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Cerebral Palsy = Brain Paralysis
   Definition
   Prevalence
   Etiology
   Classifications
   Clinical Presentation
   Treatments & management
Cerebral Palsy: Definition
   Cerebral palsy is a static encephalopathy
   Encephalopathy = Brain Injury that is non-
    progressive disorder of posture and movement
   Variable etiologies
   Often associated with epilepsy, speech
    problems, vision compromise, & cognitive
    dysfunction
Cerebral Palsy: Prevalence
   2-4/1000; 7-10,000 new babies each yr
   150 years ago described by Dr. Little an
    orthopedic surgeon and known as Little’s
    Disease
   During past 3 decades considerable
    advances made in obstetric & neonatal
    care, but unfortunately there has been
    virtually no change in incident of CP
Cerebral Palsy: Classification
   Various classifications of Cerebral Palsy
   Physiologic
   Topographic
   Etiologic
Cerebral Palsy: Physiologic
   Athetoid
   Ataxic
   Rigid-Spastic
   Atonic
   Mixed
Types of Cerebral Palsy
Spastic (70%)
     Quadriplegia, hemiplegia, diplegia
Athetoid (15%)
     Choreoathethoid, Dystonic
Ataxic (5%)
Mixed (10%)
     Combination of any two types of CP
Hypotonic
 Early stages of the Spastic, Dyskinetic and
 Ataxic forms
CP Spastic Hemiplegic
   Clinical features are those of pyramidal
    release involving one side of the body
     Posture and gait
     Tone & Deep tendon reflexes
     Contractures and Deformities
     Wasting of affected limbs
   Note any facial muscle weakness
       Cortical sensory loss
       Visual field defect
       Speech defects
Ataxic Cerebral Palsy
 Rare form of CP
 Hypotonic and hyporeflexic in infancy

 Ataxic – Titubation( a tremor of the head
  and sometimes trunk, commonly seen in
  cerebellar disease )
 Intention tremors and Incoordination

 Mental deficit is Mild

 Nystagmus is uncommon
Cerebral Palsy: Topographic
   Monoplegic
   Paraplegic
   Hemiplegic
   Triplegic
   Quadraplegic
   Diplegic
Cerebral Palsy: Etiologic
   Prenatal (70%)
    Infection, anoxia, toxic, vascular, Rh
    disease, genetic, congenital malformation
    of brain
   Natal (5-10%)
    Anoxia, traumatic delivery, metabolic
   Post natal
    Trauma, infection, toxic
Causes of Cerebral Palsy
 90%  of the causes are Idiopathic
 Prenatal (Before delivery)

 Maternal Infection, Genetic, Developmental,
 Vascular problems
 Natal   (During the time of Delivery)
 Anoxia, Asphyxia, Birth Trauma such as
 Dispropotion , Forceps, Rapid or Breech
 delivery
 Postnatal   (After Delivery)
 Trauma to Skull, Kernictures (Jaundice after
 birth), Infections, Vascular complications such
 as Thrombosis, Embolism, Haemmorhage
Diagnosis

 Medical   History

 CT   Scan / MRI Scan
Cerebral Palsy:
         Clinical Presentation
   Remember that motor developmental
    progression is from….


           Head to Toe
Cerebral Palsy: Complications
   Spasticity                 Visual compromise
   Weakness                   Deformation
   Increase reflexes          Hip dislocation
   Clonus                     Kyphoscoliosis
   Seizures                   Constipation
   Articulation &             Urinary tract infection
    Swallowing difficulty
On Examination
 1.Assessment of higher functions
Orientation-Normal (except in MR cases)
Speech- Dysarthria , Aphasia
Vision-Squint or Blindness
Learning – May be lost
Memory-will be impaired in most of the
 cases
Emotional State- Apathic , Frightened
Contd….
2.Assessment of Muscular System
 Tone – Spastic
          Flaccid
           Rigid
          Mixed (depends on the type of
 CP)
 Muscle Power- Assessed by MRC Grading
 Girth Of the Muscle- Its is usually reduced
 due to                   DISUSE .
Contd….
3.Assessment of Sensory System
 1.Spinothalamic sensations are Normal
  2.Posterior column is involved.
    So Joint position sense, Vibration sense
 are    usually affected
Contd….
4.Assessment of Reflexes
 Deep Tendon Reflex – exaggerated in
 spastic CP
 Neonatal reflexes – Delayed or Absent
Superficial reflexes may be affected in
 spastic CP.
5.Assessment of Chest
 Normal .
6.Assessment of limbs
1.Alteration of Tone in both upper and
 Lower limb.
Contd….
7.Assessment of Co-ordination
    In co-ordination is seen in Athetoid,
 Ataxic & Mixed type.
8.Assessment of Spine
 Spinal deformity – Scoliosis or Lardosis is
 seen
9.Assessment of Balance
    Affected.
Contd….
10.Assessment of Posture
    Three types of posture are usually seen
 according to the type of CP. They are
    1.Flexion posture
    2.Extension Posture
    3.Adduction Posture
11.Assessment of compound
 movements          Affected
Contd….
12.Assessment of Gait
  Scissoring gait – The patients try to catch their
                      own centre of Gravity.
     This is due to weakness of Abductors and
 Spasm of Adductors
13.Assessment of Other Problems
 1.Ortho Problems-Stiffness, Pain & Deformity in
 Joints
 2.Pressure sores – Ulcers over the Bony
 prominence
Cerebral Palsy: Management
   Neurologic and Physiatric
   OT and PT
   Speech
   Adaptive equipment
   Surgical
   Rhizotomy, Baclofen pumps, Botoxin
Different approaches to
       Neuromuscular education
   W M Phelps-diagnosed five types of CP
   Specific combinations of muscle education &
    bracing were prescribed for different types of
    CP.
   Muscles were assessed,classified as
    spastic,weak,normal or atonic & re-education
    was given based on their condition.
   In this system muscles antagonistic to spastic
    ones are activated.
Neuro developmental treatment
    with Reflex inhibition & facilitation
                  (NDT)
   Berta Bobath-
   This technique is based on the inhibition of tonic
    reflexes,such as symmetrical& asymmetrical
    tonic neck reflexes,tonic labyrinthine reflex.
   Ones the reflex patterns of abnormal tone are
    inhibited the child is said to have been prepared
    for movements.
   Various primitive reflexes of infancy should also
    be inhibited.
Features of the approach are
   Reflex inhibitory patterns-
   Selected to inhibit abnormal tone associated with
    abnormal movement patterns & abnormal posture.
   Sensory Motor Experience-
   The reversal of these abnormalities gives the child
    the sensation of more normal tone.
   Sensory stimuli are also used for inhibition &
    facilitation & voluntary movement.
   Facilitation Techniques For Mature Postural Reflex.
`

   Key points of control
   Are used to attempt to change the patterns of
    spasticity so the child is prepared for
    movements.
   The key points are usually head&
    neck,shoulder & pelvic girdles.
   Developmental Sequences
   All-day management –should supplement
    treatment session.parents &others are advised
    on daily management & trained to treat the
    children.
Proprioceptive neuromuscular
          Facilitation (PNF)
   Herman Kabat,with Margret Knott & Dorothy Voss-
   Developed a system of movement facilitation
    techniques &methods for inhibition of hypertonus.
   The main features are :
   Movements patterns (called mass movements
    patterns)-
   Patterns observed with functional activities as
    walking ,feeding, playing sports. These patterns
    are spiral (rotational)& diagonal.

   The movements patterns consist of the following
    components-
   (1) Flexion or Extention
   (2) Abduction or Adduction
   (3) Internal or External rotation
   Sensory (afferent) stimuli:
    Those muscle group working in synergy with
    rotational& diagonal patterns were identified &
    with a combination of touch & pressure, traction
    & compression. stretch , proprioception
    ,auditory& visual stimuli are given to muscles to
    contract against resistance.
Special Techniques
   1. Irradiation-this is the predictable overflow of
    action from one muscle group to another within
    a synergy.
   2. Rhythmic stablizations-which use stimuli
    alternating from the agonist to its antagonist in
    isometric muscle work.
   3. Stimulation of reflexes- such as the mass
    flexion or extension.
   4. Repeated contractions- of one pattern using
    any joint as a pivot.
   5. Reversals-from one pattern to its antagonist.
   6. Relaxation techniques- such as
    contract-relax & hold-relax. Ice treatment
    are used for relaxation of hypertonus.
Sensory Stimulation for
         Activation & Inhibition
   It is a sensory approach in which Rood’s
    technique-By Margret Rood
   muscles are classified according to their
    function & the appropriate stimuli for their
    action are given.
   The various nerves & sensory receptors are
    described & classified into types, location,
    effect, response, distribution & indication.
   Techniques of stimulation, such as
    stroking, brushing (tactile) icing, heating
    (temp.) pressure, bone pounding, slow &
    quick muscle stretch, muscles contractions
    (proprioception) are used to activate,
    facilitate or inhibit motor response.
   Sensory motor technique uses a series of
    eight clearly defined developmental
    patterns which children learn in sequence.
   These patterns are spine withdrawal,
    rolling over, pivot prone, neck co-
    contraction, elbow weight bearing, all four
    weight bearing, standing upright &
    walking.
   Vital functions-A developmental sequence
    of respiration, sucking, swallowing,
    phonation, chewing & speech is followed.
Reflex creeping&Other Reflex
              Reactions
   By Vaclav Vojta-
   Trigger points are points on the body
    which facilitate movement patterns
    involving the head,trunk & limbs.
   These reflex zones ( 9 in number) are
    activated with sensory stimuli & creeping
    is seen as a response to this triggering.
Sensory integration treatment
              approach
   Developed by A.J.Ayers
   The goal of this technique is to teach the
    children how to integrate all their sensory
    feedback & then produce useful &
    purposeful motor response.
   Activities like catching a ball in different
    position uses integration of visual,
    vestibular & joint proprioception feedback
    system at the same time.
   Theory of this system is that sensory input
    followed by appropriate motor function
    will contribute to the improved
    development of higher cortical motor
    sensory function.
Orthopaedic Management
 For  improvement of functional mobility and
  appearance after conservative therapy has
  failed
 Correction of contractures – Tenotomy

 Correction of deformities from muscle
  imbalance Eg. Tendon transfer
 Correction of functional handicaps of
  hands and feet – Arthrodesing operations
Gentle Stretching
Stretching is the activity of gradually applying tensile
force to lengthen, strengthen, and lubricate muscles,
often performed in anticipation of physical exertion and
to increase the range of motion within a joint. Stretching
is also believed to help to prevent injury to tendons,
ligaments and muscles by improving muscular elasticity
and reducing the stretch reflex in greater ranges of
motion that might cause injury to tissue.
Strengthening exercises
These exercises are done to increase the power &
 strength of the muscle. They usually done as
 Resisted Exercises both Manually and Mechanically.
Rolling
                  Contd…..
The patient is made to move from one side to another
 side by his side. This is known as rolling
Crawling
 The child is made to move on his four limbs
Standing with support
Posture Correction
Gait Training
Speech Rehabilitation
   VERBAL APPROACH-
   Initiating auditory-verbal therapy as early
    as possible is essential because the child's
    greatest capacity for learning language
    auditorily, occurs during the first two to
    three years of life. In order to effectively
    learn spoken language, a child's hearing
    and listening skills must be stimulated
    during this critical time.
Parent-Centered Modeling
   Parents are the major influence in a young
    child's development, acting as primary role
    models and the most effective teachers.
    For this reason, the verbal approach is
    parent-oriented. The verbal therapist
    develops a working partnership with
    parents to teach speech and language to
    the child at home
Oral Sensory motor facilitation
              techniques
   Proper neural development of oral
    movements and oral sensory function is
    vital for providing the foundation for good
    speech production and mature feeding
    patterns.
   Oral Sensitivity (based on these domains -
    Temperatures, Textures, Tastes)
    Hypersensitivity - Over-sensitive
   Hyposensitivity - Under-sensitive
   Jaw Stability
    Position of the jaw and presence/absence of stability or weakness
    during oral sensory-motor activities, such as chewing.
    Lip Function
    Position and action/movement of the lips during oral sensory-
    motor activities, such as drinking, sucking, chewing or blowing.
    Tongue Function
    Position and action/movement of the tongue during oral sensory-
    motor activities, such as chewing, drinking, sucking or blowing.
TONGUE EXERCISES
           Range of Motion
    1. Tongue Extension
   Protrude tongue between lips.
   Sticking out tongue as far as you can.
   Hold tongue steady and straight for 3 to 5
    seconds.
   Relax and Repeat 5 times.
    2. Tongue Retraction
   Retract tongue, touching the back of your
    tongue to the roof of your mouth (as if
    producing the /k/).
   Hold for 1 to 3 seconds.
   Relax and Repeat 5 times.
    3. Tongue Extension and Retraction
   Combine the two procedures above, holding
    each position for 1 to 3 seconds.
   Relax and Repeat 5 times. .
    4. Tongue Tip Up
   Place tongue on alveolar ridge, (the area behind
    your top teeth.)
   If you don't have any teeth, move your tongue
    tip up to your gum where your top teeth would
    be.
   Open mouth as wide as possible maintaining
    tongue contact.
   Hold for 3 to 5 seconds.
   Relax and Repeat 5 times
    5. Tongue Elevation Along The Palate
   Tongue tip to alveolar ridge, (The area behind your top
    teeth.)
   Move tongue front to back along the roof of your mouth.
   Relax and Repeat 5 times.
    6. Tongue Side To Side
   Tongue tip to left side of mouth, hold for 3 to 5 seconds.
   Tongue tip to right side of mouth, hold for 3 to 5
    seconds.
   Relax and Repeat 5 to 10 times.
   Tongue Resistance:
     1. Tongue Push Forward
   Stick out your tongue as far as you can.
   Put something flat (back of a spoon or a tongue depressor) against
    your tongue
   Push against your tongue with the flat object at the same time as
    you push against the flat object with your tongue
   Hold for 1 to 2 seconds.
   Repeat 5 times.
    2. Tongue Push Up
   Push down on your tongue with the flat object, while, at the same
    time, you push up with your tongue.
   Hold 1 second.
   Repeat 5 times.
JAW EXERCISES
          Range of Motion
    1. Jaw Opening
   2. Side-to-Side Movement
   3. Increasing Circular Jaw Movement
LIP EXERCISES
              Range of Motion:
    1. Lip Retraction
   Smile. Hold for 5 seconds.
   Relax and Repeat 5 times.
    2. Lip Protrusion
   Pucker your lips as if you were going to give someone a
    kiss.
   Hold for 5 seconds.
   Relax and Repeat 5 times.
    3. Lip Retraction and Protrusion
   Smile then pucker your lips. Use exaggerated
    movements.
   Relax and Repeat 5 times.
   Lip Closure:
     1. Lip Press
   Press lips tightly together for 5 seconds.
   Relax and Repeat 5 times.
    2. Lip Press on Tongue Depressor
   Tightly press lips around tongue depressor,
    while the clinician tries to remove it.
   Perform for 3 to 5 seconds.
   Relax and Repeat 5 times.
Compensatory Techniques:
   Correction of Respiratory errors:
   Attention should be given to the development of speech-
    breathing patterns before the child is a year old.
   The following techniques are used for improvement of
    breathing patterns for speech :-
   1.Break Up Persistent Tonic Reflex Patterns
   Abnormal distribution of muscle tone is found in
    abdominal, thorax & neck muscles of CP Children.When
    strong tonic reflexes persist they should be weakened or
    broken up through systematic use of such techniques as
    reflex inhibition or sensory facilitation.
   2.Facilitate Developmental Sequences
    Which Lead To Good Sitting Posture
   Many of the cerebral palsied children seem to
    collapse on sitting because much of the weight
    of the trunk and head bears down on the
    abdominal areas, thus interfering with function
    of the diaphragm & abdominal musculature.
   The back is rounded & the head is flexed so that
    the chin rest on the chest.
   In this position elevation of the rib cage
    for inhalation is difficult.
   Therefore taking the child through the
    developmental sequences leading to
    unsupported sitting with good posture is
    basic fo developing speech breathing.
   3.Maintaining Proper Postural
    Relationships between Abdomen,
    Trunk, Neck & Head.
   Seating in a properly fitted & adjusted
    relaxation chair will help the child maintain
    a more satisfactory postural relationship
    between head & neck, trunk & abdominal
    areas.
   In physical therapy ,attention must be
    given to the flexors & extensors muscles
    of the neck & shoulders.
   3.Develop a Breathing Rate of Less Than
    30 Cycles/minute
   Several procedure are suggested for imposing a
    slower rest-breathing rate on child.
   A) Crossing the child’s forearm across his chest
    & pressing them tightly enough against his
    thorax to encourage a deeper exhalation.For
    inhalation the pressure is released.
   The therapist times his movement of pressure &
    relaxation of pressure to control the normal
    breathing pattern.
   B) With the child lying on his back, flex the
    knees & press the front portion of the upper legs
    against the abdomen by flexing the hips.Quickly
    extend the legs at the hips, thus releasing the
    pressure on the abdominal area. This pattern of
    movements should be repeated at a rate
    corresponding to the normal breathing rate i.e.
    about 20 cycles/ minute.
   4.Develop a Speech Breathing
    Patterns pf Quick Inhalation &
    Controlled, Prolonged Exhalation




   Contd…
   Some CP children seem to have difficulty in
    learning to inhale quickly and then produce the
    controlled, prolonged exhalation required for
    continuous speech (as in yawning & crying).It is
    difficult to modify these breathing patterns for
    speech production.
   Momentary interference with inhalation-by
    holding a tissue over the nose & mouth-will
    cause the child to breath deeply when the
    interference is removed.
   Producing deep inhalation on a reflex basis is
    only a first step.
   Next learning is to hold the inhaled air until
    given a signal to exhale.
   At first the exhalation will be rapid &
    uncontrolled.
   Having the child imitate a prolonged sigh, a
    prolonged phonation, babbling or sustained
    blowing will help him develop controlled,
    prolonged phonations.
   5.Counteract Abdominal Movements Which
    are Asynchronous with Thoracic
    Movements
   Sometimes CP children are unable to produce
    prolonged exhalations because the abdominal-
    diaphragmatic movements are antagonistic to
    the thoracic movements.
   Because of this asynchrony the child will be able
    to produce phonation of short duration.
   To overcome this difficulty, a corset or
    girdle is wrapped around which extends
    from lower border of sternum to the ileac
    crest.
   This helps in stronger voices & longer
    exhalations.

   6.Functional Techniques for
    Developing Control of Respiration
   Many techniques & pieces of equipments
    have been developed to encourage the
    child to produce prolonged exhalations
    such as sustained blowing or sustained
    phonations.
Correction Of Phonatory Errors
1.Encouraging Vocalization:
 Parents should learn not to respond to the

  crying so quickly so that the child get
  sufficient practice to use his larynx.
 Laughing also exercises larynx.

 For “quite babies “ positioning is useful in

  facilitating vocalization.
   2.Coordinate Phonation with exhalation
   Audible sigh on the exhalation.
   After the child learned to hold a deep
    inhalation ,he should be taught to phonate a
    vowel sound on the exhalation.
   If the child has difficulty initiating phonation,
    different techniques for breaking up the
    laryngeal block should be tried.
   Positioning may also be used to good
    advantage.
   3.Develop Prolonged Phonation
    without Undesirable Tension:
   Before encouraging the child to develop
    longer phonation, the therapist should be
    sure that the child inhales sufficiently
    immediately before beginning phonation.
   The therapist should be sure that the child
    has learned to hold the inhaled air & to
    coordinate phonation with exhalation.
   4.Develop Variation of Loudness &
    pitch:
   Practice in producing tones at different
    levels of loudness & pitch levels helps the
    child to increase his laryngeal function
 Only a little imagination is required to
  think of many ways to motivate the child
  to vary the loudness, pitch or inflection
  patterns of his voice.
For example- whispering, ordering like
  police man, cheering at something or
  singing.
   5. Counteract Undesirable postural
    pattern:
   The postural pattern interfere with laryngeal
    function. as the child phonates, he extends
    the leg, arch the back and throw back his
    head.
   These can be detected by placing one’s hand
    against the soles of the child’s feet, on his
    shoulders or behind his head
   The therapist must learn how to feel these
    changes in flexors and extensor tone.
   When increase in extensor tone or
    associated with phonation, he should use
    appropriate reflex –inhibiting postures or
    appropriate sensory stimulation for
    activation and inhibition of selected
    muscle group.
CORRECTION FOR
       ARTICULATORY ERRORS
   Before going for articulatory correction the
    therapist should be sure that the child has
    sufficient control over speech breathing
    and phonation.
   The patterns of neural organization as in
    sucking and swallowing must also be
    developed.
   1.Encourage and facilitate babbling
   While an infant is crying it is possible to produce
    approximation of the lips by placing the hand
    beneath the mandible and gently elevating it.
   Repetition of this technique enables the child to
    hear and feel the consonantal modification of his
    vocalization.
   Bilabial consonants may be added by rapidly
    vibrating the lips with the therapist’s or parent’s
    fingers.
   2. develop sucking, swallowing and
    chewing patterns
   Attention should be given to the develop
    of sucking, swallowing and chewing
    patterns in CP children.
   The mother can use several techniques
    which facilitate maturation of oral
    activities.
   When spooned foods are added to the
    child’s diet, it is to be placed in the front
    of the mouth, thus encouraging the child
    to develop the tongue movements which
    are essential for the first stage of chewing
    and swallowing.
   Touching the child’s lips spoon will make
    him aware of his lips and thus facilitate
    and maintenance of lip closure.
   3. Improving the Function of the
    Lips, Mandible and Tongue as
    articulators
   The therapist should help the child about
    his awareness of his movement of the
    various articulators.
   By using the mirror the child can see the
    movement of his mandible moves with his
    tongue movement.
   Stabilization of the mandible with small
    object placed between the molars, aids
    the child in developing free tongue
    movements.
Team Approach To
            Rehabilitation
   A comprehensive management plan will
    pull in a combination of health
    professionals with expertise in the
    following:
    physical therapy to improve walking
    and gait, stretch spastic muscles, and
    prevent deformities;
   occupational therapy to develop
    compensating tactics for everyday
    activities such as dressing, going to
    school, and participating in day-to-day
    activities;
   speech therapy to address swallowing
    disorders, speech impediments, and other
    obstacles to communication;
   counseling and behavioral therapy to
    address emotional and psychological
    needs and help children cope emotionally
    with their disabilities;
   drugs to control seizures, relax muscle
    spasms, and alleviate pain;
   surgery to correct anatomical
    abnormalities or release tight muscles
   braces and other orthotic devices to
    compensate for muscle imbalance,
    improve posture and walking, and
    increase independent mobility;
   mechanical aids such as wheelchairs
    and rolling walkers for individuals who are
    not independently mobile; and
   communication aids such as computers,
    voice synthesizers, or symbol boards to
    allow severely impaired individuals to
    communicate with others.
   The members of the treatment team for a
    child with cerebral palsy will most likely
    include the following:
    A physician, such as a pediatrician,
    pediatric neurologist, or pediatric
    psychiatrist, who is trained to help
    developmentally disabled children
   An orthopedist, a surgeon who specializes in
    treating the bones, muscles, tendons, and other
    parts of the skeletal system. An orthopedist is
    often brought in to diagnose and treat muscle
    problems associated with cerebral palsy.
    A physical therapist, who designs and puts
    into practice special exercise programs to
    improve strength and functional mobility.
   An occupational therapist, who teaches
    the skills necessary for day-to-day living,
    school, and work.
   A speech and language pathologist,
    who specializes in diagnosing and treating
    disabilities relating to difficulties with
    swallowing and communication.
   A social worker, who helps individuals and
    their families locate community assistance and
    education programs.
   A psychologist, who helps individuals and their
    families cope with the special stresses and
    demands of cerebral palsy. In some cases,
    psychologists may also oversee therapy to
    modify unhelpful or destructive behaviors.
   An educator, who may play an especially
    important role when mental retardation or
    learning disabilities present a challenge to
    education.
Surgical options in CP
   Intrathecal baclofen therapy uses an
    implantable pump to deliver baclofen, a muscle
    relaxant, into the fluid surrounding the spinal
    cord. Baclofen works by decreasing the
    excitability of nerve cells in the spinal cord,
    which then reduces muscle spasticity throughout
    the body. Because it is delivered directly into
    the nervous system, the intrathecal dose of
    baclofen can be as low as one one-hundredth of
    the oral dose. Studies have shown it reduces
    spasticity and pain and improves sleep.
   Orthopedic surgery is often
    recommended when spasticity and
    stiffness are severe enough to make
    walking and moving about difficult or
    painful. For many people with cerebral
    palsy, improving the appearance of how
    they walk – their gait – is also important.
   Selective dorsal rhizotomy (SDR) is a
    surgical procedure recommended only for
    cases of severe spasticity when all of the
    more conservative treatments – physical
    therapy, oral medications, and intrathecal
    baclofen -- have failed to reduce spasticity
    or chronic pain. In the procedure, a
    surgeon locates and selectively severs
    overactivated nerves at the base of the
    spinal column.
THANK YOU

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Cerebral palsy by padma

  • 1. Cerebral Palsy = Brain Paralysis  Definition  Prevalence  Etiology  Classifications  Clinical Presentation  Treatments & management
  • 2. Cerebral Palsy: Definition  Cerebral palsy is a static encephalopathy  Encephalopathy = Brain Injury that is non- progressive disorder of posture and movement  Variable etiologies  Often associated with epilepsy, speech problems, vision compromise, & cognitive dysfunction
  • 3. Cerebral Palsy: Prevalence  2-4/1000; 7-10,000 new babies each yr  150 years ago described by Dr. Little an orthopedic surgeon and known as Little’s Disease  During past 3 decades considerable advances made in obstetric & neonatal care, but unfortunately there has been virtually no change in incident of CP
  • 4. Cerebral Palsy: Classification  Various classifications of Cerebral Palsy  Physiologic  Topographic  Etiologic
  • 5. Cerebral Palsy: Physiologic  Athetoid  Ataxic  Rigid-Spastic  Atonic  Mixed
  • 6. Types of Cerebral Palsy Spastic (70%) Quadriplegia, hemiplegia, diplegia Athetoid (15%) Choreoathethoid, Dystonic Ataxic (5%) Mixed (10%) Combination of any two types of CP Hypotonic Early stages of the Spastic, Dyskinetic and Ataxic forms
  • 7. CP Spastic Hemiplegic  Clinical features are those of pyramidal release involving one side of the body Posture and gait Tone & Deep tendon reflexes Contractures and Deformities Wasting of affected limbs  Note any facial muscle weakness Cortical sensory loss Visual field defect Speech defects
  • 8. Ataxic Cerebral Palsy  Rare form of CP  Hypotonic and hyporeflexic in infancy  Ataxic – Titubation( a tremor of the head and sometimes trunk, commonly seen in cerebellar disease )  Intention tremors and Incoordination  Mental deficit is Mild  Nystagmus is uncommon
  • 9. Cerebral Palsy: Topographic  Monoplegic  Paraplegic  Hemiplegic  Triplegic  Quadraplegic  Diplegic
  • 10. Cerebral Palsy: Etiologic  Prenatal (70%) Infection, anoxia, toxic, vascular, Rh disease, genetic, congenital malformation of brain  Natal (5-10%) Anoxia, traumatic delivery, metabolic  Post natal Trauma, infection, toxic
  • 11. Causes of Cerebral Palsy  90% of the causes are Idiopathic  Prenatal (Before delivery) Maternal Infection, Genetic, Developmental, Vascular problems  Natal (During the time of Delivery) Anoxia, Asphyxia, Birth Trauma such as Dispropotion , Forceps, Rapid or Breech delivery  Postnatal (After Delivery) Trauma to Skull, Kernictures (Jaundice after birth), Infections, Vascular complications such as Thrombosis, Embolism, Haemmorhage
  • 12. Diagnosis  Medical History  CT Scan / MRI Scan
  • 13. Cerebral Palsy: Clinical Presentation  Remember that motor developmental progression is from…. Head to Toe
  • 14. Cerebral Palsy: Complications  Spasticity  Visual compromise  Weakness  Deformation  Increase reflexes  Hip dislocation  Clonus  Kyphoscoliosis  Seizures  Constipation  Articulation &  Urinary tract infection Swallowing difficulty
  • 15. On Examination 1.Assessment of higher functions Orientation-Normal (except in MR cases) Speech- Dysarthria , Aphasia Vision-Squint or Blindness Learning – May be lost Memory-will be impaired in most of the cases Emotional State- Apathic , Frightened
  • 16. Contd…. 2.Assessment of Muscular System Tone – Spastic Flaccid Rigid Mixed (depends on the type of CP) Muscle Power- Assessed by MRC Grading Girth Of the Muscle- Its is usually reduced due to DISUSE .
  • 17. Contd…. 3.Assessment of Sensory System 1.Spinothalamic sensations are Normal 2.Posterior column is involved. So Joint position sense, Vibration sense are usually affected
  • 18. Contd…. 4.Assessment of Reflexes Deep Tendon Reflex – exaggerated in spastic CP Neonatal reflexes – Delayed or Absent Superficial reflexes may be affected in spastic CP. 5.Assessment of Chest Normal . 6.Assessment of limbs 1.Alteration of Tone in both upper and Lower limb.
  • 19. Contd…. 7.Assessment of Co-ordination In co-ordination is seen in Athetoid, Ataxic & Mixed type. 8.Assessment of Spine Spinal deformity – Scoliosis or Lardosis is seen 9.Assessment of Balance Affected.
  • 20. Contd…. 10.Assessment of Posture Three types of posture are usually seen according to the type of CP. They are 1.Flexion posture 2.Extension Posture 3.Adduction Posture 11.Assessment of compound movements Affected
  • 21. Contd…. 12.Assessment of Gait Scissoring gait – The patients try to catch their own centre of Gravity. This is due to weakness of Abductors and Spasm of Adductors 13.Assessment of Other Problems 1.Ortho Problems-Stiffness, Pain & Deformity in Joints 2.Pressure sores – Ulcers over the Bony prominence
  • 22. Cerebral Palsy: Management  Neurologic and Physiatric  OT and PT  Speech  Adaptive equipment  Surgical  Rhizotomy, Baclofen pumps, Botoxin
  • 23. Different approaches to Neuromuscular education  W M Phelps-diagnosed five types of CP  Specific combinations of muscle education & bracing were prescribed for different types of CP.  Muscles were assessed,classified as spastic,weak,normal or atonic & re-education was given based on their condition.  In this system muscles antagonistic to spastic ones are activated.
  • 24. Neuro developmental treatment with Reflex inhibition & facilitation (NDT)  Berta Bobath-  This technique is based on the inhibition of tonic reflexes,such as symmetrical& asymmetrical tonic neck reflexes,tonic labyrinthine reflex.  Ones the reflex patterns of abnormal tone are inhibited the child is said to have been prepared for movements.  Various primitive reflexes of infancy should also be inhibited.
  • 25. Features of the approach are  Reflex inhibitory patterns-  Selected to inhibit abnormal tone associated with abnormal movement patterns & abnormal posture.  Sensory Motor Experience-  The reversal of these abnormalities gives the child the sensation of more normal tone.  Sensory stimuli are also used for inhibition & facilitation & voluntary movement.  Facilitation Techniques For Mature Postural Reflex.
  • 26. `  Key points of control  Are used to attempt to change the patterns of spasticity so the child is prepared for movements.  The key points are usually head& neck,shoulder & pelvic girdles.  Developmental Sequences  All-day management –should supplement treatment session.parents &others are advised on daily management & trained to treat the children.
  • 27. Proprioceptive neuromuscular Facilitation (PNF)  Herman Kabat,with Margret Knott & Dorothy Voss-  Developed a system of movement facilitation techniques &methods for inhibition of hypertonus.  The main features are :  Movements patterns (called mass movements patterns)-  Patterns observed with functional activities as walking ,feeding, playing sports. These patterns are spiral (rotational)& diagonal.  The movements patterns consist of the following components-
  • 28. (1) Flexion or Extention  (2) Abduction or Adduction  (3) Internal or External rotation  Sensory (afferent) stimuli:  Those muscle group working in synergy with rotational& diagonal patterns were identified & with a combination of touch & pressure, traction & compression. stretch , proprioception ,auditory& visual stimuli are given to muscles to contract against resistance.
  • 29. Special Techniques  1. Irradiation-this is the predictable overflow of action from one muscle group to another within a synergy.  2. Rhythmic stablizations-which use stimuli alternating from the agonist to its antagonist in isometric muscle work.  3. Stimulation of reflexes- such as the mass flexion or extension.  4. Repeated contractions- of one pattern using any joint as a pivot.  5. Reversals-from one pattern to its antagonist.
  • 30. 6. Relaxation techniques- such as contract-relax & hold-relax. Ice treatment are used for relaxation of hypertonus.
  • 31. Sensory Stimulation for Activation & Inhibition  It is a sensory approach in which Rood’s technique-By Margret Rood  muscles are classified according to their function & the appropriate stimuli for their action are given.  The various nerves & sensory receptors are described & classified into types, location, effect, response, distribution & indication.
  • 32. Techniques of stimulation, such as stroking, brushing (tactile) icing, heating (temp.) pressure, bone pounding, slow & quick muscle stretch, muscles contractions (proprioception) are used to activate, facilitate or inhibit motor response.  Sensory motor technique uses a series of eight clearly defined developmental patterns which children learn in sequence.
  • 33. These patterns are spine withdrawal, rolling over, pivot prone, neck co- contraction, elbow weight bearing, all four weight bearing, standing upright & walking.  Vital functions-A developmental sequence of respiration, sucking, swallowing, phonation, chewing & speech is followed.
  • 34. Reflex creeping&Other Reflex Reactions  By Vaclav Vojta-  Trigger points are points on the body which facilitate movement patterns involving the head,trunk & limbs.  These reflex zones ( 9 in number) are activated with sensory stimuli & creeping is seen as a response to this triggering.
  • 35. Sensory integration treatment approach  Developed by A.J.Ayers  The goal of this technique is to teach the children how to integrate all their sensory feedback & then produce useful & purposeful motor response.  Activities like catching a ball in different position uses integration of visual, vestibular & joint proprioception feedback system at the same time.
  • 36. Theory of this system is that sensory input followed by appropriate motor function will contribute to the improved development of higher cortical motor sensory function.
  • 37. Orthopaedic Management  For improvement of functional mobility and appearance after conservative therapy has failed  Correction of contractures – Tenotomy  Correction of deformities from muscle imbalance Eg. Tendon transfer  Correction of functional handicaps of hands and feet – Arthrodesing operations
  • 38. Gentle Stretching Stretching is the activity of gradually applying tensile force to lengthen, strengthen, and lubricate muscles, often performed in anticipation of physical exertion and to increase the range of motion within a joint. Stretching is also believed to help to prevent injury to tendons, ligaments and muscles by improving muscular elasticity and reducing the stretch reflex in greater ranges of motion that might cause injury to tissue.
  • 39. Strengthening exercises These exercises are done to increase the power & strength of the muscle. They usually done as Resisted Exercises both Manually and Mechanically.
  • 40. Rolling Contd….. The patient is made to move from one side to another side by his side. This is known as rolling Crawling The child is made to move on his four limbs Standing with support Posture Correction Gait Training
  • 41. Speech Rehabilitation  VERBAL APPROACH-  Initiating auditory-verbal therapy as early as possible is essential because the child's greatest capacity for learning language auditorily, occurs during the first two to three years of life. In order to effectively learn spoken language, a child's hearing and listening skills must be stimulated during this critical time.
  • 42. Parent-Centered Modeling  Parents are the major influence in a young child's development, acting as primary role models and the most effective teachers. For this reason, the verbal approach is parent-oriented. The verbal therapist develops a working partnership with parents to teach speech and language to the child at home
  • 43. Oral Sensory motor facilitation techniques  Proper neural development of oral movements and oral sensory function is vital for providing the foundation for good speech production and mature feeding patterns.
  • 44. Oral Sensitivity (based on these domains - Temperatures, Textures, Tastes) Hypersensitivity - Over-sensitive  Hyposensitivity - Under-sensitive
  • 45. Jaw Stability Position of the jaw and presence/absence of stability or weakness during oral sensory-motor activities, such as chewing. Lip Function Position and action/movement of the lips during oral sensory- motor activities, such as drinking, sucking, chewing or blowing. Tongue Function Position and action/movement of the tongue during oral sensory- motor activities, such as chewing, drinking, sucking or blowing.
  • 46. TONGUE EXERCISES Range of Motion  1. Tongue Extension  Protrude tongue between lips.  Sticking out tongue as far as you can.  Hold tongue steady and straight for 3 to 5 seconds.  Relax and Repeat 5 times.
  • 47. 2. Tongue Retraction  Retract tongue, touching the back of your tongue to the roof of your mouth (as if producing the /k/).  Hold for 1 to 3 seconds.  Relax and Repeat 5 times.  3. Tongue Extension and Retraction  Combine the two procedures above, holding each position for 1 to 3 seconds.  Relax and Repeat 5 times. .
  • 48. 4. Tongue Tip Up  Place tongue on alveolar ridge, (the area behind your top teeth.)  If you don't have any teeth, move your tongue tip up to your gum where your top teeth would be.  Open mouth as wide as possible maintaining tongue contact.  Hold for 3 to 5 seconds.  Relax and Repeat 5 times
  • 49. 5. Tongue Elevation Along The Palate  Tongue tip to alveolar ridge, (The area behind your top teeth.)  Move tongue front to back along the roof of your mouth.  Relax and Repeat 5 times.  6. Tongue Side To Side  Tongue tip to left side of mouth, hold for 3 to 5 seconds.  Tongue tip to right side of mouth, hold for 3 to 5 seconds.  Relax and Repeat 5 to 10 times.
  • 50. Tongue Resistance: 1. Tongue Push Forward  Stick out your tongue as far as you can.  Put something flat (back of a spoon or a tongue depressor) against your tongue  Push against your tongue with the flat object at the same time as you push against the flat object with your tongue  Hold for 1 to 2 seconds.  Repeat 5 times.  2. Tongue Push Up  Push down on your tongue with the flat object, while, at the same time, you push up with your tongue.  Hold 1 second.  Repeat 5 times.
  • 51. JAW EXERCISES Range of Motion  1. Jaw Opening  2. Side-to-Side Movement  3. Increasing Circular Jaw Movement
  • 52. LIP EXERCISES Range of Motion:  1. Lip Retraction  Smile. Hold for 5 seconds.  Relax and Repeat 5 times.  2. Lip Protrusion  Pucker your lips as if you were going to give someone a kiss.  Hold for 5 seconds.  Relax and Repeat 5 times.  3. Lip Retraction and Protrusion  Smile then pucker your lips. Use exaggerated movements.  Relax and Repeat 5 times.
  • 53. Lip Closure: 1. Lip Press  Press lips tightly together for 5 seconds.  Relax and Repeat 5 times.  2. Lip Press on Tongue Depressor  Tightly press lips around tongue depressor, while the clinician tries to remove it.  Perform for 3 to 5 seconds.  Relax and Repeat 5 times.
  • 54. Compensatory Techniques:  Correction of Respiratory errors:  Attention should be given to the development of speech- breathing patterns before the child is a year old.  The following techniques are used for improvement of breathing patterns for speech :-  1.Break Up Persistent Tonic Reflex Patterns  Abnormal distribution of muscle tone is found in abdominal, thorax & neck muscles of CP Children.When strong tonic reflexes persist they should be weakened or broken up through systematic use of such techniques as reflex inhibition or sensory facilitation.
  • 55. 2.Facilitate Developmental Sequences Which Lead To Good Sitting Posture  Many of the cerebral palsied children seem to collapse on sitting because much of the weight of the trunk and head bears down on the abdominal areas, thus interfering with function of the diaphragm & abdominal musculature.  The back is rounded & the head is flexed so that the chin rest on the chest.
  • 56. In this position elevation of the rib cage for inhalation is difficult.  Therefore taking the child through the developmental sequences leading to unsupported sitting with good posture is basic fo developing speech breathing.  3.Maintaining Proper Postural Relationships between Abdomen, Trunk, Neck & Head.
  • 57. Seating in a properly fitted & adjusted relaxation chair will help the child maintain a more satisfactory postural relationship between head & neck, trunk & abdominal areas.  In physical therapy ,attention must be given to the flexors & extensors muscles of the neck & shoulders.
  • 58. 3.Develop a Breathing Rate of Less Than 30 Cycles/minute  Several procedure are suggested for imposing a slower rest-breathing rate on child.  A) Crossing the child’s forearm across his chest & pressing them tightly enough against his thorax to encourage a deeper exhalation.For inhalation the pressure is released.
  • 59. The therapist times his movement of pressure & relaxation of pressure to control the normal breathing pattern.  B) With the child lying on his back, flex the knees & press the front portion of the upper legs against the abdomen by flexing the hips.Quickly extend the legs at the hips, thus releasing the pressure on the abdominal area. This pattern of movements should be repeated at a rate corresponding to the normal breathing rate i.e. about 20 cycles/ minute.
  • 60. 4.Develop a Speech Breathing Patterns pf Quick Inhalation & Controlled, Prolonged Exhalation  Contd…
  • 61. Some CP children seem to have difficulty in learning to inhale quickly and then produce the controlled, prolonged exhalation required for continuous speech (as in yawning & crying).It is difficult to modify these breathing patterns for speech production.  Momentary interference with inhalation-by holding a tissue over the nose & mouth-will cause the child to breath deeply when the interference is removed.
  • 62. Producing deep inhalation on a reflex basis is only a first step.  Next learning is to hold the inhaled air until given a signal to exhale.  At first the exhalation will be rapid & uncontrolled.  Having the child imitate a prolonged sigh, a prolonged phonation, babbling or sustained blowing will help him develop controlled, prolonged phonations.
  • 63. 5.Counteract Abdominal Movements Which are Asynchronous with Thoracic Movements  Sometimes CP children are unable to produce prolonged exhalations because the abdominal- diaphragmatic movements are antagonistic to the thoracic movements.  Because of this asynchrony the child will be able to produce phonation of short duration.
  • 64. To overcome this difficulty, a corset or girdle is wrapped around which extends from lower border of sternum to the ileac crest.  This helps in stronger voices & longer exhalations. 
  • 65. 6.Functional Techniques for Developing Control of Respiration  Many techniques & pieces of equipments have been developed to encourage the child to produce prolonged exhalations such as sustained blowing or sustained phonations.
  • 66. Correction Of Phonatory Errors 1.Encouraging Vocalization:  Parents should learn not to respond to the crying so quickly so that the child get sufficient practice to use his larynx.  Laughing also exercises larynx.  For “quite babies “ positioning is useful in facilitating vocalization.
  • 67. 2.Coordinate Phonation with exhalation  Audible sigh on the exhalation.  After the child learned to hold a deep inhalation ,he should be taught to phonate a vowel sound on the exhalation.  If the child has difficulty initiating phonation, different techniques for breaking up the laryngeal block should be tried.
  • 68. Positioning may also be used to good advantage.  3.Develop Prolonged Phonation without Undesirable Tension:  Before encouraging the child to develop longer phonation, the therapist should be sure that the child inhales sufficiently immediately before beginning phonation.
  • 69. The therapist should be sure that the child has learned to hold the inhaled air & to coordinate phonation with exhalation.  4.Develop Variation of Loudness & pitch:  Practice in producing tones at different levels of loudness & pitch levels helps the child to increase his laryngeal function
  • 70.  Only a little imagination is required to think of many ways to motivate the child to vary the loudness, pitch or inflection patterns of his voice. For example- whispering, ordering like police man, cheering at something or singing.
  • 71. 5. Counteract Undesirable postural pattern:  The postural pattern interfere with laryngeal function. as the child phonates, he extends the leg, arch the back and throw back his head.  These can be detected by placing one’s hand against the soles of the child’s feet, on his shoulders or behind his head
  • 72. The therapist must learn how to feel these changes in flexors and extensor tone.  When increase in extensor tone or associated with phonation, he should use appropriate reflex –inhibiting postures or appropriate sensory stimulation for activation and inhibition of selected muscle group.
  • 73. CORRECTION FOR ARTICULATORY ERRORS  Before going for articulatory correction the therapist should be sure that the child has sufficient control over speech breathing and phonation.  The patterns of neural organization as in sucking and swallowing must also be developed.  1.Encourage and facilitate babbling
  • 74. While an infant is crying it is possible to produce approximation of the lips by placing the hand beneath the mandible and gently elevating it.  Repetition of this technique enables the child to hear and feel the consonantal modification of his vocalization.  Bilabial consonants may be added by rapidly vibrating the lips with the therapist’s or parent’s fingers.
  • 75. 2. develop sucking, swallowing and chewing patterns  Attention should be given to the develop of sucking, swallowing and chewing patterns in CP children.  The mother can use several techniques which facilitate maturation of oral activities.
  • 76. When spooned foods are added to the child’s diet, it is to be placed in the front of the mouth, thus encouraging the child to develop the tongue movements which are essential for the first stage of chewing and swallowing.  Touching the child’s lips spoon will make him aware of his lips and thus facilitate and maintenance of lip closure.
  • 77. 3. Improving the Function of the Lips, Mandible and Tongue as articulators  The therapist should help the child about his awareness of his movement of the various articulators.  By using the mirror the child can see the movement of his mandible moves with his tongue movement.
  • 78. Stabilization of the mandible with small object placed between the molars, aids the child in developing free tongue movements.
  • 79. Team Approach To Rehabilitation  A comprehensive management plan will pull in a combination of health professionals with expertise in the following:  physical therapy to improve walking and gait, stretch spastic muscles, and prevent deformities;
  • 80. occupational therapy to develop compensating tactics for everyday activities such as dressing, going to school, and participating in day-to-day activities;  speech therapy to address swallowing disorders, speech impediments, and other obstacles to communication;
  • 81. counseling and behavioral therapy to address emotional and psychological needs and help children cope emotionally with their disabilities;  drugs to control seizures, relax muscle spasms, and alleviate pain;  surgery to correct anatomical abnormalities or release tight muscles
  • 82. braces and other orthotic devices to compensate for muscle imbalance, improve posture and walking, and increase independent mobility;  mechanical aids such as wheelchairs and rolling walkers for individuals who are not independently mobile; and
  • 83. communication aids such as computers, voice synthesizers, or symbol boards to allow severely impaired individuals to communicate with others.
  • 84. The members of the treatment team for a child with cerebral palsy will most likely include the following:  A physician, such as a pediatrician, pediatric neurologist, or pediatric psychiatrist, who is trained to help developmentally disabled children
  • 85. An orthopedist, a surgeon who specializes in treating the bones, muscles, tendons, and other parts of the skeletal system. An orthopedist is often brought in to diagnose and treat muscle problems associated with cerebral palsy.  A physical therapist, who designs and puts into practice special exercise programs to improve strength and functional mobility.
  • 86. An occupational therapist, who teaches the skills necessary for day-to-day living, school, and work.  A speech and language pathologist, who specializes in diagnosing and treating disabilities relating to difficulties with swallowing and communication.
  • 87. A social worker, who helps individuals and their families locate community assistance and education programs.  A psychologist, who helps individuals and their families cope with the special stresses and demands of cerebral palsy. In some cases, psychologists may also oversee therapy to modify unhelpful or destructive behaviors.  An educator, who may play an especially important role when mental retardation or learning disabilities present a challenge to education.
  • 88. Surgical options in CP  Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle relaxant, into the fluid surrounding the spinal cord. Baclofen works by decreasing the excitability of nerve cells in the spinal cord, which then reduces muscle spasticity throughout the body. Because it is delivered directly into the nervous system, the intrathecal dose of baclofen can be as low as one one-hundredth of the oral dose. Studies have shown it reduces spasticity and pain and improves sleep.
  • 89. Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving about difficult or painful. For many people with cerebral palsy, improving the appearance of how they walk – their gait – is also important.
  • 90. Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of severe spasticity when all of the more conservative treatments – physical therapy, oral medications, and intrathecal baclofen -- have failed to reduce spasticity or chronic pain. In the procedure, a surgeon locates and selectively severs overactivated nerves at the base of the spinal column.