CEREBRAL PALSY

WHAT IS CEREBRAL PALSY?

Cerebral palsy is permanent , nonprogressive and occasionally evolving, disorder of tone

movement and posture as a result of immature brain or by an insult to developing brain.

It is most common chronic motor disability in childhood affecting 2-3 infants per 1000 live births. Serious
and mild motor disability estimated as 3.7 and 2.1 per thousand among 2 to 9 years old children.

RISK FACTORS
OF CEREBRAL
PALSY:

Prenatal Perinatal Postnatal

Infections Birth asphyxia CNS infection

Fetal anoxia Prematurity, low birth weight Trauma

Maternal diabetes Drugs, CNS infections Toxins, eg. Lead

Hypertension Birth trauma hypoxia

Mal development of brain Antepartum hemorrhage

Obstetric complication Intracranial hemaorrhage

*RISK OF CP RISES AS BIRTH WEIGHT DECLINES*

CAUSES:

1.Prematurity : Preterm infants suffer from hemorrhagic or hypotensive ischemia. Preterm infants
include premature rupture of membrane, monochorionic twin placentation and respiratory distress
syndrome, Broncho pulmonary dysplasia and ventriculomegaly.

2.Asphyxia : It is characterized by progressive hypoxia , hyper-capnia , hypo-perfusion and acidosis

leading to multi-organ dysfunction that may cause death.

3.Infections : Intrauterine viral infections- rubella, herpes simplex and cytomegalovirus can cause CNS
injury to manifest CP with spastic quadriplegia .

4.Prenatal abnormalities : Maternal disorder can interfere with normal fetal nutrition oxygenation such
as placental infarction, intrauterine infection, congenital malformation of brain leading to CP.

5.Toxins : Irradiation to pregnant women results in microcephaly and cerebral palsy. Methlymercury,
alcohol, cocaine, lead are other toxins.

6.Postnatal cause: Viral and bacterial infections of CNS . Gastroenteritis with hypernatremic
dehydration and accidental injuries are other causes of cerebral palsy.

CLINICAL FEATURES:

Developmental delay

Physical findings:

 Persistence of neonatal reflexes

 Increased tone
 Fisting with cortical thumb
 Scissoring of legs
 Toe-walking
 Abnormal posture and gait
 Abnormal reflexes or hyper-reflexia

Common comorbidities:

 Intellectual disability
 Microcephaly
 Seizures
 Behavioral problems
 Difficulty in speech, language, swallowing and feeding
 Blindness
 Deafness
 Squint
 Malnutrition
  Sleep disturbance
 Excessive drooling

Contractures may develop that are initially dynamic and later fixed.

CLASSIFICATION/TYPES:

Topographically: Quadriplegic, Hemiplegic, Monoplegic, or Diplegic

Physiologically : Spastic, Dyskinetic , Ataxic or Mixed

Spastic cerebral palsy:

Spasticity is characterized by increased muscle tone, limited movements, decreased active and passive
range of movement, tendency todevelop contracture and deformities,persistence of primitive and tonic
reflexes and poor development of postural reflex mechanism.

1. Spastic hemiplegic palsy: result from vascular insult or perinatal stroke. One side of body show
abnormal tone and movement. The entire half of body is involved with upper limb more than
lower limb. Early hand preference is clue. Delay in all motor milestones sice lack of balance of
trunk. Sitting may be late and child may fall to affected side. These children are usually mobile
may have preserved or impaired intellect.
2. Spastic diplegia: second most coomon type linked with prematurity. Intellect is often preserved.
Involvement of whole body with greater involvement of trunk and lower limbs. There is delay in
motor milestones. Child reach spastic stage by the age of 2-3 years. In erect posture child stands
with his hips and knee flexed taking weight on toes with legs internally rotated . gait is abnormal
.
3. Spastic quadriplegia: most common type in India. Caused by neonatal illness or perinatal
asphyxia there is total involvement of body i.e head, neck, trunk, arms which are equally or
more involved than legs. Spasticity, hyper-reflexia , intellectual disability, seizures, pseudobulbar
palsy, mental retardation, squint or visual disturbance, speech abnormalities, hearing defects,
 and deformities.

Dyskinetic cerebral palsy:

Results from asphyxia . Abnormal movements, muscle tone is variable and purposeful movements are
poorly executed and coordinated. Involuntary movements are exaggerated , changes in emotions and
anxiety or speech is hallmark of this type. Rigidity, dystonia, impaired speech, hearing loss, dyskinesia
and drooling are prominent while intellect is relatively preserved. These children have characteristic
appearance with open mouth, grimacing face and bizarre contractions of limbs at every attempted
movement.

Ataxic palsy:
Caused by cerebellar malformation. There is initial stage of hypotonia and delay milestone. Intention
tremors and ataxia. Low postural tone and disturbed equilibrium. Gait is wide based and poor balance
on standing. Defect in speech ,Intellectual impairment and epilepsy.

Mixed cerebral palsy:

Combination of spastic diplegia with dyskinesia. Children with ataxic form often have diplegia- ataxic
diplegia.

ASSOCIATED PROBLEMS:

 Neurological: mental retardation, cortical sensory defects, visual and hearing problems,
epilepsy, communication disorders.
 Orthopedic: scoliosis, hip subluxation or dislocation, hamstring contracture, eqinus.
 Gastrointestinal: oropharyngeal dysphagia, constipation, malnutrition, drooling of saliva.
 Miscellaneous: sleep problems, urinary tract dysfunction, emotional and behavioral problems.

WARNING SIGNS :

 Less movement or excessive and disorganized manner

 Stereotyped behavior
 Hypotonicity with frog like posture
 Hyperextension of head and neck
 Consistent fisting of hands
 Delay development
 Sitting in ‘W’ posture
EVALUATION:

Detailed history, physical and neurological examination, spasticity, family size and support, financial
resource, MRI and ECG.

MANAGEMENT:

1. Rehabilitation: infancy is the crucial period to raise concern because this period can set patterns
of thought and behavior that may last for years. early the treatment , easier to form correct
movement habits. Goal is to achieve promotion of motor and functional development and
independence as far as possible in ADLs and prepare child for schooling depending upon his
mental status.
2. Physical therapy: improve motor function and prevent contractures and deformities. Aim at
reducing abnormal movement patterns and posture and enable child to gain maximal functional
independence, reduce spasticity and stimulation of sensory, cognitive and perceptual functions.
 Muscle Education and Bracing: consisted of massage, passive motion, active assisted motion,
active motion, resisted motion, rest, conditioned motion, confused motion, combined motion,
balance, reach and grasp, skills, relaxation, movement from relaxation and reciprocation. braces
to correct deformity and braces to control athetosis.
 Progressive Pattern Movements: The primitive patterns of movement and reflexes can be
stimulated , useful for coordination, reciprocal motion, concentration and rhythm. A strict
sequence of this phylogenetic development is stressed. The creeping movements are taught
with passive motion. Reflex movements or 'unlocking' reflexes are used to relax spasticity.
 Proprioceptive Neuromuscular Facilitation: . Movement patterns rather than muscle education
of individual muscle groups are recommended. such as rolling over, getting up, locomotion and
various daily skills using the upper limb. The diagonal and rotary aspects of movement patterns
are used. Sensory (afferent) stimuli were shown to stimulate motion. Proprioception is
emphasised although the techniques include touch, auditory and visual stimuli as well as the
stimuli from stretch, pressure and muscle contraction. Resistance is used to facilitate stronger
muscle action within the synergic patterns of movement.
 Neurodevelopmental Treatment with Reflex Inhibition and Facilitation: tonic reflexes and
asymmetrical tonic neck reflexes have to be inhibited. Once the abnormal tone and reflex
patterns have been inhibited, there should be facilitation of more mature postural reflexes. All
this is carried out in a developmental context.
 Sensory Stimulation for Activation and Inhibition: Techniques of stimulation, e.g. stroking,
pressure, brushing (tactile); icing, heating (temperature); bone pounding; slow and quick muscle
stretch; joint retraction and approximation, muscle contractions, muscle pressure
(proprioception), are used to activate, facilitate or inhibit motor.
 Reflex creeping: the creeping patterns involving head, trunk and limbs are facilitated at various
'trigger' points or 'reflex zones'. The creeping is an active response to the appropriate 'triggering'
from the zones with sensory stimuli.
 Child with Spasticity: a. Useful techniques to inhibit spasticity include weight bearing; weight
shifting; slow, rhythmic rocking; and rhythmic rotation of the trunk and body segments. Active
trunk rotation, dissociation of body segments, and isolated joint movements should be included
in the treatment activities.
 Child with Athetosis or Ataxia: Useful techniques include approximation, weight bearing, and
moving within small ranges of motion with resistance as tolerated. The assistant can use sensory
cues that provide the child with information about joint and postural alignment, such as mirrors,
weight vests, and heavier toys that provide some resistance but do not inhibit movement.
holding any other fixed posture such as stork standing. Use of hand support in sitting, kneeling,
and standing can improve the child's stability. Visually fixing on a target may also be helpful.
 First Stage of Physical Therapy Intervention: Early Intervention (Birth to 3 Years): During this
time, typically developing infants are establishing trust in their caregivers and are learning how
to move about safely within their environment. . By educating the family about the child's
disability and by teaching the family ways to position, carry, feed, and dress the child, the
therapist and the assistant practice family-centered intervention. knowledge of positioning and
handling techniques, use of adaptive equipment, management of impaired tone, and
developmental activities that foster motor abilities and movement transitions within a
functional context. Active head lifting when in prone can be encouraged by using toys that are
brightly colored or make noise. Some infants do not like being prone, and the caregiver has to
be encouraged to continue to put the infant in this position for longer periods. Carrying the
infant in prone can increase the child's tolerance for the position. The more upright the child is,
the easier it is to promote a flexed posture of the head and neck.
 Second Stage of Physical Therapy Intervention: Preschool Period: Activities may include
promoting postural reactions to improve head and trunk control, teaching transitions such as
moving from sitting to standing, stretching to maintain adequate muscle length for function,
strengthening and endurance exercises for promoting function and health, and practice of self-
care skills as part ofthe child's daily home or classroom schedule. Amhulation may be possible in
children with spastic quadriplegia if motor involvement is not too severe. Children with spastic
diplegia can practice stand over a holster can provide a deterrent to lower extremity adduction
while the child works on muscular strengthening and weight bearing. If the child cannot support
all the body's weight in standing or during a sit-to-stand transition, have part of the child's body
weight on extended arms while he practices coming to stand, standing, or shifting weight in
standing. Practicing lateral trunk postural reactions may automatically result in lower extremity
separation. Pushing a toy and shifting weight in step stance are also useful activities to practice
lower extremity separation. Single-limb balance can be challenged by using a floor ladder or
taller steps. Having the child hold on to vertical poles decreases the amount of support and facil-
itates upper trunk extension. Kicking balls, carrying objects of varying weights, reaching
overhead for dressing or undressing, pulling pants down and up for toileting, and climbing or
walking up and down stairs and ramps can be used to promote strength, endurance, and
coordination. Endurance can be promoted by having a child who can ambulate use a treadmill
(Fig. 6-16) or through dancing or playing tag during recess.
 Third Stage of Physical Therapy Intervention: School Age and Adolescence: Physical therapy
goals during the school years and through adolescence are to Continue independent mobility,
Develop independent skills related to ADLs and instrumental ADLs, Foster fitness and
development of a positive self-image, Foster community integration, Develop a vocational plan,
Foster social interaction with peers. Recreational and leisure activities, sports-related or not,
should be part of every adolescent's free time. Swim programs, local athletic club, or elsewhere
provide wonderful opportunities to socialize, develop and improve cardiovascular fitness,
control weight, and maintain joint and muscle integrity. encouraging children and adolescents
with CP to participate in aquatic and martial arts programs to improve movement, balance, and
self-esteem. Wheelchair athletics may be an option for school-age children or adolescents in
places with junior wheelchair sports program.
  Fourth Stage of Physical Therapy Intervention: Adulthood: Physical therapy goals during
adulthood are to foster Independence in mobility and ADLs, A healthy lifestyle, Community
participation, Independent living, and a vocation. Determine the ability of an adult with CP to
live and work independently are cognitive status, degree of functional limitations, and adequacy
of social and financial support.
3. Occupational therapy: assess and treat problems related to fine motor development, cognitive
and perceptual maturation and functional skills. Advice parents on ADLs –bathing, feeding,
dressing, use of assistive devices , positioning devices like bucket seat, feeder chair, hammock,
baby rattles, standing frames walkers.
4. Speech therapy: help in overcoming communication problems, developing an effective feeding
program, appropriate positioning of head and jaw is basic for both feeding and speech.
Excessive drooling can be treated with behavioral modification or by drug hyoscine.
5. Orthotic management: splints made of plaster of paris or plastic help to prevent contractures in
knee and tendoachilles. bilateral hip knee and ankle orthosis for spastic diplegia . gait training
with walkers, parallel bars and crutches. For non ambulatory childrens use strollers and
wheelchairs. a Solid ankle foot orthosis for dorsiflexion and moulding foot. Hinged ankle foot
orthosis allowing dorsiflexion for gait, stairs, half-kneeling and sit-tostand. Minimal
plantarflexion for push-off in gait. Ground reaction ankle foot orthosis limits excessive
dorsiflexion. Knee element maintains knee extension. Ground reaction ankle foot orthosis with
stiffening at ankle and with extended sole to correct flexion of toes. Front can be moulded to
the lower leg in severe crouch-walk. The SWASH (Standing, Walking And Sitting Hip) Orthosis,
with variable hip abduction, dynamically corrects adduction and/or hip dysplasia. May need
trunk support.
6. Orthopedic management: hip subluxation abduction splinting with adductor tenotomies. TA
tightness bracing casting. Scoliosis – bracing
7. Neurosurgery: selective dorsal rhizotomy – partial division of posterior lumbar roots to reduce
spasticity between 2-6 years of age. Hypotonia, sensory loss, bladder dysfunction and spinal
deformity reported after the surgery. Presence of concomitant dystonia, severe fixed joint
deformity, scoliosis and previous orthopedic operations are contraindicated for surgery.
8. Medications: antiepileptic drugs- tigabine. Antispasticity drugs- baclofen, dantolene, diazepam.
Botulinium toxin. Antireflux drugs- metoclopramide, cisapride. For excess salivation-
benztropine. For dystonia- levodopa, carbamazepine.

PROGNOSIS:

Spastic hemiplegia walked by 2years and all by 3 years. Ataxic CP will walk although later. Quadriparesis
have poor prognosis. Affected patients survive till adulthood. Social outcome for education and
employment depend on intellectual impairment and mobility .

Reference: pediatrics(ghai), cash neuro, martin kesller, sophy levitt, cerebral palsy: a profile(s aneja,
beena ahuja)

By, ARSHIYA KHAN

M.A.Rangoonwala college of physiotherapy and research

Date:22/02/2022