CEREBRAL PALSY

Sagar Naik, PT

Cerebral Palsy Sagar Naik,

PT
Cerebral palsy (CP) is a common cause of childhood disability. It is defined as a group of nonprogressive but often changing motor impairment syndromes secondary to lesions or anomalies of brain arising in early stages of its development. Although the damage is non-progressive, the clinical picture changes as the undamaged nervous system develops and the child grows. It can also be defined as a non-progressive neuromotor disorder of cerebral origin. Cerebral palsy includes a group of heterogeneous clinical syndromes of variable severity ranging from minor incapacitation deficits. Cerebral palsy is a form of chronic motor disability, which is non-progressive, nonfatal and yet noncurable, and results from damage to the growing brain before or during birth, or in postnatal period. It is the commonest cause of crippling in children. Though mental retardation is associated in about 25% to 50% cases of cerebral palsy, it is, by no means, an essential feature of the clinical picture. The other handicaps that the patient may have are epilepsy, orthopedic deformities, partial or complete deafness and blindness, psychologic disturbances, etc.

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Associated Handicaps:

Brain damage in cerebral palsy may also be responsible for special sense defects of vision and hearing, abnormalities of speech & language and aberrations of perception. Perceptual defects or agnosias are difficulties in recognizing objects or symbols, even though sensations are normal. There may be apraxias, some of which are also called visuomotor defects. This means that the child is unable to perform certain movements even though there is no paralysis, because the patterns or engrams have been lost or have not developed. Apraxia can involve movements of the limbs, face, eyes, and tongue or specially restricted to such acts as writing, drawing,

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CEREBRAL PALSY

Sagar Naik, PT

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Prenatal Causes:
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and construction or even dressing. In other words there seems to be problem in motor planning in those children who are apraxic. Cerebral palsied children may also have various behavioral problems such as distractibility and hyperkinesis, which are based on the organic brain damage. All these defects result in various learning problems and difficulties in communication. In addition there may also be various epilepsies or intellectual impairment. Not every child has some or all of these associated handicaps. Even if the handicap were only physical, the resulting paucity of movement would prevent the child from fully exploring the environment. Child is therefore limited in the acquisition of sensations and perceptions of everyday things. A child may then appear to have defects of perception, but these may not be organic but caused by lack of experience. Similarly, lack of everyday experiences retards the development of language and affects the childs speech. His general understanding may suffer so that he appears to be mentally retarded. Lack of movement can affect the general behavior of the child. Thus some abnormal behavior may be due to lack of satisfying emotional and social experiences for which movement is necessary.

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Aetiology (Risk Factors):

Cerebral palsy is a condition with multiple etiologies or predisposing risk factors, which may be antenatal, natal, or postnatal.

Primary causes - Trauma during pregnancy - Infections in mother (Rubella, Cytomegalovirus, Toxoplasmosis) - Maternal infections involving the placental membranes

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CEREBRAL PALSY

Sagar Naik, PT

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Perinatal Causes:

Secondary Causes - Problems of the mother, such as diabetes or toxemia of pregnancy. - Consanguity marriages. Differences between the blood of mother and child (Rh incompatibility) - Age of the mother (Below 20 years & above 40 years pregnant women) - Common habits (Alcoholism, Smoking) - Any drug disorder - Exposure of mother to various toxins

- Premature baby i.e., before 37 weeks of gestation (Preterm infants are much more likely to be brain-damaged both at delivery by trauma, and after because of their immature respiratory and cardiovascular systems making them more likely to develop hypoxia and low blood pressure) - Asphyxia - Knotted umbilical cord around the neck - Multiple deliveries - Forceps delivery (especially high forceps with rotation of the head in the birth canal) - Breech presentation - Partial or absent of cervix dilatation during delivery - Disproportion (babys head or shoulders are too large to pass safely through the birth canal) - Rapid delivery (especially of a preterm infant with a very soft skull) - Lack of oxygen (air) at birth

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- Reproductive or Urinary tract infection - Insufficient oxygen reaching the fetus (when placenta is not functioning properly or it tears away from the wall of the uterus before delivery) - Any condition due to vascular change - Inherited. This is rare, but there is a 'familial spastic paraplegia' - No cause can be found in about 30% of the children

CEREBRAL PALSY

Sagar Naik, PT

Postnatal Causes:
Primary Causes - Delayed birth cry leading to hypoxia - Prematurity - Asphyxia - Neonatal meningitis - Severe jaundice (High level of unconjugated bilirubin in the blood damages the basal ganglia causing athetoid cerebral palsy and high tone deafness) - Hypoglycemia (Low blood sugar for a long period can cause severe brain damage and epilepsy) - Occlusion of internal carotid or middle cerebral artery

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Other Causes:
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Secondary Causes - Brain injuries that occur during the first 2 years of life - Hydrocephalus - Microcephaly - Shaken Baby Syndrome - Very high fever due to infection or dehydration (water loss from diarrhea). It is more common in bottle-fed babies - Lack of oxygen from drowning, gas poisoning, or other causes - Poisoning from lead glazes on pottery, pesticides sprayed on crops, and other poisons

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First child or child fifth or later in the family One of a pair of twins, especially if one twin dies Low birth weight, less than 3.5 pounds Premature infant, less than 37 weeks

Classification:
Physiological Classification:
Spastic (Pyramidal) CP Dyskinetic CP

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CEREBRAL PALSY

Sagar Naik, PT

Topographic Classification:

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Tetrapleia / Quadriplegia Involvement of all limbs. Arms are equally or more affected than the legs. Many are asymmetrical (one more affected) and are called double hemiplegia Diplegic Involvement of limbs, with arms much less affected than legs Triplegia Hemiplegia Limbs on one side affected Monoplegia One limb only affected (very rare)

Classification based on patients status about functional capacity:

Class I No practical limitation of activity Class II Slight to moderate limitation of activity Class III Moderate to gross limitation of activity Class IV Inability to carry on any useful physical activity

Classification based on patients status about therapeutic needs:

Class I Not requiring any treatment Class II Requiring minimal bracing and minimal therapy Class III Requiring bracing and services of a cerebral palsy team Class IV Requiring long-term institutionalization and treatment

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Choreoathetoid (Athetoid) CP Dystonic CP Ataxic CP Hypotonic (Atonic) CP Mixed CP

CEREBRAL PALSY

Sagar Naik, PT

Types:
Spastic Cerebral Palsy:
It is the most common form and accounts for 70% - 75% of cases. It is also known as pyramidal cerebral palsy. Spasticity is a disorder of tone characterized by an initial increased resistance to stretch, which may then lessen abruptly. It is caused by damage to the upper motor neuron in the cortex or along the pathways, which terminate in the spinal cord. Spastic muscles are continuously contracting, and there is apparent weakness of their antagonists leading to abnormal positions of the joints on which they act. Abnormal postures are usually associated with the antigravity muscles, which are extensors in the leg and the flexors in the arm. Deformities of joints develop which may become fixed contractures with time. Changes in spasticity and postures may occur with excitement, fear or anxiety and pain which increase muscle tension. Shifts in spasticity occur in the same affected parts of the body or from one part of the body to another i.e., stimulation of abnormal reactions such as associated reactions or remnants of tonic reflex activity. Changes in spasticity are seen with changes of position in some children. Position of the head and neck may affect the distribution of spasticity. Sudden or fast movements, rather than slow movements, increase spasticity. Co-contraction of the agonist with the antagonist instead of the normal reciprocal relaxation persists in the spastic type. Voluntary movements are directly affected as poor postural control interferes with their efficiency creating weakness of both postural muscles and voluntary synergies. Sensory loss occasionally occurs in hemiplegia with visual field loss and lack of sensation in the hand.

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Sagar Naik, PT

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Spastic Quadriplegia:

Perceptual problems especially of body and spatial relationships are more common in the spastic type. Poor respiration with later rib cage abnormalities ma exist. Feeding problems exist. Upper motor neuron signs characterize it: Clasp knife hypertonia Exaggerated deep tendon reflexes Extensor plantar responses Ankle clonus may be positive Sudden lifting of the child may produce visible adductor spasm and even crossing of the legs, the so-called scissoring Bilateral spasticity may lead to pseudobulbar palsy and resultant swallowing difficulties and excessive drooling Cortical thumb and a firm grasp is common Severely handicapped children may be in a position of opisthotonos Variable degrees of mental and other handicaps and behavioral problems

These patients are severely disabled. All four limbs are affected with upper limbs equally or more affected than lower limbs. Microcephaly Severe mental retardation Pseudobulbar palsies Growth failure Visual and hearing deficits Epilepsy Hypertonicity leading to arching of the back and scissoring of legs Hip subluxation or dislocation may occur Walking is markedly delayed and generally the child has toe walking because of tendo-achilles tightening

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CEREBRAL PALSY

Sagar Naik, PT

Arms are internally rotated, elbows extended or slightly flexed and hands fisted Later, flexion contractures develop at ankles, knees and elbows

Spastic Diplegia:

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Spastic Hemiplegia:

Lower limbs are involved more than upper limbs Deep tendon reflexes are exaggerated and the plantar response is extensor In severe cases, there is delay in walking and there is characteristic shuffling gait with flexion and adduction of the hips and flexion of knees Intellectual involvement is minimal Growth of lower limbs may suffer, whereas upper torso grows normally It is characteristically seen in preterm babies with periventricular leukomalacia The older diplegic child may have poor growth and vasomotor changes in lower extremities

This refers to involvement of one side of the body The arm is usually more severely affected than the leg Right side involvement is more frequent than left Poverty of movements and fisting of hand on affected side Definite hand preference in children less than 12 months of age Child may start sitting and crawling at the normal age but walking is delayed generally by 2 3 months In severe cases, arm is held adducted, flexed and internally rotated at the shoulder, with the elbow flexed, forearm pronated, wrist flexed and thumb adducted. The leg is held adducted, semiflexed at knee and plantar flexed at the ankle

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CEREBRAL PALSY

Sagar Naik, PT

In long standing cases, asymmetries of limb growth may occur

Athetoid (Dyskinetic) Cerebral Palsy:

There is involvement of extra-pyramidal system. This includes the Dystonic and Choreoathetoid forms. The damage is centered on the basal ganglia. Choreoathetosis is most frequently found with damage to the caudate nucleus and dystonia with damage to the globus pallidus. Athetosis are involuntary movements that are bizarre, purposeless movements, which may be uncontrollable. These movements may be slow or fast; they may be writhing, jerky, tremor, swiping or rotary patterns or they may be unpatterned. Choreic movements are rapid involuntary jerks present at rest, which are increased by voluntary movement. Dystonia is a disorder of the muscle tone expressed as postural abnormality, intermittent contractile spasms and complex action dystonias where purposeful movements are deformed. Excitement, any form of insecurity, and the effort to make a voluntary movement or even to tackle a mental problem increase the involuntary motion. Factors, which decrease athetosis, are fatigue, drowsiness, fever, prone lying or the childs attention being deeply held. The child has severe motor disability, with persistent neonatal reflexes. Tremors and rigidity may be present. Asymmetric tonic neck response (ATNR) is prominent. Postural reflexes appear late. Infants are usually hypotonic with marked head lag, drooling of saliva and feeding difficulties. Both hypertonia and hypotonia may exist. Paralysis of gaze movements may occur so that athetoids may find difficult to look upwards and sometimes also to close their eyes voluntary. Athetosis generally manifests after one year of age. It may be present all parts of the body including the face and tongue. It

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CEREBRAL PALSY

Sagar Naik, PT

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Ataxic Cerebral Palsy:
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may only appear in hands or feet or in proximal joints or in both distal proximal joints. Voluntary movements are possible but there may be initial delay before the movement is begun. The involuntary movement may partially or totally disrupt the willed movement making it incoordinated. There is a lack of finer movements and weakness. Flaying of fingers, overflow movements, and facial grimacing are prominent. Some athetoids are unable to maintain weight on their feet and continually withdraw their feet upwards or upwards and outwards, in an athetoid dance. They may take weight on one foot whilst pawing or scraping the ground in a withdrawal motion with the other leg. Standing and walking are delayed. Intelligence is often preserved, but because of severe physical and communicative disabilities, children may appear to have mental retardation. Hearing loss of a specific high frequency is associated with athetoids caused by kernicterus (rare). Emotional lability is more frequent than in other cerebral palsies. Articulatory speech difficulties and breathing problems may be present, and childs oro-motor problems create feeding difficulties.

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Ataxia is caused by damage to the cerebellum or its pathways. There is poor fixation of the head, trunk, shoulder and pelvic girdles. Voluntary movements are present but clumsy or uncoordinated. The child overreaches or underreaches for an object, which is called dysmetria. Infants are hypotonic and inactive with excessive flexibility of joints and poor muscle power. Hyporeflexia Intentional tremor by age of 2 years Walking is delayed Gait is ataxic, and wide-based

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CEREBRAL PALSY

Sagar Naik, PT

Cerebellar signs are present; nystagmus is, however, rare Ataxia may also be associated with spasticity (ataxic diplegia) Intellectual impairment appears, especially in the presence of visual and perceptual problems.

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Site Clinical Features Cerebral Cortex Premotor area Spastic Cerebral Palsy Flaccid Cerebral Palsy Diminished deep tendon reflexes Abnormal elongation of muscle Cerebral Cortex Motor area Cerebral flaccid muscle may be made to contract by confusion on resisted contraction of another muscle If both the motor and premotor areas are affected mixture of spastic and flaccid muscles will result. If the lesion involves the cortex, legs are affected and if lower than the cortex than arms are affected. If on the dominant side of brain, the speech area is affected. Athetoid Cerebral Palsy Expressionless face but involvement of facial muscles Basal Ganglia causes constant grimacing and twitching Stretch reflex is absent

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Clinical Features depending on the Site of Lesion:

CEREBRAL PALSY

Sagar Naik, PT

Cerebellum Pyramidal Lesion

Extra-pyramidal Lesion

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Associated Features:

Eyes Nearly half of the patient may have strabismus, paralysis of gaze, cataracts, coloboma, and retrolental fibroplasias, perceptual and refractive errors. Ears Partial or complete loss of hearing is usual in kernicterus. Brain damage due to rubella may be followed by receptive auditory aphasia. Speech Aphasia, dysarthria and dyslalia are common in dyskinetic individuals. Sensory defects Astereognosis and spatial disorientation are seen in of the patients. Seizures Spastics usually have generalized or focal tonic seizures. Seizures are more common in the disorders acquired postnatally. Intelligence About a quarter of the children may have borderline intelligence; and half of them are severely mentally retarded. Loss of association fibers linking parts of the brain causing learning problems. Emotional problems Early bonding problems may occur, with extreme irritability, poor sleep and feeding problems. The spastic child may be hypersensitive and very anxious. Later

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Ataxic Cerebral Palsy Abnormal reflexes Spasm of adductor muscles producing scissoring gait Brisk stretch reflex Babinski response is positive Athetosis Chorea Dystonia Tremors Rigidity Arm, legs, neck and trunk may be involved

CEREBRAL PALSY

Sagar Naik, PT
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depression may affected children.

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Principle Motor Disorders:

These are the disorders of posture and movement, which justify the diagnosis of cerebral palsy. These can be subdivided into

Positive Signs Negative Signs

Positive Signs:

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Reflexes & Reactions Disorders of muscle tone Asymmetric Tonic Neck Reflex (ATNR) Symmetrical Tonic Neck Reflex (STNR) Tonic Labyrinthine Reflex (TLR) Moro Reflex

These are abnormal or primitive clinical signs, which are often used as diagnostic tests. It includes

Reflexes and reactions can be either those that are seen in normal newborn babies (persistent perinatal reflexes/reactions), or those seen only as a result of brain damage (abnormal or primitive reflexes). These reflexes includes

Associated reactions are also included which results from the inability to isolate the effort of a movement, examples of which are irradiation and grimacing. The disorder of muscle tone is the characteristic that defines the cerebral palsied child by the type of abnormality. There are to types of tones: Intrinsic Tone is specified by the state of reactivity of the stretch reflex, and in the normal child can only be elicited with the tendon tap. Postural Tone is the state of continuous and unfatiguable contraction of postural muscles that is needed to overcome gravity and maintain posture.

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CEREBRAL PALSY

Sagar Naik, PT

Negative Signs:

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Mechanism for Postural Fixation:

Negative signs results from the absence of normal functions, including the stretch reflex, so muscular hypotonia, paralysis and incoordination. The most important negative signs are those due to deficiency of postural reactions, which are as follows: Antigravity Mechanism, which supports the body against gravity. (Antigravity mechanism helps to support the weight of the body against gravity. This rigid pillar is decreased with development of the postural mechanism)

1) Head & trunk erecting mechanisms 2) Counterpoise reactions which prevent the body falling by resisting external & internal forces causing it to pivot about its base (Counterpoising mechanisms are adjustments of the trunk and other body parts of the body so that a movement can be made whilst the person maintains posture or equilibrium) 3) Tilting reactions of head, trunk and limbs as a result of instability of the base of support (Tilt reactions occur when a person is tilted well off the horizontal plane and adjusts his trunk so that he preserves his balance) Protective or Staggering Reactions that protect the upright posture following horizontal displacement of the body. (These reactions in the limbs prevents person from falling over, if the tilt reactions cannot preserve balance also known as parachute reactions) Righting Reactions are those sequences of movement that enable the body to gain or regain the upright position while maintaining balance in the process. (Righting or rising

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In cerebral palsied child these postural tone is decreased, as the postural mechanism is impaired. The child who is very floppy in the early years develops positive signs of athetosis, as he grows older. (Hypertonic child never develops ataxic features throughout life whereas flaccid child may develop ataxic or athetoid features)

CEREBRAL PALSY

Sagar Naik, PT

Complications:

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Management:
Proper management of a child with CP requires a detailed assessment to find out the functional capacity of the child and the nature and extent of the motor as well as associated deficits. This is best done by a multidisciplinary team comprising of Neuro-developmental pediatrician as a team leader Physiotherapist Occupational therapist Clinical psychologist ENT specialist Ophthalmologist Orthopedic surgeon Teacher & Social worker The main aim is to maximize the functional capacity of the child and make him or her as independent as possible through a planned intervention program.

Tightness Spasm Contractures & Deformities Joint Stiffness Irritation and mood swinging (Emotional Sway) Depression Secondary respiratory complications Pressure sores

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reactions make it possible for the person to rise from lying to standing or sitting to standing or many other changes of position) Locomotive Reactions serves to initiate stepping, continue stepping and stop stepping, turning and maintenance of gait. Ocular Postural Responses and control of facial musculature are also interwoven with the postural mechanisms.

CEREBRAL PALSY

Sagar Naik, PT

Involvement of the family is essential for the success of any management plan.

Counselling:
Early counselling of parents is important and difficult. Professionals must explain their plans based on assessment and taking into account the problems and prospects as seen by the family.

Medical Treatment:

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Surgical Treatment:
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Tendon Lengthening Tenotomy (division) of contracted tendon Tendon Transfer Operation

Medical treatment for the cerebral palsy child is symptomatic depending on the symptoms present. The use of drugs in cerebral palsy may be helpful at times, but any prolonged use should usually be unnecessary.

Diazepam Decrease muscle spasm Phenytoin Tension athetosis & generalized seizures Amphetamines Behaviour disturbances & hyperkinesia Spasticity Intrathecal Baclofen Therapy Botulinum Toxin A (BTA)

Surgery is not always necessary, but it is sometimes recommended to improve muscle development, correct contractures, and reduce spasticity in the legs. Aims of surgery: To improve function To decrease pain To correct deformities and stabilize joints To prevent further deformity To improve cosmesis The following are the surgical procedures commonly used:

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CEREBRAL PALSY

Sagar Naik, PT

Neurectomy Stabilization of joints (Arthrodesis) Selective Dorsal Rhizotomy (Spasticity)

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Rehabilitation:
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Splints, Casts & Calipers:

Various simple modifications like angled spoons, two handled cups etc can be made to help the child. A stiff cloth collar with velcro adjustment can be used to help provide neck support. Cloth hammocks can help in keeping the child in a flexed posture. Old stools and boxes can be adapted to provide support during sitting. Parallel bars can be constructed with logs of wood to help gait training. Many such home made modifications can be made to prevent deformities to develop in cerebral palsied child.

Specially designed shoes, AFO and calipers may be required to provide stability to the joints in a child who is learning to stand and walk. AFO are useful in children with spastic diplegia who have spasticity with tendoachilles tightening. Lightweight splints may at times be required to maintain normal postures. Splints and casts should not be used for prolonged periods of time as they may lead to disuse atrophy of the muscles.

Children with cerebral palsy need prolonged treatment. It is better to keep them in special institutions where physiotherapy and occupational therapy can be given along with special education. They are also given prevocational training.

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Assistive & Adaptive Devices:

CEREBRAL PALSY

Sagar Naik, PT

Speech & Language Therapy:

Children with problems in speech and hearing require the services of an audiologist and a speech therapist. Communication skills may mean talking, using sign language, or using communication aid.

Occupational Therapy:

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Recreational Therapy:

An occupational therapist trains the child for daily activities and for sensory-perceptual-motor coordination. They usually work with children on better ways to use their arms, hands and upper body. Helps children to find right special equipments to make some everyday jobs little easier.

Recreational therapists help kids with cerebral palsy have fun. They work with children on sports skills or other leisure activities like dancing etc.

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CEREBRAL PALSY

Sagar Naik, PT

Physiotherapy Assessment:
Assessment of the child gives a baseline to appropriate treatment and management aims and techniques. Re-assessment should be continuing part of treatment, which allows for improvement or deterioration to be noted, thus enabling treatment to be more effective. The therapist must have knowledge of normal development. During physical examination, it is important to discriminate between delay in motor development and abnormal motor patterns. It is very essential for the therapist to explain, what he is going to do before handling the child. Assessment needs to be playful, interesting and non-threatening. Assess young child as much as possible on parents lap. Observe child among familiar toys as well as with selected toys to activate interest as well as reveal dormant abilities. Keep sessions within the bounds of a childs concentration. Have an unhurried atmosphere. Have easy, successful actions of a child interspersed with difficult tasks.

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Subjective Examination:

Subjective information should be obtained from the parents especially mother or from relatives and through case-sheet. General details includes Name Age & Sex Address When the mother did first noticed the dysfunctions Siblings having same type of symptoms Prenatal History Age of mother Consanguity marriage Any drugs taken during pregnancy Any trauma & stress Any addiction smoking or alcoholism

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CEREBRAL PALSY

Sagar Naik, PT

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Objective Examination: On Observation:
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History of rubella or cytomegalovirus, toxoplasmosis infection History of previous abortions, still born or death after birth Multiple pregnancies (duration between pregnancies) Status & cast of the mother Perinatal History Place of delivery History preterm or full-term delivery History of asphyxia at birth Type of delivery Forceps delivery Presentation of child Breech presentation Any history of prolonged labour pain Condition of mother at the time of delivery Postnatal History Delayed birth cry (when child cried) Weight of the child at birth Low Birth Weight (LBW) History of any trauma to brain during the first 2 years of life History of neonatal meningitis, jaundice, or hypoglycemia Hydrocephalus or Microcephaly Nutritional habits of the child (malnutrition) Feeding difficulties Any medical or surgical treatment taken Any physiotherapy treatment previously taken What was the ability level of child at that time? What obstructs the child from progress? What treatment was used? Was the treatment effective or not? Apgar score from the case-sheet

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Behaviour of the child Whether child is alert, irritable or fearful in the session or during particular activities Child becomes fatigued easily or not during activity

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Find out what motivates his action particular situation, person or special plaything Communication of the child How child communicates with the parents Whether child initiates or responds with gestures, sounds, hand or finger pointing, eye pointing or uses words and speech Attention span What catches childs attention? For how much time childs attention is maintained on particular thing How does parent assist him to maintain attention? What distracts the child? Does child follows suggestions to move or promptings to act? 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 or increased Postural control & alignment How much parental support is given? Postural stabilization and counterpoising in all postures Proper & equal weight bearing If the childs center of gravity appears to be unusually high, resulting in floating legs and poor 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

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Sagar Naik, PT

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Any involuntary movements, tremors or spasms, which interfere with actions, are present Sensory aspects Observe childs 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 Observe any recurring position of the whole child Any part of the 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 the body - In the arm, this generally consists of Shoulder protraction or retraction, adduction and internal rotation Elbow flexion Forearm pronation Wrist & Fingers flexion - In the legs, it includes 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 internally rotated and in danger of posterior dislocation

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CEREBRAL PALSY

Sagar Naik, PT

On Examination:
Sensory Assessment It is difficult to assess sensation in babies and young children with severe multiple impairments. If any hearing or visual or psychological abnormalities are present then assessment done by specialist is required Motor Assessment Growth Parameters - Height Until 24 to 36 months of age, length in recumbency is measured using an infantometer. After the age of 2 years standing height is recorded by a stadiometer.

At birth At 1 year 2 to 12 years

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At birth 3 to 12 months 1 to 6 years 7 to 12 years

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Height Centimeters
50 75 (Age in years 6) + 77 - Weight of the child

Weight

3.25 (Age in months + 9) / 2 (Age in years 2) + 8 [(Age in years 7) + 5] / 2

- Head circumference of the child The tape is used to measure the occipitofrontal head circumference from external occipital protuberance to the glabella.

Head circumference
At birth 3 months 1 year 2 years 12 years
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Inches
20 30 (Age in years 2) + 30

Kilograms

Pounds

7 Age in months + 11 (Age in years 5) + 17 (Age in years 7) + 5

Centimeters
35 40 45 48 52

CEREBRAL PALSY

Sagar Naik, PT

Developmental Assessment

Age
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 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

Developmental Milestones
Social smile Head holding Sits with support Sits without support Reaches out for a bright object & gets it Transfers object from one hand to other Starts imitating cough Crawls Creeps Standing holding furniture Walks holding furniture Stands without support Walks without much of a support Says one word with meaning Says three words with meaning Joints 2 or 3 words into sentence Feeds self with spoon Climbs stair Takes shoes and socks off Puts shoes and socks on Takes some clothes off Dresses self fully Dry by day Dry by night Knows full name and sex Rides tricycle

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Joint Range of Motion (active & passive) - Active head and trunk flexion, extension, rotation observed during head raise in prone, supine, sitting, standing developmental channels - Active shoulder elevation, abduction, rotation, flexion and extension movements are observed during the

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CEREBRAL PALSY

Sagar Naik, PT

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functional examination of creeping, reaching and other arm movements - Active elbow flexion and extension observed during childs reach to parts of body or toys - Active wrist and hand movements will be observed during function development - Active hip flexion and extension will be observed during all functions - Active knee flexion and extension seen with active hip flexion extension - Foot movements are also check during functional development Reactions, Responses and Reflexes - Sucking Reflex (3 months) - Rooting Reflex (3 months) - Grasp Reflex (3 months) - Reflex Stepping (2 months) - Galants Trunk Incurvation (2 months) - Moro Reflex (0-6 months) - Startle Reflex (remains) - Landau Reflex (3 months - 2 years) - Flexor Withdrawal (2 months) - Extensor Thrust (2 months) - Asymmetric Tonic Neck Reflex (ATNR) (usually pathological) - Symmetrical Tonic Neck Reflex (STNR) (usually pathological) - Tonic Labyrinthine Supine (pathological) - Tonic Labyrinthine Prone (3 months) - Neck Righting (5 months) - Positive Supporting (3 months) - Negative Supporting (3-5 months) - Protective Reflexes If reflexes are persistent beyond the usual duration then they are called positive signs. If reflexes, which are supposed to be, present during particular age but are absent are known as negative signs. Muscle tone

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Reflexes - Superficial Reflexes - Deep Tendon Reflexes Limb Length Discrepancy - Apparent (umbilicus to lateral malleolus) - True (ASIS to medial malleolus) Contractures Deformities Gait (if applicable) Transfer activities (if applicable) Balance (if applicable) Assessment of daily activities Assessments of feeding, dressing, washing, toileting, play and hand function Ambulation (dependent or independent) Cognitive Assessment (if applicable) Response to external environment Behaviour Sense of colour, size, shape Sense of common dangers as fire Toilet training Sense of household articles

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CEREBRAL PALSY

Sagar Naik, PT

Physiotherapy Treatment:
Aims (Goals) of Physiotherapy Treatment:
To normalize the tone To achieve normal milestones To maintain muscle length To correct the posture Teach activities of daily living Parents counselling

Treatment Approaches:

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Muscle Education & Braces (W.M. Phelps):

He prescribed special braces to correct deformity, to obtain the upright position and to control athetosis. Children with spasticity are given muscle education based on an analysis of whether muscles are spastic, weak, normal or zero cerebral, or atonic. Muscles antagonistic to spastic muscles are activated. This is to obtain muscle balance between spastic muscles and their antagonists. Athetoids are trained to control simple joint motion and do not have muscle education. Ataxics may be given strengthening exercises for weak muscle groups.

Progressive Pattern Movements (Temple Fay):

He recommended that the cerebral palsied be taught motion according to its development in evolution. He regarded ontogenetic development (in humans) as a recapitulation of phylogenetic development (in evolution of the species). He suggested building up motion from reptilian squirming to amphibian creeping, through mammalian reciprocal motion on all fours to the primate erect walking.

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CEREBRAL PALSY

Sagar Naik, PT

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Fay also described unlocking reflexes which reduces hypertonus. He developed progressive pattern movements based on above ideas which consist of five stages: Stage 1 Prone lying - Head and trunk rotation from side to side Stage 2 Homolateral stage - Prone lying, head turned to side - Arm on the face side in abduction-external rotation, elbow semi-flexed, hand open, and thumb out towards the mouth - Leg on the face side in abduction, knee flexion opposite stomach, and foot dorsiflexion - Arm on the occiput side is extended, internally rotated, hand open at the side of the child or on the lumbar area of his back - Leg on occiput side is extended. - Movements involves head turning from side to side with the face, arm and leg sweeping down to the extended position and the opposite occiput arm and leg flexing upto the position near the face as the head turns round Stage 3 Contralateral stage - Prone lying - Head turned to side, arm on the face side as in stage 2 - Leg on the face side is extended - Other leg on the side of occiput is flexed - As the head turns this contralateral pattern changes from side to side Stage 4 On hands and knees - Reciprocal crawling and on hands and feet stepping in the bear walk or elephant walk Stage 5 Walking pattern - This is sailors walk called by Fay reciprocal progression on lower extremities synchronized with the contralateral swing of the arms and trunk - A wide base is used and the child flexes one hip and knee into external rotation and then places his foot on the ground, still in external rotation

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CEREBRAL PALSY

Sagar Naik, PT

- As the foot is being placed on the ground, the opposite arm and shoulder are rotating towards it - As weight is taken on the straight leg, other leg flexes up

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He produced motion by provoking primitive movement patterns or synergistic movement patterns, which are observed in fetal life or immediately after pyramidal tract damage. Reflex responses are used initially and later voluntary control of these reflex patterns is trained. Control of head and trunk is attempted with stimulation of attitudinal reflexes such as tonic neck reflexes, tonic lumbar reflexes, and tonic labyrinthine reflexes. These are followed by stimulation of righting reflexes and later balance training. Associated reactions are used as well as hand reactions.

Proprioceptive Neuromuscular Facilitations (Herman Kabat):

Movement patterns (mass movement patterns) based on patterns observed with functional activities are spiral and diagonal with synergy of muscle groups. The movement patterns consist of the following components: Flexion or extension Abduction or adduction Internal rotation or external rotation Sensory (afferent) stimuli are skillfully applied to facilitate movement. Stimuli used are touch & pressure, traction & compression, stretch, proprioceptive effect of muscle contracting against resistance and auditory and visual stimuli.

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Synergistic Brunnstrom):

Movement

Patterns

(Signe

CEREBRAL PALSY

Sagar Naik, PT

Neuromotor Development (Eirene Collis):

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Strict developmental sequence was followed. The child was not permitted to use motor skills beyond his level of development. She placed the child in normal postures in order to stimulate normal tone. Once postural security was obtained, achievements were facilitated and developmental sequences were followed throughout this training.

Neurodevelopmental with Reflex Inhibition & Facilitation (Karl Bobath):

According to Bobath, once the reflex patterns of abnormal tone are inhibited the child is said to have been prepared for movement. Reflex inhibitory patterns specifically selected to inhibit abnormal tone associated with abnormal movement patterns and abnormal posture. Sensory motor experience The reversal or break down of these abnormalities gives the child the sensation of more normal tone and movements. The therapist to attempt to change the patterns of spasticity so that child is prepared for movement and mature postural reactions uses key-points of control.

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Resistance to motion is used to facilitate the action of the muscles, which form the components of the movement patterns. Special techniques Irradiation Rhythmic Stabilization Stimulation of Reflexes Repeated Contractions Reversals Relaxation techniques Hold Relax & Contract Relax

CEREBRAL PALSY

Sagar Naik, PT

The key-points are usually head & neck, shoulder & pelvic girdles, but there is also work from distal keypoints.

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Techniques of stimulation, such as stroking, brushing, icing, heating, pressure, bone pounding slow & quick muscle stretch, joint retraction & approximation, muscle contractions (proprioception) are used to activate, facilitate or inhibit motor response. Ontogenetic developmental sequence is strictly followed in the application of stimuli. Total flexion or withdrawal pattern (in spine) Roll over (flexion of arm & leg on the same side and roll over) Pivot prone (prone with hyperextension of head, trunk & legs) Co-contraction neck (prone head over edge for cocontraction of vertebral muscles) On elbows (prone & push backwards) All fours (static, weight shift & crawl) Standing upright (static, weight shifts) Walking (stance, push off, pick up, heel strike)

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Reflex Creeping & other Reflex Reactions (Vaclav Vojta):

Reflex creeping The creeping patterns involving head, trunk and limbs are facilitated at various trigger points or reflex zones. Touch, pressure, stretch and muscle action against resistance are used in triggering mechanisms or in facilitation of creeping. Resistance is recommended for action of muscles.

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Sensory Stimulation for Activation & Inhibition (Margaret Rood):