Definition

  

A sensorimotor nonprogressive disorder that affects the control of posture and movement. Lack of oxygen before, during or shortly after the birth process. Congenital c.p and acquired c.p 

Although the brain lesion is unchanging, from clinical point of view signs and symptoms do change together with children s development and maturation of the CNS. 

2.08 per 1000 school age children in Euroupin 2002 with approximately one third to half of children with cerebral palsy of low birth weight.

The classical distribution of symptoms

Spastic quadriplegia  



All four involved with a mixture of spasticity & dyskinesia Severe motor disability Can not sit or walk independently

Spastic diplegia  



Increased tone in the legs but little or no involvement in the arms. Walk with or without aids W kneeling posture in preference to long sitting

Spastic hemiplegia 


Most walk independently Wide variation in the function of the affected arm and hand

Classification according to the impairment (McCarthy) 
   

Spastic (70%) Dyskinetic (20% - 25%) Ataxic (5% 7%) Hypotonic Mix

Classification
Motor type , Cortical lesion Dystonic or Atetoid Non Progressive Ataxia Mixed of spasticity, ataxia, dystonia Rigidity

Fay Classification 
    

Spastic paralysis,non-spastic, atonic Atetosis (mid brain) Tremor & rigidity (basal ganglia) Ataxia High spinal (Medulla) Mixed

Aetiology 
  

 

Birth asphyxia Low birth weight Hypoxia, vascular accidents, infections and toxicity Familial influences Teratogens like toxoplasmosis, rubella, CMV &herpes simplex Iodine deficiency and consanguinity

Functional Mobility scale
1. Uses wheelchair, stroller or buggy: May stand for transfers and may do some stepping supported by another person or using a walker/frame.

FMS
2. Uses K-Walker or other walking frame: without help from another person

3. Uses two crutch: without help from another person 4. Uses one crutch or two sticks: without help from another person

FMS
5.Independent on level surfaces: does not use walking aids or need help from another person. If uses furniture, walls, fences, shop fronts for support please use 4 as the appropriate description

FMS
6. Independent on all

surfaces: does not use any walking aids or need any help from another person when walking, running, climbing and climbing stairs.

Walking distance
Walking 5 meters (eg, in bedroom or other room) Walking 50 meters (eg, at school, in the classroom and playground) Walking 5oo meters ( eg, in the shopping mall or street)

Rating (1-6)

GMFC 


5 level system Severity of motor involvement based on age, motor ability and use of assistive technology

Natural history 
  

Child below normal size Poor motor and cognitive skills Deformities of joints and bones Associated complications; epilepsy, visual impairment, musculoskeletal deformities, growth delay, sleep disturbance and reduced life expectancy

Epilepsy   

Higher incidences in quadriplegia than dyskinesia and spastic diplegia esp, preterm infants Epilepsy is linked with an increased risk of sensory & cognitive impairment Seizures lead to developmental regression

Sensory impairment 
 



Visual impairment (7% to 9%) Visual impairment leads to uncontrolled trunk and head Lack of proprioceptive & tactile system Diminished anticipatory control  



Nutritional factors and ability to walk are significant factors in decreased bone mineral density Difficulty in swallowing and chewing Reflux result in aspiration and consequent chest infection

Sleep disturbance due to: 
   

Sleep hypoxemia Upper airway obstruction Decreased melatonin level Nocturnal seizures Reflux and positional discomfort

Causes of hypoxemia 


Brainstem dysfunction Upper airway obstruction (hypertrophy of tonsils & adenoids

Musculoskeletal deformities in different types of cerebral palsy 
 

Imbalances in muscle group Deformities of joints and bones Osteopororosis in children unable to walk

Hemiplegia 
   

Smaller limbs in affected side Leg shortening Equinus of the foot and ankle Flexion of the elbow, wrist and fingers Adducted thumb

Diplegia   



Contractures of the hip flexors & adductors & hamstrings & calf & internal rotation of the hip and femoral anteversion Hyperextension of the knee to compensate for tight tendo-achilles Kyphosis as a sequel to tight hamstrings Hyperlordosis as a compensatory balance mechanism

Quadriplegia 
   



Dislocation of hips Pelvic obliquity Spinal curvature Limitation in sitting, standing and walking and hygiene and personal care Windswept deformity Joint pain

Gross Motor Function Classification System  

Level I Walks without restriction: limitations to more advanced gross motor skills Level II Walks without assistive devices; limitations in walking outdoors and in community

Level III:
Walks with assistive devices ; limitations in walking outdoors and in community

Level IV:
Self-mobility with limitations; children are transported or use powered mobility outdoors and in community

Level V 

Self mobility is severely limited , even with the use of assistive technology

Effects of C.P in life periods   

Birth to 3 years conservative and non invasive treatment Preschool increasing complications School age social participation

Effects of C.P in life periods  



Maturation sexual maturation social acceptance emphasize on function Adulthood Senior adult

Medications 
     

Antiemetrics to control gastric reflux Baclofen orally or intrathecally Dantrolen sodium Weakness, liver Tizanidine dysfunction Neurolytic blocks BTX-A Anticonvulsants

Surgical and orthopedic management  



Release of tendon, muscle or connective tissue for lengthening Bony surgery Multilevel surgery at the hip, knee and ankle

Selective Dorsal rhizotomy 

Devide the posterior nerve rootlets in the lumbosacral region to reduce lower limb spasticity

Management assistance 
   

Holding, Baby carrying Positioning Daily care Orthosis Adaptive equipments

Management 

Assessment of Tone, Motor behavior pattern, posture, sensory status specially vision (cataract, congenital glaucoma, strabismus, visual acuity, blindness, nistagmus, hemianopia Strengthening, coordination, gait, balance, dexterity 

Management 
 

Comprehensive treatment Functional recovery (task-oriented approach) maintenance of physiologic conditioning

Management 
     

Training of compensatory mechanisms Adaptive equipments Functional head control W.B Sitting control Serial casting Using crutch, walker, cane, shoe insert

NDT Approach   



Handling for abnormal tone and posture and movement pattern Inhibition of abnormal tone and primitive reflexes Facilitating normal movements Weight shift & W.B

Vojta approach  



Activation of postural reaction & equilibrium reaction Reaching normal development Proprioceptive inputs

Fay (Patterning) 
 



Breath control Neurological organization by encouraging prone position & creeping & crawling Head rotation for flex, ext of limbs Sensory inputs

Rood approach 

Sensory and Motor stimulations

SI therapy 
  

Jean Ayers Sensory processing Vestibular, Proprioception, Tactile 9 sensory inputs) Learning disabilities

Other techniques 


PNF, Strengthening spasticity? Electrical stimulation for weakness, spasticity, ROM, voluntary control

Before 2nd Birthday 

Level I ( Walking Independently) infants move in & out of sitting and floor sit with both hands free to manipulate objects. Infants crawl on hands & knees ,pull to stand & take steps holding on to furniture. Infants walk between 18 months and 2 years of age without the need for any assistive mobility device.

Level II (Walking with Assistance) 

Infants maintain floor sitting but may need to use their hands for support to maintain balance. Infants creep on their stomach or crawl on hands and knees. Infants may pull to stand and take steps holding on to furniture.

Level III 

(Roll & Creep)

Infants maintain floor sitting when the low back is supported. Infants roll and creep forward on their stomachs

Level IV 

( just Rolling)

Infants have head control but trunk support is required for floor sitting. Infants can roll to supine and may roll to prone.

Level V 

(No head Control)

Physical impairments limit voluntary control of movement. Infants are unable to maintain antigravity head and trunk postures in prone and sitting. Infants require adult assistance to roll.

Between 2nd and 4th Birthdays
Level I Children floor sit with both hands free to manipulate objects. Movements in and out of floor sitting & standing are performed without adult assistance. Children walk as the preferred method of mobility without the need for any assistive mobility device. 

Level II
Children floor sit but may have difficulty with balance when both hands are free to manipulate objects. Movements in & out of sitting are performed without adult assistance. Children pull to stand on a stable surface. Children crawl on hands & knees with a reciprocal pattern, cruise Holding onto furniture and walk using an assistive mobility device as preferred Methods of mobility.

Level III 

Children maintain floor sitting often by W- sitting (sitting between flexed & internally rotated hips & knees) and may require adult assistance to assume sitting. Children creep on their stomach or crawl on hands and knees (often without reciprocal leg movements) as their primacy method of self- mobility. Children may pull to stand on a stable surface and cruise short distances. Children may walk short distances indoors using an assistive mobility device an adult assistance for steering and turning.

Level IV 

Children sit on a chair but need adaptive seating for trunk control and to maximize hand function . Children move in and out of chair sitting with assistance from an adult or a stable surface to push or pull up on with their arms. Children may best walk short distances with a walker and adult supervision but have difficulty turning & maintaining balance on uneven surfaces. Children are transported in the community. Children may achieve self- mobility using a power wheelchair.

Power wheelchair

Level V 

Physical impairments resist voluntary control of movement and the ability to maintain antigravity head &trunk postures. All areas of motor function are limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment & assistive technology. Children have no means of independent mobility and are transported. Some children achieve self-mobility using a power wheelchair with extensive adaptations.

Between 4th and 6th Birthdays 

Level I: Children get into & out of, and sit in, a chair without the need for hand support. Children move from the floor & from chair sitting to standing without the need for support. Children walk indoors & outdoors, and climb stairs. Emerging ability to run & jump.

Level II 

Children sit in a chair with both hands free to manipulate objects. Children move from the floor to standing and from chair sitting to standing but often a stable surface to push up with their arms. Children walk without the need for any assistive mobility device indoors and for short distances on level surfaces outdoors. Children climb stairs holding onto a railing but are unable to run or jump.

Level III 

Children sit on a regular chair but may require pelvic or trunk support to maximize hand function .Children move in & out of chair sitting using a stable surface to push on or pull up with their arms. Children walk with an assistive mobility device on level surfaces and climb stairs with assistance from an adult. Children frequently are transported when traveling for long distances or outdoors on uneven terrain.

Level IV 

Children sit on a chair but need adaptive seating for trunk control & to maximize hand function. Children move in & out of chair sitting with assistive an adult or a stable surface to push or pull up on with their arms. Children may at best walk short distances with a walker and adult supervision but have difficulty turning and maintaining balance on uneven surfaces. Children are transported in the community. Children may achieve self-mobility using a power wheelchair.

Level V 

Physical impairments restrict voluntary control of movement and the ability to maintain antigravity head and trunk postures. All areas of motor function are limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment and assistive technology. Children have no means of independent mobility & are transported. Some children achieve self- mobility using a power with extensive adaptations.

Manual Ability Classification System for Children with Cerebral Palsy 4-18 years March 2005

MACS
1. Handles objects easily and successfully.
At most, limitation in the ease of performing manual tasks requiring speed and accuracy. However , any limitation in manual abilities do not restrict independence in daily activities.

MACS
2. Handles most objects but with somewhat reduced quality and/or speed of achievement.
Certain activities may be avoided or be achieved with some difficulty; alternative ways of performance might be used but manual abilities do not usually restrict independence in daily activities.

MACS
3. Handles objects with difficulty; needs help to prepare and/or modify activities.
The performance is slow and achieved with limited success regarding quality and quantity. Activities are performed independently if they have been set up or adapted.

MACS
4. Handles a limited selection of easily managed objects in adapted situations.
Performs parts of activities with effort and with limited success. Requires continuous support and assistance and/or adapted equipment, for even partial achievement of the activity.

MACS
5. Does not handle objects and has severely limited ability to perform even simple actions. Requires total assistance

Morbidity  

Those children with severe spastic quadriplegia and poor nutritional status have been shown to have a high risk of dying The most common cause of death for those at high risk was respiratory problems(59%),with epilepsy as the second most common cause of death.  

Mortality risk increased with increasing intellectual impairment, motor impairment & number of severe impairment. With the exception of those children with profound learning difficulty, most children with c.p can expect survive into adulthood.

Risks for severe types 
    

Osteopenia & osteoporosis Fractures may be caused by: Joint contracrure poor nutrition hip dislocation immobilisation

Learning disabilities Behavioural difficulties Epilepsy Sensory difficulties Hydrocephalus Eating & swallowing problems gastroesophageal reflux Speech & language difficulties Problem with manual dexterity

Impairments, Functional limitation, and focus of treatment in children with spasticity
Impairments Functional limitations Stereotypical Increased movement muscle stiffness, slow , patterns, poor static & labored dynamic movement balance; postural insecurity, Treatment focus Decrease stiffness, head & trunk righting & equilibrum & protective reactions,

continue
impairments Functional limitations treatment focus Practice mvt transitions like, trunk rot, rolling, come to sit & walking Mvt in all ranges, variation Decreased poor trunk Rotation movement transitions

Decreased ROM

Reaching, walking

continue
Impairment Skeletal malalignment Muscle weakness Inaccurate muscle recruitment Functional limitations Scoliosis, musculoskeletal deformities. Movements against gravity, Inefficient movement ; high energy cost Treatment focus Position properly for function; use orthoses, Strengthen through mvt experiences, use novel environment

Influence of Tonic Reflexes on Functional movement
Tonic Reflex Impairment Functional Movement Limitation Rolling from supine to prone, Reaching in supine, coming to sit, sitting

TLR in supine

Contractures Abnormal Vestibular input Limited visual field

Tonic Reflex

Impairment Impairment Contractures, Abnormal vestibular input, Limited visual field Contractures Hip dislocation Trunk asymmetry, scoliosis

Functional Movement Limitation Rolling from prone to supine, Coming to sit, sitting Segmental rolling, reaching, Bringing hand to mouth,sitting

TLR in prone

ATNR

Tonic Reflex

STNR

Functional Movement Limitation Contractures, Creeping, lack of upper & kneeling, lower Walking extremity dissociation, lack of trunk rotation

Tonic Reflex

Impairments

Functional limitation

Treatment focus in children with Athetosis Hold postures, cocontraction in midline, control & direct mvt with resistance;resi st reciprocal mvts

Low or fluctuating muscle toneWide , incoordinated movements

Potural instability ; poor balance & safety, poor mvt transitions; Unsafe mvt

Impairment

Functional limitation Reaching, walking

Treatment focus

Lack of midrange control Lack of use of hands for support

Hold in midrange; work in small increment of range Weight bearing through arm;use upper extremity weight bearing for safe movement transitions

Poor movement transitions; unsafe movement

Impairment

Functional limitation

Treatment focus Facilitating shoulder position; stabilize trunk or opposite extremity Modify behavior

Lack of graded Difficulty movement grasping; changing positions

Emotional Lability

Poor judgement of balance risk

Predictors of ambulation for cerebral palsy
Predictor By diagnosis: Monoplegia Hemiplegia Ataxia Diplegia Spastic quadriplegia Ambulation Potential 100%
100% 100% 85-90% 0-70%

Predictor By motor function Sit independently by 2 years

Ambulation Potential
100%

Sit independently by 3-4 years 50% Presence of primitive reactions beyond 2 years
community ambulation poor

Absence of postural reactions poor beyond 2 years Independently crawled symmetrically or reciprocally 100% by 2 & half- 3 years

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