to process sounds is non existent, his language development is likely to be non existent. -successful sensory reception leading to successful motor output -injury to the left hemisphere of the cortex, around the regions known as Wernicke's area: responsible for our ability to understand language) and Broca's area: responsible for our ability to produce language). -ability of his brain to process information is slowed down -not be able to process the content of meaning of of interaction quickly enough and if he does, he might be unable to respond quickly enough

-provides hot packs ,stretching activities , Strengthening activities - use TheraSuit while walking on treadmill or doing balance activities or standing. -children are progressed to doing activities in the cage or spider, using the resistance of the bungees and the assistance of the bungees to do jumping, bounce activities, inversion exercises. -TheraSuit-Re-trains CNS; Provides external stabilization; Normalizes muscle tone; Aligns the body to as close to normal as possible; Provides dynamic correction; Corrects gait pattern; Provides tactile stimulation; Influences the vestibular system; Improves balance and coordination; Decreases uncontrolled movements in ataxia and athetosis; Improves body and spatial awareness ; Supports weak muscles; Provides resistance to strong muschles to further increase strengthening; Promotes development of fine and gross motor skills (94%); Improves bone density; Helps improve hip alignment through vertical loading over the hip joint. - program for children with CP 2-4 weeks intensive exercise program. - Aquatic Therapy- exercise program that is performed in the water. Patient is immersed in water and is able to perform exercises. -uses the physical properties of water to assist in patient healing and exercise performance -- Buoyancy (Water reduces the pressure on bones and joints which enables the patients to move freely this benefits the patient by strengthening muscle tone, improving coordination and increasing endurance; Viscosity (provides an excellent source of resistance that can be easily incorporated into an aquatic therapy exercise program. This resistance allows for muscle strengthening without the need of weights. Using resistance coupled with the waters buoyancy allows a person to strengthen muscle groups with decreased joint stress that can not be experienced on land; Hydrostatic Pressure(decrease swelling and improve joint position awareness. The hydrostatic pressure produces forces perpendicular to the bodys surface. This pressure provides joint positional awareness to the patient. As a result, patient proprioception is improved. This is important for patients who have experienced joint sprains, as when ligaments are torn, our proprioception becomes decreased. The hydrostatic pressure also assists in decreasing joint and soft tissue swelling that results after injury or with arthritic disorders; Warmth of the water (assists in relaxing muscles and vasodilates vessels, increasing blood flow to injured areas. Patients with muscle spasms, back pain, and fibromyalgia find this aspect of aquatic therapy especially therapeutic) -Hippotherapy-is a greek word meaning treatment with the help of a horse; improves balance, posture, mobility and function for children with cerebral palsy, autism and down syndrome. -The warmth of the horse stimulate the muscle; The movement of the horse simulates human walking.

POSSIBLE TX PROGRAM
-Intensive Therapy Program-3 hours a day, 5 days a week, for 2-4 weeks ; designed to stretch and strengthen muscles & to increase balance and endurance.