CEREBRAL PALSY

CEREBRAL PALSY

 “Cerebral palsy describes a group of permanent disorders of the development of

movement and posture, causing activity limitations that are attributed to nonprogressive
disturbances that occurred in the developing fetal or infant brain.

 The motor disorders of CP are often accompanied by disturbances of sensation,

perception, cognition, communication and behavior as well as seizures and secondary
musculoskeletal problems.”

 International Workshop on Definition and Classification of Cerebral Palsy (2007)

3 MAJOR CRITERIA FOR DIAGNOSIS OF CP

 A neuromotor control deficit that alters movement and

posture
 A static brain lesion
 Timing of causative brain lesion either before birth or in
the first years of life
COMPONENTS OF CEREBRAL PALSY CLASSIFICATION

 Motor abnormalities
 Associated impairments
 Anatomic and radiological findings
 Causation and timing
ETIOLOGY

 PRENATAL CAUSES
• Congenital 30.5%
• Prematurity 11.4%
• Genetic factors 1.6%
• Rh incompatibility 0.3%
• Maternal influenza 0.2%
• Maternal German measles 0.9%
44.2%
• Review of 1008 Filipinos afflicted with CP (Textbook of Pediatrics by Del Mundo)
ETIOLOGY

PERINATAL FACTORS

• Birth injuries due to forceps,

caesarian section, etc 10.8%
• Cerebral anoxia or hypoxia 5.6%
• Cerebral hemorrhage 0.8%
17.2%

• Review of 1008 Filipinos afflicted with CP (Textbook of Pediatrics by Del Mundo)

ETIOLOGY
CLASSIFICATIONS

Based on Etiology – congenital or acquired

Topographic – body parts affected
Clinical or neurological – brain parts affected
Pathogenic – pre-,peri-, postnatal or untraceable
Severity or functional – mild, moderate, severe
 Neurological Affectation

• CEREBRAL CORTEX:
• controls thought, movement and sensation.
• Damage : spastic cerebral palsy.

• BASAL GANGLIA:
• help movement become organized, graceful and
economical.
• Damage : athetoid cerebral palsy.

• CEREBELLUM:
• co-ordinates movement, posture and balance.
• Damage : ataxic cerebral palsy
 NEUROLOGIC CLASSIFICATION

• SPASTIC CP – 50-60%

• DYSKINETIC CP – 25-30%

• ATAXIC CP – 5%

• MIXED CP - rare
 SPASTIC CEREBRAL PALSY

 STIFF
 Caused by damaged nerve cells in the outer layer of the brain called the
cortex

 Control over muscles is seriously reduced, leaving them permanently tight,

tense and weak.

 May be hemiplegic, diplegic, quadriplegic, or triplegic

 *SPASTIC DIPLEGIA – most common CP due to Prematurity

https://www.berestonlaw.com/blog/2019/november/what-is-spastic-diplegic-cerebral-palsy-/
SIGNS AND SYMPTOMS OF SPASTIC CP

• Stiff, tight muscles (hypertonia) on

one or both sides of the body
• Exaggerated movements
• Limited mobility
• Abnormal gait
• Crossed knees
• Joints don’t full extend
• Walking on tiptoes
• Contractures
• Abnormal reflexes

https://www.slideshare.net/MadhuVamsi2/cerebral-palsy-69107924
 DYSKINETIC CEREBRAL PALSY

 INVOLUNTARY MOVEMENTS
 Caused by damage to the basal ganglia.
 Muscles rapidly change from floppy to tense with many unwanted movements.
 Speech may be hard to understand because of difficulty controlling the tongue and
vocal cords.
 May have athetosis, choleric, dystonic, or hemiballismus
 * Athetosis – most common CP due to Rh incompatibility or kernicterus
 ATHETOSIS

 involuntary writhing movements.

https://www.medfriendly.com/athetosis.html
.

 CHOREA
 involuntary, irregular, quick, jerky
unpredictable muscle movements.

 BALLISIMUS
 Chorea that affects proximal joints
such as shoulder or hip that leads to
large amplitude flailing movements
of the limbs

https://twitter.com/lucasdriskell/status/1262367583635988481
 ATAXIC CEREBRAL PALSY

• Affected area: cerebellum

• Manifestations: (SHAKY)
• clumsy
• lack balance
• unsteady gait
• shaky hand, movements and jerky speech.

https://www.physio-
pedia.com/images/a/ac/Test_for_ataxia.jpg
 NEUROLOGIC TOPOGRAPHIC PATHOGENIC FUNCTIONAL

Spastic Monoplegia Prenatal Class I – no

Athetoid Paraplegia Perinatal limitation of activity
Choreoid (jerky, Hemiplegia Postnatal
abrupt, flailing Triplegia Untraceable Class II – slight to
motion) Quadriplegia moderate limitation
Rigid (resistant to Diplegia
movement) Class III –
Double hemiplegia
Ataxic moderate to great
Tremor limitation
(uncontrollable
shaking) Class IV – no useful
Atonic (flaccid) physical activity
Mixed
Unclassified
Topographic Classification
ANATOMICAL DEPICTION OF CP
FUNCTIONAL MOTOR ABILITIES

 Gross motor function classification system (GMFCS)

 Manual ability classification system (MACS)
 Communication functional classification system (CFCS)
 GROSS MOTOR FUNCTION CLASSIFICATION SYSTEM
(GMFCS)

Before 2 years 2-4 years 4-6 years 6-12 years

Level I Manipulate objects with Gets up from sitting Can climb stairs Walk indoors and outdoors, climb stairs.
hands and walk without holding unto
independently something

Level II Belly crawls, pull to stand Can assume sitting Sitting with both Walk indoors or outdoors on level surface only
on furniture and cruise position without hands free, walk short
assistance, walk with distances without
assistive device assistive device

Level III Can roll and creep forward ‘w’ sit and require adult Walk with assistive Walk indoors or outdoors on level surface with an
on stomach assistance to assume device assistive mobility device.
sitting

Level IV Can roll independently Able to roll and creep, Sit independently in a Rely on wheeled mobility, may achieve self-mobility
can sit when placed, but chair but minimal using assistive device
need both hands on the hand function
floor.

Level V Limited voluntary Requires adult All areas of motor Functional limitations in sitting and standing are not
movements, no head assistance to roll functions are limited. fully compensated for through the use of assistive
control device.
COMMUNICATION FUNCTIONAL
CLASSIFICATION SYSTEM
SIGNS AND SYMPTOMS

 Very diverse
 Present in all forms of CP:
 abnormal muscle tone
 Abnormal posture (i.e. slouching over while sitting)
 Abnormal reflexes, or motor development and coordination
 CLASSICAL SYMPTOMS:
 spasticity, spasms, other involuntary movements (e.g. facial gestures), unsteady gait,
problems with balance, and/or soft tissue findings consisting largely of decreased
muscle mass.
 Scissor walking, toe walking
SIGNS AND SYMPTOMS OF CP IN BABIES

 Irregular posture : very floppy or very stiff

 May not have obvious signs of CP at birth
 Delayed development
 Abnormal reflexes
 May have associated birth defects
 ASSOCIATED PROBLEMS

• Mental retardation
• Epilepsy / seizure disorder
• Hearing, speech, cognitive and behavioral
abnormalities
ASSOCIATED PROBLEMS

• Visual
- Strabismus
- crossed eyes
- eyes do not properly align with each other when looking at an object.
- Esotropia
- form of strabismus in which one or both eyes turn inward.
- Homonymous hemianopsia – sees only one side of the visual world of
each eye.
- Nystagmus
- involuntary, rapid and repetitive movement of the eyes — either horizontal (side-
to-side), vertical (up and down) or rotary (circular).
https://www.physio-pedia.com/images/c/c4/Assoc_Conditions.jpg
https://www.researchgate.net/profile/Iona-Novak/publication/263355497/figure/fig1/AS:296060636418049@1447597764147/Evidence-based-decision-making-algorithm-for-diagnosing-
cerebral-palsy-early.png
DIAGNOSIS

• DETAILED HISTORY
• PHYSICAL EXAMINATION
• (neurologic exam: tone and reflexes )
 frog-legposition with their hips abducted, flexed, and
externally rotated – severe hypotonia
 Persistent fisting or scissoring – increased tone
 delay in the disappearance of primitive infantile reflexes
– earliest sign
http://regiebia.blogspot.com/2012/03/project-in-science.html
 FROG LEG POSITION

https://www.sciencedirect.com/science/article/abs/pii/S1751722207002648?_escaped_fragment_=&showall%3Dtrue
https://www.youtube.com/watch?v=yDq4eukqmA4
 DIAGNOSIS

 NEUROIMAGING ( to determine the etiology )

 CT scan
 hemorrhagic lesions when there is a history of birth
trauma, low hematocrit, or coagulopathy
 MRI
 Cranial ultrasonography

 Electroencephalography (EEG)
DIAGNOSIS

• Tests of hearing and visual function

• Multidisciplinary approach
• Assessment of Movement
 Assessment of Reflexes
 Musculoskeletal Assessment
 Evaluation of the Gait
 Assessment of Fine Motor and Adaptive Skills
 Consideration of Speech and Language Abilities
DIAGNOSIS

Delayed motor milestones

 Fisting after 5 months of age

 Inability to sit with support by 8 months

 Inability to walk at age 15-18 months

 Discrepancies between intellectual and motor development

 Persistent or evolving increase or decrease in muscle tone

DIAGNOSIS

 Head lag beyond 6 months of age

 Poor trunk control and balance
 Opisthotonic posturing and extensor thrusting
 Development of Dystonia
 Toe walking/scissoring of feet
 Abnormal motor or gait patterns
 OPISTHOTONIC POSTURING

https://musculoskeletalkey.com/cerebral-palsy-2/
DYSTONIA

https://en.wikipedia.org/wiki/Dystonia
ASSESSMENT OF MOVEMENT

• Observation of the baby being held in the mother’s arms

• Observation of wheelchair-bound child
• Observation of an ambulatory child
• Assessment of Functional Antigravity Control
• Prone
• Supine
• Side-lying
• Quadruped
• Kneeling
• Standing
• Walking
DIAGNOSIS

 Evaluation of the Spine

 Thoracic Movement
 Evaluation of the Shoulder Girdle and Upper Extremity
 Examination of the Hip
 Examination of the Knee
 Examination of the Foot
Evaluation of Gait

Medium-guard Position
High-guard Position Low-guard Position
CONSIDERATION OF SPEECH AND
LANGUAGE ABILITIES

 Did the child appear to hear your voice or other environmental

sounds?
 Did the child understand questions asked during the evaluation?
 Did the child vocalize or verbalize during the assessment?
 Was the child’s communication at a functional level?
 ASSESSMENT OF REFLEXES

• Provides a major assessment of brainstem function

• Provide the earliest indication of fixed motor deficit consistent with
cerebral palsy
• Two major categories:
• Primitive reflexes
• Startle, moro, palmar grasp, rooting, sucking, asymmetric
tonic neck reflex (ATNR)
• Postural reflexes
• Righting, equilibrium reactions
MANAGEMENT
 THE MULTI-DISCIPLINARY TEAM

 Pediatricians - provide general care and coordinate the

activities of other members of the Multi-Disciplinary Care
Team

 Surgeons –provide specialist care and perform corrective

surgeries.

 Occupational therapists- help manage fine motor activities

 Physiotherapists- help manage gross motor movements

 THE MULTI-DISCIPLINARY TEAM

• Speech therapists - help improve speech and swallowing.

• Clinical Psychologists - provide emotional well-being as
well as cognitive evaluation for school placement.
• Special need educators - provide the right kind of
education for children with cognitive impairment
OTHER MANAGEMENT OPTIONS

 PROSTHETIC DEVICES
 Braces and other orthotics
 Wheelchairs
 Rolling walkers
 IT devices ( computers, voice synthesizers )
SURGICAL MANAGEMENT

 Surgeries most common to those with Cerebral Palsy usually

fall under the following categories:
 Gastroenterology Surgery
 Hearing Correction Surgery
 Medicine Related Surgery
 Orthopedic Surgery
 Neurosurgery
 Vision Correction Surgery
 NASOGASTRIC TUBE

 placed through the

nose to introduce
food to the
stomach.

https://www.gillettechildrens.org/your-visit/patient-
education/using-a-nasogastric-tube
 GASTROSTOMY TUBE

 inserted through the

abdominal wall to the
stomach allowing for
uninterrupted oral
feeding while
supplementing nutrients.

https://www.gillettechildrens.org/your-visit/patient-education/about-gastrostomy-tubes
FUNDOPLICATION

 surgical procedure that

places a valve at the top
of the stomach to reduce
recurrent vomiting,
gastro-esophageal-reflux
disease (GERD) and chest
infections and
complications caused by
recurrent vomiting

https://www.mayoclinic.org/medical-professionals/digestive-
diseases/news/endoscopic-fundoplication-bridges-gap-in-
gerd-management/MAC-20429858
SUBMANDIBULAR DUCT RELOCATION

 surgical
procedure that
addresses
drooling

https://www.youtube.com/watch?v=PBWGQKNt6TI
 BLADDER AUGMENTATION
(AUGMENTATION CYSTOPLASTY – AC)

 bladder surgery
which provides
urinary continence
for those that lack
bladder capacity

https://msktc.org/sci/factsheets/bladdersurgery
BACLOFEN PUMP

 a pump is implanted in the

child’s abdomen to
continuously deliver muscle
relaxant into the intrathecal
space ( where CSF is found ) in
an effort to reduce spasticity.

http://nbiacure.org/learn/living-with-nbia/what-is-a-baclofen-pump/
 SELECTIVE DORSAL RHIZOTOMY (SDR)

 corrects muscle
spasticity by cutting
the nerve rootlets in
the spinal cord that
are sending abnormal
signals to the muscles.
PHARMACOLOGICAL MANAGEMENT

 BOTULINUM TOXIN
 neurotoxin produced by Clostridium botulinum
 causes temporary muscle paralysis by binding to synaptic proteins at the
neuromuscular junctions, thus preventing the junctions from releasing
acetylcholine
 reduces spasticity in the upper and lower extremities
PHARMACOLOGICAL MANAGEMENT

 For TREATMENT OF SPASTICITY

 DIAZEPAM

 DANTROLENE

 BACLOFEN
REHABILITATION MANAGEMENT

NDTS (NEURODEVELOPMENTAL TECHNIQUES)

MUSCLE EDUCATION
AND BRACES

 Special braces ( W.M. Phelps )

 To maintain upright position
 To control athetosis
 To correct deformity
 Long leg braces with pelvic bands
and back supports or spinal brace
 Below the knee braces
MUSCLE EDUCATION

 Muscles antagonistic to spastic muscles are activated.

 Athetoids are trained to control simple joint motion.
 Ataxics may be given strengthening exercises for weak
muscle groups.
 PROGRESSIVE PATTERN MOVEMENTS
(Temple Fay)

 Based on ontogenetic development

 motion be taught according to its development in evolution
 Build up motion
 Reptilian squirming -> amphibian creeping -> mammalian
reciprocal motion on all 4’s ->> primate erect walking
PROGRESSIVE PATTERN OF MOVEMENTS

Stage 1 – Prone lying – head and trunk rotation from side to side
Stage 2 – Homolateral stage -
Stage 3 – Contralateral stage
Stage 4 – On hands and knees (quadruped on hands and knees)
 Reciprocal crawling and on hands and feet stepping in the bear walk or elephant walk
Stage 5 – Walking pattern
 Sailor’s walk
 SYNERGISTIC MOVEMENT PATTERNS
Signe Brunnstrom
 producing motion by provoking primitive movement patterns which are observed in fetal
life or immediately after pyramidal tract damage.
 REFLEX RESPONSES
 Used initially
 Later on voluntary control trained
 CONTROL OF HEAD AND TRUNK
 stimulation of attitudinal reflexes such as tonic neck reflexes, tonic lumbar reflexes, and tonic
labyrinthine reflexes.
 stimulation of righting reflexes and later balance training.
PROPRIOCEPTIVE NEUROMUSCULAR FACILITATIONS
(HERMAN KABAT)

 involves repeated muscle activation of the limbs by quick stretching, traction,

approximation, and maximal manual resistance in functional directions (ie, spiral and
diagonal patterns) to assist with motor relearning and increasing sensory input.
 MOVEMENT PATTERNS
 Flexion or extension
 Abduction or adduction
 Internal rotation or external rotation
 Neurodevelopmental with Reflex Inhibition & Facilitation
(Karl Bobath)

 “once the reflex patterns of abnormal tone are inhibited the child is
said to have been prepared for movement.”
 Goal is to reduce abnormal tone
 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.
 Neuromotor Development
(Eirene Collis)

 stressed neuromotor development as a basis for assessment and treatment

 Strict developmental sequence
 child is not permitted to use motor skills beyond his level of development.
 At all times the child is given a ‘picture of normal movement’
 child is placed in ‘normal postures’ in order to stimulate ‘normal tone’
 Sensory stimulation for activation and inhibition
(Margaret Rood)

 Techniques of stimulation are used to activate, facilitate or ‘inhibit’ motor response.

 stroking, brushing (tactile)
 icing, heating (temperature)
 pressure
 slow and quick muscle stretch
 joint retraction and approximation
 muscle contractions (proprioception)
 Sensory stimulation for activation and inhibition
(Margaret Rood)

 Ontogenetic developmental sequence is followed.

 Supine withdrawal flexion
 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 co- contraction of vertebral
muscles)
 Prone On elbows (prone & push backwards)
 Quadruped - All fours (static, weight shift & crawl)
 Standing upright (static, weight shifts)
 Walking (stance, push off, pick up, heel strike)
 REFLEX CREEPING & OTHER REFLEX
REACTIONS (VACLAV VOJTA)

 Vojta method
1. Reflex creeping (lying flat with the chest down and back up)
2. Reflex rolling (lying flat with the chest up and back down)
OTHER PT MODALITIES
ELECTRICAL STIMULATION TECHNIQUES

 neuromuscular electrical stimulation

(NMES)
 transcutaneous electrical stimulation
(TES) in cerebral palsy physiotherapy.

https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-35552008000400011
 HIPPOTHERAPY

 performed on horseback with a thin

soft saddle
 To improve balance and motor
coordination
 AQUATIC THERAPY

 relief of hyper-tonus in the spastic type of CP

 body is immersed in warm water (92° to 96°F)
 reduction in gamma fiber activity
 Reduction in muscle spindle activity
 Muscle relaxation ➔ reduction in spasticity

https://www.roydswithyking.com/hydrotherapy-children-cerebral-palsy-necessary-latest-
research-case-law/
 DOLPHIN THERAPY

 Developed by American psychologist David E.

Nathanson around 1978

 engage in activities targeted at improving

specific skills, movement or behaviors.

 children are motivated to complete the task

 dolphins can sense areas of disability in the

human body and they motivate children to use
these parts.

http://eventscuracao.com/dolphin-assisted-therapy/
 SPACE SUIT THERAPY

 THERA SUITS / THERAPY SUITS

 works to align the body in order to correct posture
and movement patterns
 forcibly encourage movement within a normal
range of motion.
 Improves muscle tone
 Strengthens body

https://www.theglobeandmail.com/life/parenting/a-space-suit-
based-therapy-may-help-physically-disabled-
childrendevelop/article33672396/
 VIDEO GAMES

 NINTENDO Wii
 Improvement in:
 visual perception
 bodily control
 functional mobility.

https://www.theguardian.com/world/2016/jun/14/video-games-transform-physical-therapy-
something-fun-mira-rehab-nhs
CASE DISCUSSION

 A mother of a 2 year old boy who has been diagnosed with cerebral palsy came
to you for some advice. She stated that her son was born premature at 34 weeks
of gestation. He stayed 1 week in the hospital because he developed yellowish
discoloration of the skin because of increased bilirubin. What will be your
response to the following questions?
 1. What caused his cerebral palsy? Is this hereditary? Was it something I did
during my pregnancy?
 2. Will he get better in the future? Is there a definitive treatment for cerebral
palsy?
 3. Can he go to school later on?
 4. Can he still live a normal life?