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MUHAMMED KOCABIYIK PHYSICAL MEDICINE & REHABILITATION IV.CLASS V.

COURSE

Cerebral Palsy: Definition
Cerebral palsy is a static encephalopathy  Often associated with epilepsy, speech problems, vision compromise, & cognitive dysfunction  The cognitive aspect of brain function (I.Q.) is often, but not always affected. But the musculoskeletal system is always affected to some degree.

LATEST DEFINITION OF CEREBRAL PALSY
Cerebral palsy describes a group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behavior, by epilepsy, and by secondary musculoskeletal disorders”

Cerebral Palsy: Etiology
Prenatal (70%) Infection, anoxia, toxic, vascular, Rh disease, genetic, congenital malformation of brain  Natal (5-10%) Anoxia, metabolic, prematurity, traumatic delivery  Post natal Trauma, infection, kernicterus, toxic

Distinctive features

Motor impairment
Insult to developing brain

Neurological deficit which is non-progressive.

Although the neurological deficit is permanent, the effect it has on the patient is dynamic. So, orthopedic aspect of it is ever-changing with the developmental growth.

Type of Motor Dysfunction
spastic  Athetoid  Choreiform  Rigid  Ataxic  Hypotonic  Mixed

Topographic distribution
Hemiplegic  Monoplegic  Paraplegic  Diplegic  Quadraplegic  Double  hemiplegic  Total Body

Clinical features

Life expectancy in CP is about the same as for the general population for individuals without severe cognitive impairment or multiple disabilities. For the severely impaired, survival rates are improving

Early


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Full blown pictures take months to years to develop Obstetrical history or perinatal complications Difficulty in sucking, swallowing, with dribbling at the mouth Baby feels stiff or wriggles awkwardly Motor reflexes develop from cephalad-to- caudal, Sucking and swallowing present at birth. Sphincter control at 24-36 month age Primitive reflex patterns persist longer than normal and in some cases permanent. By assessing which reflex present or absent the child's neurological quotient can be determined.

Primitive Reflexes
Asymmetric tonic neck reflexes. B. Moro reflex C. Extensor thrust reflex D. Neck-righting reflex E. Parachute reaction F. Symmetrical tonic neck reflex G. Foot placement reaction
A.

Later
Neonatal reflexes delayed (grasp, withdrawal reflexes)  Milestones delayed Holds head – 3 months Walking – about 1 year

Child over 1 year  Primitive reflexes (Moro, extensor thrust response) should have disappeared  Sitting – difficulty, slump forward, lower limbs into extension, check the spine and the pelvis  Standing – Posture Position of the lower limbs Pelvis and spine, whether fixed or correctable Equilibrium reactions

Gait – Flexed knee-toe walking Ataxia or athetoid gait Scissors gait  Neuromuscular examination Typical features of UMN lesion  Sensations – skin sensations usually present, however stereognosis may be impared

Deformities  Whether fixed or correctable  Muscle contracture  Bony  associated disorders: - convulsive seizures occur in about 30% of patients, most often in those with hemiplegia - strabismus and other visual field defects may be seen. - children with athetosis due to kernicterus commonly display nerve deafness and paralysis of upward gaze - children with spastic hemiplegia or paraplegia frequently have normal intelligence and a good prognosis for social independence - spastic quadriplegia and mixed forms often are associated with disabling mental retardation;

Assocated conditions
1. mental and learning disability 40% 2. seizures 30% 3. complex movement disorders 20% 4. visual impairment 16% 5. malnutrition etc obesity 15% 6. Hydrocephalus 14%

Tests and diagnosis
Brain scans Brain-imaging technologies can reveal areas of damage or abnormal development in the brain. These tests may include the following:  Magnetic resonance imaging (MRI)  Cranial ultrasound uses high-frequency sound waves to obtain images of the brain.  Computerized tomography (CT)  Electroencephalogram (EEG)  Additional tests: Vision impairment Hearing impairment Speech delays or impairments Intellectual disabilities or mental retardation Other developmental delays

Therapy for Cerebral Palsy

Physical therapy, occupational therapy, speech and language therapy, along with adaptive equipment, are popular treatment options for children with cerebral palsy. Used within a coordinated, comprehensive treatment plan, therapy plays a vital role in managing the physical impairment while maximizing mobility potential. Therapy is employed to manage impairment (primarily spasticity, contractures and muscle tone), manage pain, and provide optimum qualityof-life by fostering functionality, self-care, and independence. Therapy also wields mental, emotional, academic, and social benefits for those with cerebral palsy.

If implemented as part of an early intervention program while the child is still developing, some therapy for cerebral palsy can lessen the impact of impairment and minimize the child’s potential for developing associative conditions. Therapy can be used alongside other treatment options, such as drug therapy, surgery, assistive technology, complementary medicine and alternative interventions. When the multidisciplinary team of practitioners determines the child’s care plan goals, they will determine appropriate therapy options. Over time, as the child develops and as conditions arise, other therapies may also be considered. Therapy is not limited to the child. Therapy can be helpful to caregivers and parents, as well. For instance, nutrition counseling can help a caregiver understand the dietary needs of the child. Behavioral therapy can help a parent learn how to best reinforce the child’s therapy progress in a positive manner. Therapy comes in many forms, for differing purposes, and may be applied at various stages of the child’s development or during adulthood.

COMMON THERAPIES USED IN CEREBRAL PALSY TREATMENT
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AQUA THERAPY BEHAVIORAL THERAPY (PSYCHOTHERAPY) HIPPOTHERAPY NUTRITIONAL AND DIETARY COUNSELING OCCUPATIONAL THERAPY PLAY THERAPY PHYSICAL THERAPY AND REHABILITATION RECREATION THERAPY (THERAPEUTIC RECREATION) SENSORY INTEGRATION THERAPY SOCIAL THERAPY SPEECH AND LANGUAGE THERAPY MASSAGE THERAPY

MASSAGE THERAPY

Massage therapy embodies the power of bodywork. The human body contains 11 major organ systems; massage can manipulate these systems in differing ways, based on the momentary needs of the individual. Massage therapy uses the power of human touch for therapeutic purposes, as well as pampering and rejuvenation. Therapeutic benefits are wide ranging and include controlling stress levels, reducing pain, releasing muscular tension, improving digestion, stimulating sensory receptors, stimulating circulation, providing flexibility, and enhancing range of motion.

The different techniques used in massage include
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Compressions Friction Gliding Holding Joint movement (active and passive) Kneading Percussions Pinching Pressure (structure, unstructured, stationary, motion or vibration)

Rocking  Rubbing  Shaking  Stretching (active, passive, resisted)  Stroking  Tapping  Touching  Traction  Vibration

Traditional Acupuncture

Fundamentally we used the group of "Tien- Hsin Twelve Points," also referred to as "Ma Dan Yang's Twelve Points." Ma Dan Yang was the name of a famous doctor in the 12th century (1123-1183) under the Sung Dynasty. He became well known because he successfully used these "Twelve Points" to treat his patients.

These twelve points are:
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Zusanli (St-36) Weizhong (UB-40) Lieque (Lu-7) Hegu (LI-4) Neiting (St-44) Quchi (LI- 11) Chengshan (UB-57) Taichong (Liv-3) Kunlun (UB-60) Yanglingquan (GB-34) Huantiao (GB-30) Tongli (H-5)

These twelve points belong to only seven meridians, but according to ancient Chinese medicine, the distribution of seven meridians actually reaches the head and the upper trunk and in this way it has the ability to master the whole body.For symptomatic treatment, we also used selected points on the Governing Vessel meridian (GV-14, 15, 16, 20, 21); Conception Vessel meridian (CV-1, 4, 6); Spleen (SP-6, 10); Extraordinary points, etc., in collaboration with the "Twelve Points."

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1. Zusanli (St-36) Indications: Gastralgia, abdominal distension, diseases of the digestive tract, paralysis, numbness of the fingers, aching legs, weak eyesight, hemiplegia, hypertension, shock, epilepsy, neurosis, and for tonic purposes. Technique: Size 28-gauge needles are inserted 1 to 1 1/2 inches at a downward slant. Every two minutes the needles are strongly twisted back and forth during the 20-30 minute treatment. Indirect moxibustion is applied for three minutes to warm the needles. 2. Weizhong (UB-40), "water element" Indications: Sciatica, back pain, paralysis of lower extremities, heat stroke, hemiplegia. Technique: Size 30-gauge needles, two inches long, inserted 1.5 cun vertically from the back, to the front. Needles are manipulated strongly every 2 minutes for 20-30 minutes. Moxibustion is applied to warm the needles for 3 minutes. 3. Lieque (Lu-7), "metal element" Indications: Headache. stiff neck, cough, asthma, facial paralysis, hemiplegia, limb swelling, painful urination. Technique: A size 32-gauge needle, 1.5 inches long, is inserted 0.5 cun at a slant toward the elbow. It is manipulated in the same manner as previously described.

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4. Hegu (LI-4), "metal element" Indication: Headache, toothache, facial paralysis, ophthalmalgia, pain and paralysis of the upper extremities, apoplexy, hemiplegia. Technique: Size 32-gauge needles, 1.5 inches long, are inserted perpendicularly towards the point Laogong (Pericardium 8) to a depth of 1.5 cun. Needles are manipulated the same way as above. 5. Neiting (St-44), "earth element" Indication: Gastralgia, headache, tonsillitis, dysentry, toothache, vocal cord paralysis, eye sores, swollen and painful arch, dyspepsia, leg cramps. Technique: Needle size 30-gauge, 1 inch in length, inserted 1 cun perpendicular to the surface. The same needle manipulation is employed and moxibustion applied indirectly as for point Hegu. 6. Quchi (LI-11) Indications: Paralysis, hemiplegia, shoulder and back pain, upper limb joint pain, hypertension, fever, swollen and painful oropharynx, disorders of the cubital joint and its surrounding soft tissue. Technique: Size 30-gauge needle, 2 inches long is inserted 1.5 cun at a perpendicular slant towards point Shaohai (H-3). The needle is manipulated strongly for 20 minutes. Indirect moxibustion was used every other session for five minutes.

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7. Chengshan (UB-57), "water element" Indications: Sciatica, paralysis of the lower extremities, prolapse of the rectum, pain in the sole, leg pain. Technique: Needles of size 30-gauge, two inches in length, are inserted 1.5 cun at a perpendicular slant. Stimulation and indirect moxibustion is applied at alternate sessions. 8. Taichong (Liv-3), "wood element" Indications: Headache, dizziness, convulsion in children and infants, epilepsy, eye diseases, uterine bleeding, mastitis, cold feet, hypertension, insomnia, hepatitis, platelet deficiency. Technique: Chinese needles, 30-gauge, two inches long, are inserted at an angle 1.5 cun deep. Stimulation and indirect moxibustion is applied as for point Chengshan. 9. Kunlun (UB-60), "water element" Indication: Paralysis of the lower extremities, lumbago, sciatica, disorders of the ankle joint and its surrounding soft tissues, stiff neck, headache. Technique: Size 30-gauge needles, 1.5 inches in length, are inserted 1.5 straight into the point. Stimulation and indirect moxibustion are applied as for point Taichong.

10. Yanglingquan (GB-34), "wood element" Indication: Hemiplegia, diseases of the gall bladder, lumbago, leg pain, dizziness, vertigo, acid regurgitation, sciatica, asthma.  Technique: Size 28-gauge needles, three inches long, are inserted straight into the point, 2 cun deep. Stimulation of the needles by twisting and indirect moxibustion is given as above.  11. Huantiao (GB-30), "wood element"  Indications: Sciatica, paralysis of lower extremities, lumbago, leg pain, disorders of the hip joint and its surrounding soft tissue.  Technique: Size 28-gauge needles, four inches long, are inserted perpendicular 2 to 4 cun deep (depending on the patient's size). The needles are manipulated in the same manner as previously described to provide stimulation, and moxibustion is added to every treatment for five minutes.  12. Tongli (H-5), "fire element"  Indications: Hysteric aphasia, cardialgia, painful arm and wrist, neurasthenia, hoarseness, stiffness of the tongue, insomnia.  Technique: One-inch needles, size 30-gauge, are inserted perpendicular to the surface 0.5 cun.
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Tam Healing and Tong Ren Therapy for Cerebral Palsy

Tong Ren Therapy is a form of energy healing developed by the prominent Boston area acupuncturist and healer, Master Tom Tam. Tong Ren was originally developed to aid in the treatment of cancer, but has been extended to treat a broad range of conditions. Tong Ren classes are now offered around the world. The clinical success of Tong Ren Therapy is due in part to the precise and scientific focus on particular areas of the body for a particular condition. The Tam Healing System utilizes information from both western and eastern medicine as well as a vast amount of clinical experience to develop these treatment protocols.

Main Points: T1 - bone marrow, immunity T2 - thymus gland, immunity C1 - effect nerves to motor cortex, development and communication between head and body C2 - effect nerves to frontal lobe, development and communication between head and body TH 16 - sky window point, foster circulation to brain, developmental issues LI 17 - sky window point, foster circulation to brain, developmental issues  Secondary Points: GV 19 - used to help balance hormonal related issues as well as subconscious patterns GV 20 - motor cortex area of the brain, coordination, development Tiandong - sky window point, improve the circulation between the head and the body UB 9 - medulla area, control circulation, blood pressure, development

Why massage therapy is important for treating cerebral palsy

cerebral palsy is an umbrella term which is used to cover a variety of different disorders. It’s something that differs from person to person, and influences all the functions of the body in some way. It’s important to realize that what’s happening doesn’t just affect a child’s motor skills, sensory function or speech. So, when we talk about a child with cerebral palsy, brain injury, stroke or other neurological conditions, treatment has to lean towards a more ‘holistic’ approach which takes the function of the entire body into consideration. For this reason, massage therapy is something that is very beneficial for children with cerebral palsy when performed alongside other needed therapies. Massage stimulates circulation, blood flow and nutrient exchange in the whole body, including the organs, soft tissues and the brain. This helps to improve the global function of the body and, in turn, a child’s cognitive function.

Ultimately, it’s important to note that every therapist working with a child will be involved in his cognitive development. Massage therapy is no exception, as it works to complement other treatments (such as functional education) to help improve bodily functions and enable the creation of new pathways in his brain.

VOJTA METHOD IN CP

In 1950, in Czechoslovakia, Vaclav Vojta had developed this technique after he observed some differences at the development of a cerebral palcied child’s spasticity treatment.In the following years, in infant and adolesant children, some muscle movements occured with applying some manuplations.This differences supplied spontan and otomatical muscle functions also some vejetative reactions such as eritema, sweating, changes in blood pressure and pulse differences.After that it has used as a therapy method.

MAIN STIMULATION POINTS
 Medial

epicondyle of humerus at the arm face side  Processus stiloideus radii at the arm after the occipital side  Medial condyle of femur at the face side  Tübercül of calcaneus at the leg after the head

ACCESSORY STIMULATION POINTS
 Medial

side of scapula  Between 7.-8. costas  Under the jaw  Acromion  Gluteals  SIAS

EXAMPLES OF THERAPEUTIC SITUATIONS

EXAMPLES OF THERAPEUTIC SITUATIONS

New Cerebral Palsy Study: Baclofen Pump

A new study measuring the efficiency of a baclofen pump in assisting cerebral palsy sufferers is being undertaken by Professor Ruth Benedict. If this pump (which is an implant that helps loosen and tone the muscles) is effective in building up flexibility and toning muscle movement, individuals will have an improved quality of life as mobility will be substantially increased.

The pump sends a little bit of baclofen (a drug from a mammalian neurotransmitter acid) to the child’s spinal fluid, boosting consistent muscle tone. This enables the child to engage in his or her daily activities with greater ease and comfort. It is also more efficient than taking pills or getting injections as these did not last as long, and often have side effects like exhaustion. Further research is being undertaken as to how to further use the pump to assist cerebral palsy sufferers.

Side effects, risks and benefits

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Side effects of baclofen can include hypotonia (loose muscle tone), sleepiness, upset stomach, vomiting, headaches and dizziness. Baclofen therapy is a surgical procedure and like all surgery will carry risks in itself. Infection, bruising, bleeding, spinal fluid leakage, headache and discomfort may be experienced but the medical team will discuss all these with you beforehand. Some potential risks include those associated with the pump. For example, the tube may move, kink or break or part of the pump may fail to work. With cerebral palsy some of the specific benefits are as follows: Facilitating improvements in self care and social function Improved motor control and function If offered at appropriate time, Baclofen therapy may reduce need or extent or orthopaedic and surgical intervention Reduction in muscle tone with Baclofen therapy may slow or prevent hip problems or dislocation Long term control of spasticity