Clinical examination and management of

impairments in Cerebral Palsy

(Recent Advances)

Presented By: Upama Dawadi

Moderated By: Inosha Bimali
MPT 1st year
Associate Professor
Contents
• Cerebral Palsy
• Types and Prevalence
• Clinical Examination
• Recent Interventions Employed
• Recent Advances
• Summary
• Take Home Messages

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Cerebral palsy

• a group of permanent disorders of the development of movement and posture, causing activity
limitation. (Horae BJ et. Al, 2016)

• attributed to non progressive disturbances that occurred in the developing fetal or infant brain.
(Horae BJ et. Al, 2016)

• 2-3 in every 1000 live births (Paul S et. AL, 2022)

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Types of cerebral palsy

Global
NEPAL
diplegia hemiplegia quadriplegia
dyskinetic ataxic mixed Spastic Dyskinetic Ataxic
4%
2%
13%
25%

29%

12%

69%
17%
29%

Paul S et. Al, 2022 Shrestha N et.Al, 2017

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Clinical Examination of Cerebral Palsy

Sarathy K et. Al, 2019

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 Clinical Examination of Cerebral Palsy
Physical Examination Functional Assessment

Early diagnosis (Before 5 months corrected age) • Range of Motion and • Functional Mobility Scale
• Neonatal magnetic resonance imaging (MRI) Joint contractures • Gross Motor Functional
• Prechtl Qualitative Assessment of General • Muscle Strength and Classification system
Movements (GMs) Analysis • Gillette Functional Ability
• Hammersmith Infant Neurological Examination • Muscle tone Questionnaire (FAQ)
(HINE) (scores <57 at 3 mo are 96% predictive of CP) Assessment • Peabody Developmental
• Balance and Motor Scales-2 (PDMS-2)
Equilibrium • Pediatric Outcomes Data
Collection Instrument (PODCI)

Novak I et. Al, 2017 Sarathy K et. Al, 2019

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 Interventions employed in recent years
• Home programs
• Goal-Directed training
• Action Observation therapy
• Intra-muscular Botulinum toxin-A
• Casting orthoses and Lycra splinting surgery strengthening programs
• Repetitive transcranial magnetic stimulation
• Sensory cueing
• Mirror therapy
• Constraint-Induced Movement Therapy (CIMT)
• Robotic Therapy
• Virtual Reality Therapy
(Horae BJ et. Al, 2016)
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Robotic therapy

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 Robotic therapy

Objective: Review the evidence that is available on the effectiveness of the robotic system in children
who have been diagnosed with CP.
• Total of 7 Randomized Controlled Trials
• All studies included between 20 to 52 children (4 to 14 years)
• Intervention: Received robotic treatment as a complement to conventional physiotherapy treatment in
comparison to conventional treatments only, which acted as the control group
• Treatment Duration: 4 to 12 weeks
• Session duration: 30 to 40 minutes
• Periodicity: 20 sessions over 4 weeks (5 times a week)
18 sessions over 6 weeks (3 times a week)
16 sessions over 8 weeks (2 times a week)

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Robotic therapy

Result:

• Robotic system showed improvements in walking

ability, and postural and locomotor systems

• Balance showed an increase in the robotic therapy

group in comparison to the conventional group.

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Virtual Reality Therapy

7/10

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Virtual Reality Therapy
Objective: To evaluate the effect of VR therapy on functional development in children with Cerebral
Palsy.

Methods:
Participants: 41 children (5 to 15 years)
Group 1 (n=21) Group 2 (n=20)
Conventional treatment methods Conventional treatment methods
+ occupational therapy + VRT + occupational therapy

3 days a week for 4 weeks

Virtual reality Therapy: 1 hour session (eye toy game)

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Virtual Reality Therapy
Outcome Measures: (Before and After treatment)
i) Bimanual Fine Motor Function
ii) Gross Motor Functional Classification System
iii) Functional Mobility Scale

Result:
Significant improvement in the function and mobility in the cerebral palsy patients receiving Virtual
Reality Therapy.

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Virtual Reality Therapy

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Constrained induced movement therapy (CIMT)

• The two key components:

i. Restraint of the less affected upper limb

ii. Intensive structured upper-limb therapy

(Eliasson CA et. Al, 2013)

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Article 1

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 Article 1
• Objective: To investigate the effect of mirror therapy (MT) together with taping compared to
modified constraint-induced movement therapy (mCIMT) and MT alone on the quality of upper
extremity (UE) function, dexterity, and grip strength in children with hemiplegic cerebral palsy
(CP).

• Methods: 60 children (6 to 8 years)

Group A (n=20) Group B (n=20) Group C (n=20)

MT + Taping mCIMT MT

upper limb (UL) exercise program

1h, 5 days/week for 12 successive weeks

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 Article 1
• Outcome Measure (before and after 12 successive weeks of treatment)
i. Quality of Upper Extremity Skills Test (QUEST)
ii. Box and Block Test (BBT)
iii. hand-held dynamometer

Result:
• Significant increase in all items of QUEST, dexterity and grip strength in all groups
• Significant increase all variables in group A compared to group B and C
• Significant Increase in all variables in group B compared to C

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Article 2

7/10

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 Article 2
Objective: to compare the effects of modified constraint-induced movement therapy(mCIMT) and
bimanual training (BIT).
-Effectiveness of these treatment approaches in different environments
(clinic, school and home)

Method:
• Participant: 32 children with hemiplegic CP, mainstreamed in regular school

Group A Group B
mCIMT (n=16) BIT (n=16)
10 weeks, 3 days/week, 2.5 h/day -At school and clinic (1 or 2 sessions/week respectively)
1h/day during study, 2h/day throughout follow up -At home

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 Article 2
Outcome Measure: (before and after treatment, and at 16 weeks postintervention)
i. Handheld dynamometer (Body function)
ii. Quality of Upper Extremity Skills Test , Children’s hand use experience Questionnaire(Activity Limitation)
iii. Child and Adolescent Scale of Participation (Participation Restriction)

Result:
- mCIMT had a significant effect on grip strength
- mCIMT effect size in unimanual capacity component of QUEST was large and was maintained in follow up
period
-BIT improved quantity of bimanual use while mCIMT improved quality.
-Magnitude of changes in both global participation and participation in the school activities were greater in
mCIMT group

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Article 3

8/10

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Article 3

• Objective: to explore the efficacy of a caregiver directed prolonged CIMT intervention and
compare it with intermittent manual CIMT.

• Method:
Participants: 62 children (18 months to 4 years)

Prolonged restraint (n=30) Manual restraint (n=32)

24 hr short arm restraint throughout the 2 Intermittent holding restraint, hand to hand
weeks
1 hr/ day therapy by caregiver for 6 weeks (3 blocks of 2 weeks) with 2 weeks of rest in between

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Article 3

Outcome Measure: (at baseline, 10 week follow up, 24 weeks follow up)
i) Assisting Hand Assessment
ii) Quality of Upper Extremity Skills Test
iii) Pediatric- Quality of life inventory
iv) Brimingham Bimanual Questionnaire

Result:
-Bimanual performance of children after 10 weeks of therapy was similar in two groups
-Adherence was better in the manual group

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Article 4

7/10

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Article 4
• Objective: to investigate the combined value of Action Observation Training(AOT) to mCIMT on
UL kinematics in children with unilateral CP.

• Methods:
Participant: 44 children (6-12 years) with unilateral CP
Group A Group B
mCIMT + AOT mCIMT+ placebo

• delivered in a day camp model for 9 out of 11 consecutive days (6 h/day, total of 54 h of therapy)
• 3 blocks – Individual therapy (9 hours)
- Group activities (30 hours)
-AOT/ Placebo (15 hours)
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 Article 4
Outcome Measure: (before the intervention, after and at 6 months follow-up.)
-3 dimensional movement Analysis
-Examined changes in motor control (movement duration, peak velocity, time-to-peak velocity, and
trajectory straightness) and kinematic movement patterns during the execution of three unimanual
relevant tasks.
Result:
CIMT and AOT showed a shortened movement time for the task to be performed.
-Both group showed improvement in motor control and movement patterns with no significant
difference between groups.
-Both groups performed the tasks with higher peak velocity and straighter trajectory

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Article 5

8/10

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 Article 5
Objective: To evaluate ‘remind-to-move’ (RTM) treatment by comparing it with constraint-induced
movement therapy (CIMT) and conventional rehabilitation of the upper extremity in children with
hemiplegic cerebral palsy (CP).

Method:

Participant: 73 children (5 to 16 years)

Group A Group B Group C
RTM mCIMT Conventional rehab
5 hrs/day, 5 days a week, for 3 weeks 1h/day, 2 to 3 days a week, for 3 weeks
1 hr of shaping practice and 4 hrs of
unstructured practice

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 Article 5
• Outcome measures: (baseline, post-test, and 1-month and 3-month follow-ups.)
i. The Jebsen–Taylor Hand Function Test, the Bruininks–Oseretsky Test of Motor Proficiency
(manual capacity of UE)
ii. The Caregiver Functional Use Survey (hand use in real life)
iii. grip strength, AROM (hand impairment)

Results:
-Group A and B had significant decrease in time taken to complete a task
-Both group A and B had a significant increase in functional hand use, but there was no statistical
difference in between 2 groups
-Greater improvement in motor efficiency and spontaneous use of the affected hand in children in
both groups.

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 Summary

• Robotic Therapy, Virtual Reality Therapy can have a significant improvement in the mobility and
functional aspects of children with cerebral Palsy.

• However, in the Nepali context, these approaches are not feasible everywhere.

• CIMT is a approach which is easier to use and feasible.

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Take Home Messages

Mirror Therapy + taping > CIMT CIMT + Action observation ≥

CIMT alone

Remind to move = CIMT • Can be used as alternative to CIMT

• Dosage: 1 to 2, 3 to 5 days a week, for 4 to 12 weeks

• Can be administered by caregivers alone at school, at
CIMT home or even in camp.
• Significant improvement in the activity as well as
participation level
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References
• Hoare BJ, Wallen MA, Thorley MN, Jackman ML, Carey LM, Imms C. Constraint‐induced movement therapy in
children with unilateral cerebral palsy. Cochrane database of systematic reviews. 2019(4).
• Paul S, Nahar A, Bhagawati M, Kunwar AJ. A Review on Recent Advances of Cerebral Palsy. Oxidative
Medicine and Cellular Longevity. 2022 Jul 30;2022.
• Shrestha N, Paudel S, Thapa R. Children with cerebral palsy and their quality of life in Nepal. Journal of Nepal
Paediatric Society. 2017;37(2):122-8.
• Sarathy K, Doshi C, Aroojis A. Clinical examination of children with cerebral palsy. Indian journal of
orthopaedics. 2019 Feb;53:35-44.
• Novak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, Cioni G, Damiano D, Darrah J,
Eliasson AC, De Vries LS. Early, accurate diagnosis and early intervention in cerebral palsy: advances in
diagnosis and treatment. JAMA pediatrics. 2017 Sep 1;171(9):897-907.
• Eliasson AC, Krumlinde‐Sundholm L, Gordon AM, Feys H, Klingels K, Aarts PB, Rameckers E, Autti‐Rämö I,
Hoare B. Guidelines for future research in constraint‐induced movement therapy for children with unilateral
cerebral palsy: an expert consensus. Developmental Medicine & Child Neurology. 2014 Feb;56(2):125-37.

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 Thank you

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