16-10-2014

CEREBRAL PALSY

Prof. V.P.Sharma
M.S.,(Ortho), DNB(PMR), .FACS, FICS, FIMSA, MAMS, PG (Spine-Aus.)
Professor
Deptt. of Physical Medicine & Rehabilitation
K.G. Medical University, Lucknow
 CEREBRAL PALSY

• C.P. refers to a disorder of motor function

resulting from a non progressive brain lesion
occurring before the brain is fully mature.
C.P. refers exclusive to the motor dysfunction
May also have – Cognitive dysfunction or
seizures
• Lesion is static, symptoms often change with time.
• Eg. Hypotonia to hypertonia
• increasing dystonia with age
• Bony deformities
• Contractures
 Classification

1. Limbs involved - Monoplegia

Diplegia

Triplegia

Quadriplegia

Hemiplegia

2 Tone - Hypotomia
Spasticity
3 Associated Movement Disorders -
Dystonia
Chorea

Athetosis

Ataxia
 Assessment of spasticity

• Evaluation of muscle tone

• R.O.M.
• Associated movements disorders
• Psycho Social Assessment
 Physical and occupational therapy

1. Spastic
– Passive ROM
– Active ROM
– Spinal mobility
– Use of varied and differential movement pattern
incorporating varied speed and directions
– Equipment to aid with weight bearing movement and
position transitions.
– Promotive muscle Elongation as well as joint mobility
& stability
 Athetoid

• Postural tone and balance

• Promoting midline & Symmetrical muscle control
• Small graded movements

Hypotonic

• Antigravity positioning of head

• Trunk control
• Promoting automatic reactions
• Stabilization of joins
 Treatment According to age

Infancy and toddler

• Optimal movement patterns and postures during daily
care activities such as feeding, playing , carrying,
toileting and movement.
• Adaptive equipments
• Special strollers
• Bath chairs
• Feeding equipments
• Fist, hand or limbs splints
Pre-school-
• Promote skill acquisition for independent function.
• Therapy promotes strength, endurance and
movement patterns.
Mobility issues wheel
chairs crutches,
walkers, strollers, car
seats school chairs,
splints and orthotics
 Schooling

• Architecture
adaptations
• Home modifications
• Installing wheel chair
lifts
• Classroom
accommodations
Ambulation
Sports
 Formal Evaluation tools

• Modified ashworth scale (MAS)

• Measure resistance to passive movements in
upper/lower limbs
• Goniometer measurements PROM / AROM
• Gross motor functional measure
• Assess current level of function and provides goal for
treatment.
• Paediatric evaluations of disability inventory.
• Functional skills in the areas of mobility
• Self care
• Social functions
• Strength measurements by dynamometers
 Facilitation of movement patterns

• Neuro developmental training NDT/ Bobath

• Inhitit abnormal muscle tone and primitive reflaxes
• Facilitate normal movement patterns via postioning and
handling techniques that promote sensation of normal
movement
• Emphasis is on acquiring functional skills
• Weight bearing
• Weight shifting
• Normalizing tone
 Electrical stimulation
• FES
• Other Therapies
• Strengthening / Stretching
• Serial casting
• Functional Activities
• Dynamic approach repetition of activities by the patient
• Adaptive equipments
• Sealing system
• Walker
• Canes
• Splinting low temperature thermoplastics
 Oral Pharmacotherapy

• AIM Spasticity
• Associated movement eg. Dystomia
• CNS acting
• Benzodia zepines Diazepam
• Clonazepam
• Lorazepam
• Tizanidine
• Baclofen
• Peripheral- Dantrolene
 Benzodiazepines
• Acts via inhibitory neuro transmitter GABA in spinal
cord
• Effect - relief in painful muscular spasm
- Improvement in sleep
- Long term muscle tone
- Anticonvulsiant property
• Side effect - Habituation
- Sedation
- Secrctions
- Rebound seizures with abrupt
withdranwal
 Baclofen

Action on GABA receptor in spinal cord

• Effect Toletrated long term
• Muscle tone / Active Passive
• Side effect - Sedation
- Truncal hypotomia
- Change in bladder habits
 Clonidine quanfacine Tizanidine

• Effect - Aplha 2 adrenergic effects

- Anti hypertensive

- Treat movement disorder & eg tics

 Dantrolene

• works directly on the sarcoplasmic reticulum of

muscle and is effective in decreasing muscle tone

• Side effect - Muscle weakness

- GI upset, fatigue

- Hepato Toxicity
 Intrathecal Baclofen

• In patients with
spasticity of cerebral
origin
• Continuous infusion of
baclofen in intrathecal
space
 Surgery

• Maintain mobility & Stability of joints

– Surgery at hip when subluxation or abduction less

them 300
 Bracing

• Improves function
– prevent worsening of
contractures
– Prevents recurrence of
deformities after surgical
correction
 Future Direction

• Treatment for CP with focus on prevention of CP as

well as effective and permanent at the level of brain.
Treatment occurs most effectively with a
multidisciplinary approach to assessment and
treatment.
1. The commonest etiologies for cerebral palsy include all
of the following except,

I. Prematurity

II. Cerebral hypoxemia

III. Vitamin C deficiency

IV. Hyperbilirubinemia
2. Which of the following is not a Pre-natal cause of C.P.,

I. Prolonged and difficult labor

II. Premature rupture of membranes

III. CNS infection (encephalitis, meningitis)

IV. Multiple pregnancies

3. Which of the following scale is used for assessment of
spasticity-

I. GCS

II. MAS

III. AS

IV. AIS
4. Which of the following is not a centrally acting anti
spastic medication,

I. Diazepam

II. Tizanidine

III. Dantrolene

IV. Baclofen
5. Among the following which is not used for spasticity
management in C.P.,

I. Stretching Exercises.

II. Bracing.

III. Baclofen

IV. Anti spasmodic drugs.