CEREBRAL PALSY

Rahul AP BPT,MPT (CRD&ICU) C-HSET, MIAP

 Definition
• It is a None progressive disease of the CNS
secondary to a perinatal insult, resulting in
varying degrees of motor milestone delay
and dysfunction
 Types of cp
• Spastic CP-It is characterised by increased
muscle tone and tension

1.Spastic hemiplegia

2.Spastic diplegia
3.Spastic monoplegia
4.Spastic triplegia
5.Spastic quadriplegia
• Athetoid cerebral palsy-also called dyskinetic CP
Frequent involuntary movements [slow writhing
movements that results from imperfectly co-
ordinated activity of agonist and antagonist muscles
(choreo-athetosis) combined with distonic posture]
• Ataxic CP- The signs are of hypotonia, disturbance
of balance, in-cordination, intention tremor
• Mixed Cerebral Palsy
• It is a combination of spasticity and athetoid
movements
 Common Complications
• Spasticity
• Weakness
• Seizures
• Swallowing difficulty
• Visual problems
• Deformation
• Hip dislocation
• Kyphosis
• Scoliosis
• Urinary tract infection
 SIGNS AND SYMPTOMS
• Abnormal muscle tone and reflex
• Abnormal motor development
• Abnormal co-ordiantion
• Bone deformity
• Contracture
• Spasticities
• Spasms
• Involuntary movemnts
• Unsteady gait
• Problems with balance
• Decresed muscle mass
• Scisor walking and toe walking are common among
people with cp who are able to walk
• Irregular posture
• Spinal curvature
ASSESSMENT
SUBJECTIVE EXAMINATION
• Subjective information should be obtained from the
parents especially mother or relatives and through
case-sheet
General details includes
• Name
• Age and sex
• Address
• When did the mother first noticed the dysfunctions
• Siblings having same type of symptoms
Prenatal history
• Age of mother
• Consanguity marriage
• Any drugs taken during pregnancy
• Any trauma and stress(damage to cerebrum before
during or with in 5 years of birth can cause cp)
• Any addiction-smoking or alcohol
• History of previous abortions
• Multiple pregnancies
• General Status of mother
• History of rubella, cytomegalovirus, toxoptasmosis
infection These viruses cause the mother’s immune
system to release proteins that cause inflammation
in the baby’s brain
• (Periventricular leukomalacia is a kind of damage
that affects the brain's white matter because of
lack of oxygen in the womb)
Perinatal history
• History preterm or full term delivery
• History of asphyxia at birth (due
to hypoventilation during anesthesia, heart
diseases, pneumonia, respiratory failure,Knotting of
umbilical cord around the neck of infant
• Type of delivery-forceps delivery
• Presentation of child-breech presentation
• Condition of mother at the time of delivery
Postnatal history
• Delayed birth cry (when child cried)
• Weight of child at birth-low birth weight (LBW)
• History of any trauma to brain during the first 2
years of life
• History of neonatal meningitis, hypoglycaemia,
jaundice (severe jaundice can turn into a condition
known as kernicterus which is toxic to the brain)
• Hydrocephalus or microcephaly
• Nutritional level of the child (malnutrition) Feeding
difficulties
• Any medical or surgical treatment taken

• Any physiotherapy treatment previously taken

• What was the ability level of child at that time

• What obstructs the child from progress?

• What treatment was used ?

• Was the treatment effective or not?

Check the score from the case sheet
 OBJECTIVE EXAMINATION
On observation
Behaviour of the child
• Whether child is alert ,irritable or fearful in the
session or during particular activities
• Child becomes fatigued easily or not during activity
• Find out what motivates his action particular
situation,person or special playing
Communication of the child
• How child communicates with the parents
• Whether child initiates or respond with
gestures,sound,hand or finger pointing,eye pointing
or uses words and speech
Attention span
• What catches child attention?
• For how much time child’s attention is maintained
on particular thing?
• What distracts the child?
• How does parent assist him to maintain attention?
Does child follows commands
Position of the child
• Which position does the child prefer to be in?
• Can child get into that position on his own or with
help?
• Does child makes any effort to go in that position
with or with out assistance
• Symmetry of the child(actively or passively
maintained)
• If involuntary movements are present, then in
which positions these movements are decreased or
increased
Postural control and alignment
• Postural stabilization and counter positioning in all
postures
• Proper and equal weight bearing
• Fear of fall in child due to poor balance
Use of limbs and hands
• Attitudes of limbs during playing in all positions
• Whether one or both hands are used, type of grasp
and release
• Accuracy of reach and hand actions
• Any involuntary movements,tremor,or
spasms,which interfere with actions are present
Sensory aspects
• Observe child’s use of vision,hearing,touch,smell
and temperature in relevant task
• Does child enjoys particular sensations
• Whether child enjoys being moved or position
change
Form of locomotion
• How child is carried
• Any use of wheelchair or walking aids
• Which daily activities motivates child to
roll,creep,crawl,walk
Deformities
• Any part of the body, which remain in particular
position in all postures and in the movements
In the arm, this generally consist of
• Shoulder protraction 0r retraction ,adduction and
internal rotation
• Elbow flexion
• Forearm pronation
• Wrist and finger flexion
In the legs it includes
• Hip semi flexion ,internal rotation and adduction
• Knee semi flexion
• Ankle plantar flexion
• Foot pronation or supination
• Toes flexion
• Wind swept deformity of hip- one hip flexed,
abducted and external rotated other hip flexed
adducted and internal rotated, there is chance of
posterior dislocation of hip
Wind swept deformity
ON PALPATION
• Tone-hypo or hyper
• Warmth

ON EXAMINATION
Cranial nerve examination
• All cranial nerve especially optic and
vestibulocochlear to rate out the visual and hearing
impairment
Sensory examination
• It is difficult to assess sensation in babies and If
any hearing or visual or psychological
abnormalities are present/ found refer to a
specialist
Motor examination
• Muscle power and strength MMT
• Tone- hyper or hypo (modified ashworth scale)
• Atrophy
• Fasciculation
• Involuntary movements
Reflex
• Deep tendon reflex
• Superfacial
• Neonatal –ATNR, STNR, sucking, routing babinski
sign etc
ROM
• Both active and passive
Assess ADL
• Feeding
• Dressing
• Toileting
• Playing
• Growth parameters
• Height-Until 24 to 36 months of age, length in
recumbency is measured using an
infantometer .After the age of 2 years standing
height is recorded by a stadiometer
 Physiotherapy management
• Here the treatment techniques cannot be
prescribed because different techniques or
variations work for different children
AIMS OF THE MANAGEMENT ARE
• To promote the child’s abilities and to stimulate the
normal patterns of movement.
• To prevent or reduce deformity.
• To discourage the unwanted positions, movements
and behavior
 Lifting and carrying
• The physio should approach the child from
front and organize his body (especially arms
and legs)
• The physio should lift the child with a straight
back and a wide base of support
 Treatment
The physio should look into
• Child’s level of ability
• What prevent him to reach the next level
• Exercise/treatment priscription
• Its result & how to maintain the result
 FACILITATING MOTOR DEVOLEPMNT
 acceptance of prone position
• make child to prone on soft surfaces, sponge
rubber, inflatable mattress, in warm water, over
physioball, over your lap etc
• rock and sway a baby in prone suspension
postural stability of shoulder girdle
• weight on forearms and on hands
• hands on and knees & arms held stretched forward
along the ground to hold a toy at
• prone with arms held extended in air activates
• maintenance of half kneeling or upright kneeling
POSTURAL STABILITY OF PELVIS
• On elbows & knees & on hands & knees
• On half kneeling & upright kneeling with support

MAINTAINING UPRIGHT POSTURE

• Make use of adapted chairs & standing frame
• Use of orthosis
• Sitting on swiss ball etc..Helps to improve
challenges
Strengthening
• Give both eccentric and concentric works, against
gravity movements to UL LL abdomen and trunk
• If a child has some voluntary control in muscle groups,
then improve its strengthening
• Use electrical stimulation

REDUCE SPASTICITY
• Positioning
• Stretching
• ROM ex's
• Passive movements
• Splinting & casting
INCREASE MOBILITY AND FLEXIBILITY
• Rom ex's
• Maintain length of muscle by regular stretching &
splinting
• Strengthening of prime movers of a joint
PREVENT DEFORMITY
• Orthoses and night splints
• Taping techniques
IMPROVE PHYSICAL ACTIVITY
• Ex's should be intensive, challenging & meaningful &
involve integration of skills into function
• Movement should be goal oriented & interesting to
maintain motivation :-kicking a soccer ball
• IMPROVE AMBULATORY CAPACITY
• Weight bearing, promoting improving balance
• Walkers
• Adapted tricycle, wheel chair
IMPROVE PLAY
• Play is primary productive activity of children it should be
motivating & pleasurable
• Motivates social skills, intellectual & language skills
• Appropriate toys & play methods should be suggested
• Gait training
• Architectural modifications in indoor areas (ramps
or rails)
• Regular ex's, proper diet & nutrition & participation
in recreational activities
• maintain & improve cardiovascular fitness
• weight control, maintain joint & muscle integrity,
help prevent osteoporosis
Thank you….