Definition

 A sensorimotor nonprogressive disorder

that affects the control of posture and
movement.
 Lack of oxygen before, during or shortly
after the birth process.
 Congenital c.p and acquired c.p
 Although the brain lesion is
unchanging, from clinical point of
view signs and symptoms do
change together with children’s
development and maturation of the
CNS.
 2.08 per 1000 school
age children in
Euroupin 2002 with
approximately one
third to half of children
with cerebral palsy of
low birth weight.
The classical distribution of
symptoms
Spastic quadriplegia
 All four involved with a mixture of
spasticity & dyskinesia
 Severe motor disability
 Can not sit or walk independently
Spastic diplegia
 Increased tone in the legs but little or
no involvement in the arms.
 Walk with or without aids
 W kneeling posture in preference to
long sitting
Spastic hemiplegia
 Most walk independently
 Wide variation in the function of the
affected arm and hand
Classification according to the
impairment (McCarthy(
 Spastic (70%)
 Dyskinetic (20% - 25%)
 Ataxic (5%– 7%)
 Hypotonic
 Mix
Classification
 Motor type , Cortical lesion
 Dystonic or Atetoid
 Non Progressive Ataxia
 Mixed of spasticity, ataxia, dystonia
 Rigidity
Fay Classification
 Spastic paralysis,non-spastic, atonic
 Atetosis (mid brain)
 Tremor & rigidity (basal ganglia)
 Ataxia
 High spinal (Medulla)
 Mixed
Aetiology
 Birth asphyxia
 Low birth weight
 Hypoxia, vascular accidents, infections
and toxicity
 Familial influences
 Teratogens like toxoplasmosis, rubella,
CMV &herpes simplex
 Iodine deficiency and consanguinity
Functional Mobility scale
1. Uses wheelchair,
stroller or buggy: May
stand for transfers and
may do some stepping
supported by another
person or using a
walker/frame.
FMS
2. Uses K-Walker
or other
walking frame:
without help
from another
person
3. Uses two
crutch: without
help from
another person
4. Uses one
crutch or two
sticks: without
help from
another person
FMS
5.Independent on level surfaces:
does not use walking aids or need
help from another person. If uses
furniture, walls, fences, shop fronts
for support please use 4 as the
appropriate description
FMS
6. Independent on all
surfaces: does not
use any walking
aids or need any
help from another
person when
walking, running,
climbing and
climbing stairs.
 Walking distance Rating (1-6)

Walking 5 meters
(eg, in bedroom or other
room)
Walking 50 meters
(eg, at school, in the
classroom and playground)
Walking 5oo meters
( eg, in the shopping mall or
street)
 GMFC
 5 level system
 Severity of motor involvement based on
age, motor ability and use of assistive
technology
Natural history
 Child below normal size
 Poor motor and cognitive skills
 Deformities of joints and bones
 Associated complications; epilepsy,
visual impairment, musculoskeletal
deformities, growth delay, sleep
disturbance and reduced life expectancy
Epilepsy
 Higher incidences in quadriplegia than
dyskinesia and spastic diplegia esp,
preterm infants
 Epilepsy is linked with an increased risk
of sensory & cognitive impairment
 Seizures lead to developmental
regression
Sensory impairment
 Visual impairment (7% to 9%)
 Visual impairment leads to uncontrolled
trunk and head
 Lack of proprioceptive & tactile system
 Diminished anticipatory control
 Nutritional factors and ability to walk
are significant factors in decreased
bone mineral density
 Difficulty in swallowing and chewing
 Reflux result in aspiration and
consequent chest infection
Sleep disturbance due to:
 Sleep hypoxemia
 Upper airway obstruction
 Decreased melatonin level
 Nocturnal seizures
 Reflux and positional discomfort
Causes of hypoxemia
 Brainstem dysfunction
 Upper airway obstruction (hypertrophy
of tonsils & adenoids
Musculoskeletal deformities in
different types of cerebral palsy
 Imbalances in muscle group
 Deformities of joints and bones
 Osteopororosis in children unable to
walk
Hemiplegia
 Smaller limbs in affected side
 Leg shortening
 Equinus of the foot and ankle
 Flexion of the elbow, wrist and fingers
 Adducted thumb
 Diplegia
 Contractures of the hip flexors & adductors
& hamstrings & calf & internal rotation of
the hip and femoral anteversion
 Hyperextension of the knee to compensate
for tight tendo-achilles
 Kyphosis as a sequel to tight hamstrings
 Hyperlordosis as a compensatory balance
mechanism
Quadriplegia
 Dislocation of hips
 Pelvic obliquity
 Spinal curvature
 Limitation in sitting, standing and
walking and hygiene and personal care
 Windswept deformity
 Joint pain
Gross Motor Function
Classification System
 Level I
Walks without restriction: limitations
to more advanced gross motor skills
 Level II
Walks without assistive devices;
limitations in walking outdoors and in
community
Level III:
Walks with
assistive
devices ;
limitations in
walking
outdoors and in
community
Level IV:

Self-mobility with
limitations;
children are
transported or
use powered
mobility outdoors
and in community
Level V
 Self –mobility is severely limited , even
with the use of assistive technology
 Effects of C.P in life periods
 Birth to 3 years
conservative and non invasive treatment
 Preschool
increasing complications
 School age
social participation
Effects of C.P in life periods
 Maturation
sexual maturation
social acceptance
emphasize on function
 Adulthood
 Senior adult
Medications
 Antiemetrics to control gastric reflux
 Baclofen orally or intrathecally
 Dantrolen sodium
Weakness,
 Tizanidine liver
dysfunction
 Neurolytic blocks
 BTX-A
 Anticonvulsants
Surgical and orthopedic
management
 Release of tendon, muscle or
connective tissue for lengthening
 Bony surgery
 Multilevel surgery at the hip, knee and
ankle
Selective Dorsal rhizotomy
 Devide the posterior nerve rootlets in
the lumbosacral region to reduce lower
limb spasticity
Management assistance
 Holding, Baby carrying
 Positioning
 Daily care
 Orthosis
 Adaptive equipments
 Management
 Assessment of Tone, Motor behavior
pattern, posture, sensory status specially
vision (cataract, congenital glaucoma,
strabismus, visual acuity, blindness,
nistagmus, hemianopia

 Strengthening, coordination, gait,

balance, dexterity
Management
 Comprehensive treatment
 Functional recovery (task-oriented
approach)
 maintenance of physiologic conditioning
Management
 Training of compensatory mechanisms
 Adaptive equipments
 Functional head control
 W.B
 Sitting control
 Serial casting
 Using crutch, walker, cane, shoe insert
NDT Approach
 Handling for abnormal tone and posture
and movement pattern
 Inhibition of abnormal tone and
primitive reflexes
 Facilitating normal movements
 Weight shift & W.B
Vojta approach
 Activation of postural reaction &
equilibrium reaction
 Reaching normal development
 Proprioceptive inputs
Fay (Patterning)
 Breath control
 Neurological organization by
encouraging prone position & creeping
& crawling
 Head rotation for flex, ext of limbs
 Sensory inputs
Rood approach
 Sensory and Motor stimulations
SI therapy
 Jean Ayers
 Sensory processing
 Vestibular, Proprioception, Tactile 9
sensory inputs)
 Learning disabilities
 Other techniques
 PNF, Strengthening spasticity?
 Electrical stimulation for weakness,
spasticity, ROM, voluntary control
 Before 2nd Birthday
 Level I ( Walking Independently)
infants move in & out of sitting and floor
sit with both hands free to manipulate
objects. Infants crawl on hands & knees
,pull to stand & take steps holding on to
furniture. Infants walk between 18 months
and 2 years of age without the need for
any assistive mobility device.
Level II
(Walking with Assistance)
 Infants maintain floor sitting but
may need to use their hands for
support to maintain balance.
Infants creep on their stomach or
crawl on hands and knees. Infants
may pull to stand and take steps
holding on to furniture.
Level III (Roll & Creep)
 Infants maintain floor sitting when
the low back is supported. Infants
roll and creep forward on their
stomachs
Level IV ( just Rolling)
 Infants have head
control but trunk
support is
required for floor
sitting. Infants
can roll to supine
and may roll to
prone.
 Level V (No head Control)
 Physical impairments
limit voluntary control of
movement. Infants are
unable to maintain
antigravity head and
trunk postures in prone
and sitting. Infants
require adult assistance
to roll.
Between 2nd and 4th Birthdays
Level I
Children floor sit with both hands free to
manipulate objects. Movements in and
out of floor sitting & standing are
performed without adult assistance.
Children walk as the preferred method
of mobility without the need for any
assistive mobility device.
 Level II
Children floor sit but may have difficulty with
balance when both hands are free to manipulate
objects. Movements in & out of sitting are
performed without adult assistance. Children pull
to stand on a stable surface. Children crawl on
hands & knees with a reciprocal pattern, cruise
Holding onto furniture and walk using an assistive
mobility device as preferred Methods of mobility.
 Level III
 Children maintain floor sitting often by
“W- sitting” (sitting between flexed & internally
rotated hips & knees) and may require adult
assistance to assume sitting. Children creep on
their stomach or crawl on hands and knees
(often without reciprocal leg movements) as their
primacy method of self- mobility. Children may
pull to stand on a stable surface and cruise short
distances. Children may walk short distances
indoors using an assistive mobility device an
adult assistance for steering and turning.
 Level IV
 Children sit on a chair but need adaptive seating
for trunk control and to maximize hand function .
Children 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. Children may
best walk short distances with a walker and adult
supervision but have difficulty turning &
maintaining balance on uneven surfaces. Children
are transported in the community. Children may
achieve self- mobility using a power wheelchair.
Power wheelchair
 Level V
 Physical impairments resist voluntary control of
movement and the ability to maintain antigravity
head &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 & assistive
technology. Children have no means of
independent mobility and are transported. Some
children achieve self-mobility using a power
wheelchair with extensive adaptations.
 Between 4th and 6th Birthdays

 Level I: Children get into & out of, and sit

in, a chair without the need for hand
support. Children move from the floor &
from chair sitting to standing without the
need for support. Children walk indoors &
outdoors, and climb stairs. Emerging ability
to run & jump.
 Level II
 Children sit in a chair with both hands free
to manipulate objects. Children move from
the floor to standing and from chair sitting
to standing but often a stable surface to
push up with their arms. Children walk
without the need for any assistive mobility
device indoors and for short distances on
level surfaces outdoors. Children climb
stairs holding onto a railing but are unable
to run or jump.
 Level III
 Children sit on a regular chair but may
require pelvic or trunk support to maximize
hand function .Children move in & out of
chair sitting using a stable surface to push
on or pull up with their arms. Children walk
with an assistive mobility device on level
surfaces and climb stairs with assistance
from an adult. Children frequently are
transported when traveling for long
distances or outdoors on uneven terrain.
 Level IV
 Children sit on a chair but need adaptive seating
for trunk control & to maximize hand function.
Children move in & out of chair sitting with
assistive an adult or a stable surface to push or
pull up on with their arms. Children may at best
walk short distances with a walker and adult
supervision but have difficulty turning and
maintaining balance on uneven surfaces. Children
are transported in the community. Children may
achieve self-mobility using a power wheelchair.
 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. Children have no means of
independent mobility & are transported. Some
children achieve self- mobility using a power with
extensive adaptations.
Manual Ability Classification
System for Children with
Cerebral Palsy
4-18 years
March 2005
 MACS
1. Handles objects easily and
successfully.
At most, limitation in the ease of
performing manual tasks requiring speed
and accuracy. However , any limitation in
manual abilities do not restrict
independence in daily activities.
 MACS
2. Handles most objects but with
somewhat reduced quality and/or
speed of achievement.
Certain activities may be avoided or be
achieved with some difficulty; alternative ways
of performance might be used but manual
abilities do not usually restrict independence in
daily activities.
 MACS
3. Handles objects with difficulty;
needs help to prepare and/or
modify activities.
The performance is slow and achieved with
limited success regarding quality and
quantity. Activities are performed
independently if they have been set up or
adapted.
 MACS
4. Handles a limited selection of
easily managed objects in adapted
situations.
Performs parts of activities with effort and
with limited success. Requires continuous
support and assistance and/or adapted
equipment, for even partial achievement of
the activity.
MACS
5. Does not handle objects and
has severely limited ability to
perform even simple actions.

Requires total assistance

Morbidity
 Those children with severe spastic
quadriplegia and poor nutritional status
have been shown to have a high risk of
dying
 The most common cause of death for
those at high risk was respiratory
problems(59%),with epilepsy as the
second most common cause of death.
 Mortality risk increased with increasing
intellectual impairment, motor
impairment & number of severe
impairment.
 With the exception of those children
with profound learning difficulty, most
children with c.p can expect survive into
adulthood.
Risks for severe types
 Osteopenia & osteoporosis
 Fractures may be caused by:
 Joint contracrure
 poor nutrition
 hip dislocation
 immobilisation
 Learning disabilities
 Behavioural difficulties
 Epilepsy
 Sensory difficulties
 Hydrocephalus
 Eating & swallowing problems
 gastroesophageal reflux
 Speech & language difficulties
 Problem with manual dexterity
Impairments, Functional limitation, and focus
of treatment in children with spasticity

Impairments Functional Treatment

limitations focus
Increased Stereotypical Decrease
muscle movement stiffness, head
stiffness, slow , patterns, poor & trunk righting
labored static & & equilibrum &
movement dynamic protective
balance; reactions,
postural
insecurity,
continue
impairments Functional treatment
limitations focus
Decreased poor Practice mvt
trunk Rotation movement transitions like,
transitions trunk rot,
rolling, come
to sit &
walking
Decreased Reaching, Mvt in all
ROM walking ranges,
variation
 continue
Impairment Functional Treatment focus
limitations
Skeletal Scoliosis, Position properly
malalignment musculoskeletal for function; use
Muscle deformities. orthoses,
weakness Movements Strengthen
Inaccurate against gravity, through mvt
muscle Inefficient experiences, use
recruitment movement ; novel
high energy cost environment
Influence of Tonic Reflexes on
Functional movement
Tonic Reflex Impairment Functional
Movement
Limitation
TLR in supine Contractures Rolling from
Abnormal supine to
Vestibular prone,
input Reaching in
Limited visual supine, coming
field to sit, sitting
Tonic Reflex Impairment Functional
Impairment Movement
Limitation
TLR in prone Contractures, Rolling from
Abnormal prone to
vestibular supine,
input, Limited Coming to sit,
visual field sitting
ATNR Contractures Segmental
Hip dislocation rolling,
Trunk reaching,
asymmetry, Bringing hand
scoliosis to
mouth,sitting
Tonic Reflex Tonic Reflex Functional
Movement
Limitation
STNR Contractures, Creeping,
lack of upper & kneeling,
lower Walking
extremity
dissociation,
lack of trunk
rotation
Impairments Functional Treatment
limitation focus in
children with
Athetosis

Low or Potural Hold postures,

fluctuating instability ; cocontraction
muscle tone- poor balance & in midline,
Wide , safety, poor mvt control &
incoordinated transitions; direct mvt with
movements Unsafe mvt resistance;resis
t reciprocal
mvts
Impairment Functional Treatment focus
limitation

Lack of Reaching, Hold in midrange;

midrange walking work in small
control increment of
range
Lack of use Poor Weight bearing
of hands for movement through arm;use
support transitions; upper extremity
unsafe weight bearing for
movement safe movement
transitions
Impairment Functional Treatment
limitation focus

Lack of graded Difficulty Facilitating

movement grasping; shoulder
changing position;
positions stabilize trunk
or opposite
extremity
Emotional Poor Modify
Lability judgement of behavior
balance risk
Predictors of ambulation for
cerebral palsy
Predictor Ambulation
Potential
By diagnosis: 100%

Monoplegia 100%
Hemiplegia 100%

Ataxia
85-90%
Diplegia 0-70%
Predictor Ambulation
By motor function Potential
Sit independently by 2 years 100%

Sit independently by 3-4 years 50%

community
ambulation
Presence of primitive poor
reactions beyond 2 years
Absence of postural reactions poor
beyond 2 years
Independently crawled
symmetrically or reciprocally 100%
by 2 & half- 3 years