Rehabilitation Approach of

Children with Cerebral Palsy

Dr. Rida Khalafala
MBBS. Saint Petersburg Medical University I.P.Pavlov
MD. Saint Petersburg State Medical Academy
MPH University of Malaya (Malaysia)
outline
● Definitions
● Model of care
● Classification
● Outcome measures
● Intervention strategies & philosophies
What is Cerebral Palsy?
It is a group of conditions results in permanent disorders of movement &
posture due to damage in fetal or infant brain

Features:

1.epilepsy.
2. involuntary movement
3. abnormal sensation & cognition
4- abnormal vision , hearing & speech.
5- mental retardation.
6. abnormal movement / behaviours
What is Rehabilitation ?

Rehabilitation is combined and coordinated use of medical

, therapeutic , social , educational and vocational measures
for training or retraining the individual to highest possible
level of function

• Holistic Approach
• QOL
Aims
● Improve functional status
● Prevent secondary impairments & functional
limitations
● Efficiently use resources when there is reasonable
prognosis for improvement
● Facilitate integration into the community
Model of care
● Functional & social vs disease-based

● Growth & development

● Child-focused & family centered.

 International Classification of Functioning,
disability and Health (ICF)
condition

Body Function &

Activities Participation
structure

Environmental Factors Personal Factors

World Health Organization , 2001

International Classification of Functioning,
disability and Health (ICF)
C.P.

Activity Limitation
Impairments Walking on slopes Participation
Muscle weakness Walking in crowds Walking to class room
Muscle hypoextensibility Climbing on equipment Play during recess
Poor balance P.E class
Poor endurance

Environmental Factors Personal Factors

Teachers’ concern Child’s attitude toward:
Distance to play ground being transported
Children crowded in equipment Adult assistance
Multidisciplinary Team
Social worker

Physiotherapists psychologist

client
Occupational
Physician
Therapists

Speech
/language Orthotists
therapists
 Care Pathway

referral screening Initiate therapy

Discharge / long Interdisciplinary Cross referral -

term follow up clinic therapy
Interdisciplinary Approach
● Working for common goals
● Pooling of expertise
● Opportunity for personal growth & development
● Forum for problem solving
Classification of CP
● Etiology
impairment
● Body involvement
● Movement disorder
GMFCS for children with CP
GMFCS Description
Level I Walks without restrictions; limitation in more advanced gross motor
skills
Level II Walks without assistive devices; limitations are walking outdoors
and in the community
Level III Walks with assistive mobility devices; limitations are walking
outdoors and in the community
Level IV Self-mobility with limitations; children are transported or use
powered mobility outdoors or in the community
Level V Self-mobility is severely limited even with the use of assistive
technology
 Cerebral Palsy Assessment
●C
Outcome measures
● Validate progress
● Provides accountability to child/family/third-party
payers for intervention used
● Aides in plan of care
● Provides normative data to obtain developmental
levels e.g. age equivalent , standard score
Tests Measuring Developmental Age , Activity , or
participation Abilities

Test Developmental Function/Activity Participation

AIMS X X
GMFM X
PDMS II X X
TIMP X
Quest X
LAPI X
PEDI X X
 Assess gross motor Assess postural
function including control & alignment
Assesses normative needed for age
performance of maturation of skills
appropriate
gross/fine motor and postural functional activities in
function for children alignment of of early infancy
from birth to 72 infants from birth to
months of age 18 mths of age 34 wks gestational age
to 4 mths post full
term delivery date

PDMS AIMS TIMP

Used to evaluate Specifically designed for

quality of UE Assessment of motor CP , developed to
functions in 4 tone & oromotor measure change over
domains: function for preterm time . Consists of
dissociated babies activities in 5
movement, dimensions: lying &
grasping, More than 33 wks rolling, sitting, creeping
corrected age – 1 mths & kneeling, standing &
protective walking, running &
post term
extension & weight jumping.
bearing

QUEST LAPI
GMFM
communication rating scale
skill %
Pointing 0 – 10
Gestures 11- 20
Gestures with speech 21- 30
sounds
Speech sounds 31- 40
Single words 41 – 50
Phrases 51 – 60
Short sentences 61 – 70
Complete sentences 71 – 80
Complex sentences 81 – 90
paragraphes 91 - 100
 Spasticity
● Spasticity is one of the most common UMN lesion
problem seen in children with CP resulting in postural
control & movement disorder thereby limitting,
delaying or arresting the sensory motor
development.(also other areas like communication,
cognition, social , perception etc).
 What is spasticity?
● Spasticity is a motor disorder characterized by a velocity
dependent increase in stretch reflexes(muscle tone) with
exaggerated tendon jerks resulting from hyper excitability
of the stretch reflex as one component of the UMN
syndrome (Lance, 1980).

● Spasticity is a movement disorder affecting both the neural

& non-neural characteristics of postural tone and can be
described by the positive & negative UMN symptoms” (D.
Burke, 1988).
 Neural components of UMN symptoms
Positive symptoms Negative symptoms
● Spasticity. ● Weakness.
● Spasms (flexor & extensor). ● Loss of dexterity.
● Exaggerated tendon ● Fatigability.
reflexes.
● Clonus.
● Babinski response.
 Non-neural component of UMN symptoms

● Altered muscle length (elasticity): muscle fibres

shorten (hypoextensible).
● Altered muscle structure (viscosity): filaments
become sticky affecting muscle glide(stiffness).
● Abnormal co- contraction (reciprocal innervation) :
due to bio- mechanical effects of abnormal position.
(too much stability & not enough mobility).

Changes in visco-elastic properties leads to stiffness,

tightness & contracture.
 Normal
postural
tone

Normal
functional
Skills
achievements Normal
patterns of
movement

repetitions
Success in
normal
patterns of
movement
 CP?
● Abnorma
l postural
tone
● Deformity/ less
functional
skills
acheivments ● Abnormal patterns
of movement

● repetiti ● Success in
on abnormal
patterns of
movement/
stereotyped
Intervention Philosophies & strategies
Evidence based?
● There is no evidence that any one treatment
method is superior to another.
● Therapists select from the variety of
treatments available those that best meet the
child’s and family’s need.
 Analyzing
● Analysing the postural tone & patterns of movement.
● What the child can do? How? /can’t do ? why?
● Choosing appropriate intervention/frequency depends on:
● Age (infant, toddlers, preschool, adolescent etc)
● Distribution of postural tone (diplegic, hemiplegic, quadriplegic
etc)
● Quality of postural tone (mild, moderate or severe).
● Associated problems.(vision, hearing, cognitive, seizure, SPD etc)
 Early intervention

● Studies focused on child and family reported

favorable outcomes.

● The analysis also suggested that parent participation

might have a greater impact on child’s outcomes for
children younger than 3 yrs.
Neonatal Developmental screening
■ Neonatal physiotherapy is an advanced practice
subspecialty area of paediatric physiotherapy and
involves a highly complex set of skills in observation,
examination and intervention procedures for the
extremely fragile NICU population.
■ Main objective to identify developmental delay in 1st
year of life
■ Early intervention can change abnormal movement
pattern in mild to moderate cerebral palsy
■ Those whom deemed to be delay remain delay if no
intervention started.
■ All high risk preterm infants with
meeting criteria:
1. Gestation 32 weeks and below
2. Birth weight < 1.5 kg
3. IVH GR.3&4, PVL
4. Chronic lung disease or O2
dependency
5. Ventilated for RSD
Neonatal Developmental screening
● NICU : LAPI
● Outpatient : TIMP , AIMS , PDMS

● 2008 37 - 11 detected
● 2009 57 - 17 detected
Relative comparison of sensitivity and specificity of unit
assessment and BUSS in this audit

BUSS SENSITIVITY

AUDIT SENSITIVITY
54.5 65.40%
45.5

34.60%

final outcome N final outcome A

outcome N outcome A
Relative comparison of sensitivity and specificity of unit
assessment and BUSS in this audit

AUDIT SPICIFICITY
90.3
BUSS SPICIFICITY
76%
PERCENTAGE

23%
9.7
0.0
N D A final outcome N final outcome A
Intervention Philosophies & strategies
Neurodevelopmental Therapy ( NDT)

Moving through normal movement patterns to experience

normal movement

Major components : reflex-inhibiting posture, inhibition of

abnormal reflexes, normalization of muscle tone, and
adherence to normal developmental sequence of motor
progression
NDT
● Inhibiting abnormal movement patterns.
● Facilitating normal movement patterns.

No strong evidence that supports the effectiveness of NDT

for children with CP with respect to normalizing muscle
tone , increasing rate of attaining motor skills, and
improving functional motor skills

Butler C, Darrah J: Effects of Neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence
report. Dev Med Child Neurol 2001 ; 43: 778 - 790
Intervention Philosophies & strategies

Sensory Integration Therapy

Principle: a neurobiological process organizes sensation from one’s
own body and from environment and makes it possible to use the body
effectively within environment

Emphasis on importance of three body centered

sensory systems : tactile , proprioceptive &
vestibular
SI Therapy
Intervention Philosophies & strategies
Constrained - Induced Movement Therapy

● Constraining non-affected arm to encourage

performance of therapeutic task with the affected arm,
which children normally tend to disregard.
● Systematic review has found the effectiveness of CIMT
for children with hemiplegic CP.
 Serial casting
● Serial casting may serve to reduce spasticity in muscles by
decreasing the strength of abnormally strong tonic foot
reflexes.(Bertoli 1996).

● Serial casting in the CP population has been shown to improve

ROM.( Brouwer 2000)

● Casting provides stability and prolonged stretch of a muscle

which is immobilized in a lengthened position(Mosley 1997).

● At least 6 hrs of prolonged stretch is needed for

effectiveness(Tardieu 1987).
 Botox + serial casting
● Botox reduces spasticity and improves ambulatory
status.(Flett 1999)

● When used in combination with serial casting it has

shown to help maintain and improve muscle length
and passive ROM.(Kay 2004)

● Without conservative interventions such as serial

casting, (with & without botox injection) more
expensive procedures may be necessary. (Flett 1999)
Intervention Philosophies & strategies
Body Weight Supported Treadmill Training

Uses theories of motor learning &

importance of early task –specific
training

Theory : activate spinal & supraspinal

pattern generators for gait
Intervention Philosophies & strategies

Strengthening

Progressive resisted exercise improves muscle performance

& functional outcomes in CP children

Research had supported effectiveness on increasing force

production in CP
Dodd et.al. systematic review of strengthening for individuals with cerebral palsy . Arch Phys Med
Reh,83:1157-1164, 2002
Intervention Philosophies & strategies
NMES
Multiple studies have demonstrated the effectiveness of
NMES,

• Reduce spasticity.

• Increase ROM & strength.

• Increase force production.

• Promote initial learning of selective motor control.

Intervention Philosophies & strategies

Orthotic devices , splints , cast

Goals :
● Maintenance or increase ROM
● Protection or stabilization of a joint
● Promotion of joint alignment
● Promotion of function
 Ankle Foot Orthosis
● Compared with barefoot gait, AFO’s enhanced gait
function in diplegic subjects. Benefits resulted from
elimination of premature PF and improved progression
of foot contact during stance.
Intervention Philosophies & strategies
Assistive Technology & Adaptive Equipment
● Optimizes alignment, posture & function.
● Inhibits spasticity patterns.
● Facilitates more normal movement.
 Adjunct therapies
● Hippotherapy.

● Aquathearpy.

● suits.

● Theratogs.
Intervention Philosophies & strategies
Speech & Language Therapy
❖Oralmotor function using strengthening / Intraoral
stimulation
❖ verbal ( PROMPT) & non-verbal communication skills
( AAC & PECS , macatone)
❖auditory training for HI
❖audiometry screening
❖ swallowing function
Intervention Philosophies & strategies

Psychological Assessment & Management

Social support
 % of patients who did not attend PT Mx

31%

Attended PT management
Not attended PT management

69%

Out of 32 patients received botox 69% attended PT

& 31% did not attend
 % of patients included in PT Mx

9%

Attended PT Mx
Dropped out

91%

Out of 22 patients, 91% fully attended PT Mx.

% of patients who improved in ROM post botox
3-6 weeks & 3-6 months.
improved

88%

70%
68%
56%
53%
post 3-6 weeks
post 3-6 months
%

35%

18%

0%

post 3-6 weeks post 3-6 months

post 3-6 weeks & months
 Benefits of communication
● Case selection.

● Goal setting.

● Educating parents/caregiver in active participation

● Compliance
Thank you