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CEREBRAL PALSY
Definition
 It is defined as a group of disorders
resulting from permanent non
progressive cerebral dysfunction
developing before maturation of CNS
affecting the locomotor system
 It is non-contagious motor conditions
that cause physical disability in
human development
 Although brain lesions that result in
CP are not progressive, clinical picture
of CP may change with time
 In addition to primary impairments in
gross & fine motor function, there may
be associated problems with
cognition, seizures, vision, swallowing, s
peech, bowel-bladder, & orthopedic
deformities
Criteria of diagnosis
◦ Neuromotor control deficit that alters
movement or posture
◦ Static brain lesion
◦ Acquisition of brain injury either
before birth or in first years of life
History
 Formerly known as "Cerebral Paralysis,“
◦ First identified by English surgeon William Little in
1860. (Little’s disease)
◦ Believed that asphyxia during birth is chief cause
 In 1897, Sigmund Freud, suggested that
difficult birth was not the cause but only a
symptom of other effects on fetal development
 National Institute of Neurological Disorders &
Stroke (NINDS) in 1980s suggested that only a
small number of cases of CP are caused by lack
of oxygen during birth
Epidemiology
 The incidence of CP is about 2 per 1000 live
births
 The incidence is higher in males than in
females
 Other associated problems include
◦ Mental disadvantage (IQ < 50): 31%
◦ Active seizures: 21%
◦ Mental disadvantage (IQ < 50) and not walking:
20%
◦ Blindness: 11%
 During past 3 decades considerable advances
made in obstetric & neonatal care, but there
has been no change in incident of CP
 The population of children with CP may be
increasing due to premature infants who are
surviving in greater numbers, higher
incidence
 in normal-weight term infants (3), and longer
survival
 overall.
Causes of CP
 Prenatal (70%)
 Peri-natal (5-10%)
 Post natal
Prenatal
 Maternal infections E.g. rubella,
herpes simplex
 Inflammation of placenta (chorion
amnionitis)
 Rh incompatibility
 Diabetes during pregnancy
 Genetic causes
 Exposure to radiations
 Maternal jaundice
Peri- natal
 Prematurity- immature respiratory &
cardiac function
 Asphyxia
 Maconeum aspiration
 Birth trauma
 Disproportion
 Breech delivery
 Rapid delivery
 Low birth weight
 Coagulopathy
Post natal
 Brain damage secondary to cerebral
hemorrhage, trauma, infection or
anoxia
 Motor vehicle accidents
 Shaken baby syndrome
 Drowning
 Lead exposure
 Meningitis
 Encephalitis
 Additional risk factors for CP
include
◦ Kernicterus
◦ methyl mercury exposure
◦ genetic causes
Classification of CP
 Depending on the topographical
distribution
◦ Monoplegic
◦ Diplegic/ Paraplegic
◦ Triplegic
◦ Hemiplegic
◦ Tetraplegic / Double hemiplegia
 Monoplegia is one single limb being affected.
 Diplegia: LE affected, with little to no
upper-body spasticity.
◦ The most common form of spastic forms
◦ Most people with spastic diplegia are fully
ambulatory, but are "tight" & have scissors gait
◦ Flexed knees & hips to varying degrees, &
moderate to severe adduction are present
◦ Often nearsighted & intelligence is unaffected
◦ In 1/3rd of spastic diplegics, strabismus may be
present
 Hemiplegia
◦ The most ambulatory of all forms, although
they generally have dynamic equinus on
affected side
 Triplegia: three limbs affected usually
both LL & one UL
 Quadriplegia: all four limbs more or
less equally affected.
◦ Least likely to be able to walk
◦ Some children also have hemiparetic
tremors (hemiballismus), & impairs normal
movement
 Depending on tone or movement
patterns (physiologic)
◦ Spastic
◦ Athetoid/ dyskinetic
◦ Ataxic
◦ Flaccid/ Hypotonic
◦ Mixed
Spastic CP
 It is the most common type of CP,
occurring in 70% to 80% of all cases.
 The cerebral cortex is affected
 Moreover, spastic CP accompanies any
of the other types of CP in 30% of all
cases
 It can be monoplegia, diplegia,
triplegia, hemiplegia or quadriplegia.
Athetoid/ dyskinetic CP
 It is mixed muscle tone
 Often show involuntary motions
 The damage occurs to extrapyramidal motor
system & pyramidal tract
 It occurs in 10% to 20% of all cases
 In newborn infants, high bilirubin levels in
blood, if left untreated, can lead to brain
damage in certain areas (kernicterus).
 This may also lead to Athetoid CP
Ataxic CP
 It is caused by damage to
cerebellum
 They are least common types of
CP, occurring only in 10% of all cases
 Some of these individuals have
hypotonia and tremors
Hypotonic CP
 Hypotonic CP have musculature that is
limp, and can move only a little or not at
all (Floppy child)
 The location of damage is wide spread in
the CNS
 Although physical therapy is usually
attempted to strengthen muscles it is not
always fundamentally effective.
Mixed CP
 Signs & symptoms of spastic CP is
seen with any other type of CP
◦ Most commonly mixed with Athetoid
 Depending on functional level (Gross
Motor Function Classification System)
◦ It classifies acc. to age categorized
activity level
Cerebral Palsy: PT assessment and Management
pathology
 Periventricular leukomalacia (PVL) is the
most common finding in CP
 Corticospinal tract fibers to LL are medial to
those of UL in periventricular white matter.
◦ Thus children with PVL typically have spastic
diplegia (common type of CP)
 Bilirubin encephalopathy in basal ganglia is seen in
athetoid CP following a diagnosis of kernicterus
 Focal cortical infarcts involving both grey & white
matter are found in patients with hemiparesis, &
are typically related to MCA strokes
 Brain malformations can be found on neuroimaging
in approximately 10% of children
Signs & symptoms (spastic)
 Hypertonia
 Exaggerated reflexes &
+ve barbinskis
 Clonus
 Poor voluntary movement
 Scissoring gait
 Low intelligence & loss of
memory
 Epilepsy
 Synergistic pattern
 Contracture, deformity
& wasting
◦ Adduction & IR of
shoulder
◦ Flexion of elbow &
pronation of forearm
◦ Wrist flexion & thumb
inside hand
◦ Flexion & adduction of hip
◦ Knee flexion
◦ PF of ankle
Extrapyramidal CP
 May affect limb, face, tongue
& speech
 Characterized by continuous
muscular worm like movement
 Postural instability
 Decreased movement in prone
position
 Fluctuation of tone from high
to low
 Reflexes are usually normal &
muscles are able to contract
 Decreased stability
 Difficulty to look up
 Emotional liability
 Arms are more affected
 Sucking & feeding problems
 Delayed head & trunk control
 May be either quadriplegic or
rarely hemiplegic
 Subtypes -
dystonic, athetoid, choroid, h
emiballismic, rigid
Ataxic / hypotonic
 Inco-ordination
 Intension tremor
 Hypotonia
 Nystagmus
 Diminished reflexes
 Speech, visual,
hearing & perceptual
problems
 Joint hypermobility
 Dysmetria
 Incontinence
 Postural instability
 Gait disturbances
 Imbalance & lack of
trunk control
 Unsteadiness

risk babies
 Biological risk
 Established risk
 Environmental & social risk
Biological risk
 Birth weight of 1500g or less
 Gestational age of 32 weeks or less
 Small for gestational age (less & 10th percentile of
weight)
 Ventilator requirement for 36 hours or more
 Intracranial hemorrhage
 muscle tone abnormalities
 Recurrent neonatal seizures (3 or more)
 Feeding dysfunction
 Symptomatic (TORCH)
 Meningitis
 Asphyxia with apgar score <3 in 1 min after birth or <6
in 5 min after birth
Established risk
 Hydrocephalus
 Microcephaly
 Chromosomal abnormalities
 Musculoskeletal abnormalities (CDH, AMC, limb
deficiencies)
 Multiple births more than twins
 Brachial plexus injuries
 Myelodysplasia
 Congenital myopathies
 Inborn errors of metabolism
 HIV infection
Environmental/ social risk
 Single parent
 Parental age less than 17
 Poor quality infant parent
attachment
 Maternal drug or alcohol abuse
 Behavioral state abnormalities
(lethargy, irritability)
Detection of risk babies
 Principles
◦ There should be definite objective
◦ Some form of action should be possible if the
test is positive
◦ The population should be defined
◦ Test should be sensitive
◦ Test should be specific
◦ Screening should start at foetal life &
continue into early childhood
 Some test are for all children but some are for those
who are known to be at risk
Prenatal screening
 Routine check up for mother during
pregnancy is beneficial for the
mother & the foetus
 Health education
◦ Diet advice (avoid tobacco & alcohol)
◦ Exercise on prescription
◦ Sleep & working habits
 Clinical examination
◦ Breast condition
◦ Height of uterus
◦ Position of foetus
◦ BP
◦ Samples of blood & urine
 For special test condition sought are
◦ Phenylketonuria
◦ Glycosuria
◦ Albuminuria
◦ Rh incompatibility
◦ Congenital syphillis
◦ Rubella, AIDS
◦ Neural tube defect
 Special test for screening
◦ USG from 8-12 weeks
 For the assessment of the gestational period
 Congenital abnormalities in various organ defect
◦ Amniocentesis from 16-18 weeks of pregnancy
 To find chromosomal defect, if the test is positive
terminate pregnancy
◦ Chorionic villus sampling technique in 8-11
weeks of pregnancy
 For chromosomal study
Post natal screening
 Starts in the immediate neonatal
period & during the first two years
◦ To find biochemical defects
◦ Hearing & visual problems
 Clinical methods (at birth)
◦ Examination of weight, height, head
circumference
◦ Gestational age
◦ Musculoskeletal defects
◦ Testicular descent
◦ At 6 weeks repeat test
 Chemical methods
◦ Blood sample from heel prick at 2-5 days
of age & repeated where necessary
 Respiratory conditions, cardiac pathology,
haemoglobinopathies can be detected
 Neuromuscular pathologies (cpk level)
 Metabolic disorders
 Gene abnormalities
 Electronic scanning
◦ USG, CT Scan, MRI
 To find out
AVM, hemorrhage, cyst, leucodystrophies
etc
Diagnosis
 The diagnosis of CP depends on
patient's history & on the basis of
significant delay in gross & fine motor
function, with abnormalities in tone,
posture, & movement on neurological
examination.
 Once diagnosed with CP, further
diagnostic tests are optional.
 MRI is preferred over CT due to diagnostic
yield & safety.
 The CT or MRI also reveals treatable
conditions, such as
hydrocephalus, AVM, subdural hematomas
etc.
 Diagnosis, classification, & treatment are
often based on abnormalities in tone
 Apgar scores have sometimes been used as
one factor to predict whether or not an
individual will develop CP
Diagnostic tools
 Movement Assessment of Infants (MAI): able
to predict CP at 4 months (identifies motor
delay)
 Alberta Infant Motor Scale (AIMS) is able to
predict CP at 6 months (Identifies motor
delays & measures changes in motor
performance over time)
 Bayley scale is able to predict CP at 1 year
(Identifies devt delay in gross & fine motor, &
cognitive domains)
Management
 Medical
 Surgical
 Rehabilitative
Drugs
 Oral medications such as
baclofen, diazepam, and trihexyphenidyl
as well as therapeutic botulinum toxin
(Botox)
 Children with dystonic CP have dopa-
responsive dystonia, with improved
motor function using levodopa
 Children with basal ganglia/thalamic
injury from perinatal asphyxia may
develop improved expressive speech &
hand use with trihexyphenidyl
Surgery
 Dorsal rhizotomy reduces spasticity
 Joint & Tendon release most often performed on
hips, knees, & ankles.
 The insertion of a baclofen pump usually during
young adolescence.
◦ usually placed in left abdomen - a pump that is
connected to spinal cord,
◦ sends bits of Baclofen to relax muscle
 Bony correction E.g. femur (termed femoral
anteversion or antetorsion) & tibia (tibial torsion).
2ndary complication caused by spastic muscles
generating abnormal forces on bones
Prognosis
 CP is not a progressive but the symptoms
can become more severe over time
 Prognosis depends on intensity of
therapy during early childhood
 Tend to develop arthritis at a younger
age than normal because of pressure
placed on joints by excessively toned &
stiff muscles
 Intellectual level among people with CP varies
from genius to intellectually impaired
◦ (it is important to not underestimate a person with CP
and to give them every opportunity to learn)
 The ability to live independently with CP varies
widely depending on severity of each case.
◦ Some individuals with CP are dependent for all ADL.
◦ Some can lead semi-independent lives, needing
support only for certain activities.
◦ Still others can live in complete independence.
 Persons with CP can expect to have a
normal life expectancy
 Survival is associated with the ability to
ambulate, roll, & self-feed
 As the condition does not directly
affect reproductive function, some have
children & parent successfully
 There is no evidence of increased
chance of a person with CP having a
child with CP
Notable persons
 Abbey Curran, American beauty queen
with CP who represented Iowa at Miss
USA 2008 and was the first
contestant to compete with a
disability
Prediction of ambulation
Pt assessment
 Subjective Examination:
◦ Obtained from parents especially mother
or from relatives and through case-sheet.
◦ General details includes
 Name
 Age & Sex
 Address
 When did the mother first noticed the
dysfunctions
◦ Siblings having same type of symptoms
PT assessment
 History
◦ Review of complications of pregnancy &
delivery, birth weight, gestation, any
neonatal & perinatal difficulties,
feeding problems, and other health-
related problems
◦ Developmental milestones
 Prenatal History
◦ Age of mother
◦ Consanguity marriage
◦ Any drugs taken during pregnancy
◦ Any trauma & stress
◦ Any addiction – smoking or alcoholism
◦ History of TORCH infection
◦ History of previous abortions, still born or death
after birth
◦ Multiple pregnancies
◦ Status & cast of the mother
 Perinatal History
◦ Place of delivery
◦ History preterm or post-term delivery
◦ History of asphyxia at birth
◦ History of prolonged labour pain
◦ Type of delivery (Forceps, vacuum
delivery)
◦ Presentation of child (Breech)
◦ Condition of mother at the time of
delivery
 Postnatal History
◦ Delayed birth cry
◦ Weight of the child at birth
◦ History of trauma to brain during the first 2 years of life
◦ History of neonatal
meningitis, jaundice, hypoglycemia, Hydrocephalus or
Microcephaly
◦ Nutritional habits of the child (malnutrition), Feeding difficulties
◦ Any medical, surgical or physiotherapy treatment taken before
◦ What treatment was used?
◦ Was the treatment effective or not?
◦ What was the ability level of child at that time?
◦ What obstructs the child from progress?
◦ Apgar Score from the case-sheet
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
◦ What motivates his action – particular situation,
person or special plaything
 Communication of the child
◦ With the parents
◦ Whether child initiates or responds with gestures,
sounds, hand or finger pointing, eye pointing or uses
words and speech
 Other observations
◦ Involuntary movements
◦ Deformities & contracture
◦ Scar may be present
◦ Trophic changes may also be seen due to
poor positioning
◦ Postural faults
◦ Gait abnormalities
◦ Use of external appliances
 Attention span
◦ What catches child’s attention
◦ For how much time child’s attention is
maintained on particular thing
◦ How does parent assist him to maintain
attention
◦ What distracts the child
◦ Does child follows suggestions to move
or promptings to act
◦ 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?
 With assistance, child makes any effort to go in
that position
 Symmetry of the child (actively or passively
maintained)
 If involuntary movements present, then in which
positions these movements are decreased or
increased
◦ Postural control & alignment
 How much parental support is given
 Postural stabilization and counterpoising in
all postures
 Proper & equal weight bearing
 If the child’s center of gravity appears to be
unusually high, resulting in floating legs and
poor ability to raise head against gravity
 Fear of fall in child due to poor balance
◦ Use of limbs & hands
 Limb patterns in changing or going into position
as well as using them in position
◦ 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, tremors or
spasms, which interfere with actions, are
present
◦ Sensory aspects
 Observe child’s use of vision, hearing, of
touch, smell and temperature in relevant tasks
 Does child enjoys particular sensations
 Whether child enjoys being moved or having
position changed
◦ Form of Locomotion
 How child is carried
 Any use of wheelchair or walking aids
 Which daily activities motivates child to
roll, creep, crawl, bottom shuffle or walk
◦ Deformities
 Any part of body, which remains in particular position in all
postures & in the movements
 The positional preferences typically seen in spastic cerebral
palsies are for mid positions of body –
 In the UL
 Shoulder protraction or retraction, adduction and internal rotation,
Elbow flexion, Forearm pronation, Wrist & Fingers flexion
 In the LL
 Hip semi-flexion, internal rotation and adduction, Knee semi-flexion,
Ankle plantar flexion, Foot pronation or supination, Toes flexion
 Athetoid or dystonic posturing usually incorporates
extremes of movement such as total flexion or extension
 Windswept Deformity of hip – One hip flexed, abducted and
externally rotated; other hip flexed, adducted and internally
rotated and in danger of posterior dislocation
 Higher cognitive function
◦ Drowsy & lethargic
◦ Decrease in intellectual function
◦ Mental retardation (mild to profound)
◦ Attention deficit & easily distractible
◦ Poor memory
◦ Poor comprehension of speech &
language
 Cranial nerve integrity
◦ Strabismus or squint (Occulo motor
nerve)
◦ Visual defects (optic nerve)
◦ Auditory defects (auditory nerve)
◦ Feeding & swallowing problems (lower
cranial nerves) etc.
 Special senses
◦ Visual & auditory defects
◦ Tactile & vestibular hyposensitivity or
hypersensitivity
On examination
 Sensory Assessment
◦ It is difficult to assess sensation in
babies and young children with severe
multiple impairments.
◦ If any hearing or visual or psychological
abnormalities are present then
assessment done by specialist is required
 Motor integrity
◦ Abnormalities of tone
 Spasticity, hypotonicity, dystonia etc
◦ Muscular weakness
◦ Loss of voluntary control
◦ Decreased co ordination
 Reflex integrity
◦ Abnormal DTR
◦ Abnormal Superficial reflexes
◦ Abnormal primitive reflexes may be
persistent
 ATNR, Extensor thrust, gallant reflex etc
 ROM & flexibility
◦ Decreased in the ROM of the involved
limbs
◦ Tightness & contracture in hip
adductors, hamstrings, calf are very
common
 Anthropometric measurement
◦ Height or length decreased (growth
retardation)
◦ Weight – decreased (thin & lean) or obese
◦ Head circumference – decreased (growth
retardation or microcephaly), increased
(hydrocephalus)
◦ 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
Weight kg Pounds
At birth 3.25 7
3-6 months Age in months +9/2 Age in months + 11
1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17
7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
Weight kg Pounds
At birth 3.25 7
3-6 months Age in months +9/2 Age in months + 11
1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17
7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
 Weight
 Head circumference of the child -
◦ The tape is used to measure
occipitofrontal head circumference
from external occipital protuberance to
glabella
Head cicumference Cm
At birth 35
3 months 40
1 yr 45
2 yrs 48
12 yrs 52
Developmental milestones
 Age Developmental Milestones
 4 to 6 weeks Social smile
 3 months Head holding
 6 months Sits with support
 7 months Sits without support
 5 to 6 months Reaches out for bright object & gets it
 6 to 7 months Transfers object from one hand to other
 6 to 7 months Starts imitating cough
 8 to 10 months Crawls
 10 to 11 months Creeps
 9 months Standing holding furniture
 12 months Walks holding furniture
 10 to 11 months Stands without support
 13 months Walks without much of a support
 12 months Says one word with meaning
 13 months Says three words with meaning
 15 to 18 months Joints 2 or 3 words into sentence
 13 months Feeds self with spoon
 15 to 18 months Climbs stair
 15 to 18 months Takes shoes and socks off
 24 months Puts shoes and socks on
 24 months Takes some clothes off
 3 to 4 years Dresses self fully
 2 years Dry by day
 3 years Dry by night
 3 years Knows full name and sex
 3 years Rides tricycle
 Joint Range of Motion (active & passive)
◦ Active head and trunk flexion, extension, rotation observed
during head raise in prone, supine, sitting, standing developmental
channels
◦ Active shoulder elevation, abduction, rotation, flexion and
extension movements are observed during functional examination
of creeping, reaching and other arm movements
◦ Active elbow flexion and extension observed during child’s reach
to parts of body or toys
◦ Active wrist and hand movements will be observed during
function development
◦ Active hip flexion and extension will be observed during all
functions
◦ Active knee flexion and extension seen with active hip flexion
extension
◦ Foot movements are also check during functional development
 Posture
◦ Poor posture in all types of CP
◦ Kypho-Scoliosis, knock knee & flexion
deformity & inverted flat foot are
commonly seen
 Balance & gait
◦ Compromised static & dynamic balance
◦ Balance severely affected in athetoid &
ataxic CP
◦ Independent walking is rarely achieved
by spastic quadriplegic & athetoid CP,
 few diplegic CP can walk with aids,
 hemiplegic CP can achieve independent
walking
 Bowel & bladder involvement
◦ If the child is able to communicate &
understand, training can be helpful
◦ In profound MR and those unable to
communicate have dependent functions
 Functional capacity
◦ Varies from complete dependence to
complete independent
PT MANAGEMENT
INFANCY
(FIRST STAGE – BIRTH TO
3 YEARS)
PT aims
 Family education
 Handling & care
 Promote infant & parent interaction
 Encourage development of functional
skills & play
 Promote sensory motor development
 Establish head & neck control
 Attain & maintain upright position
Family education
 Educate families about CP
 Provide support in their acceptance of child
 Goal setting & programming should be done
with family
 Be realistic about the prognosis & efficacy of
PT while remaining hopeful
 Honesty & commitment towards child
 Listening to parental concerns & recognizing
personal values & strength
Handling & care
 Promote parents ease, skill & confidence in
handling child
 Positioning, feeding & carrying techniques should
be taught
 Promote symmetry, limit abnormal posturing &
facilitate functional motor activity
 Use variety of movement & posture to promote
sensory function
 Include position to allow lengthening of spastic or
hypoextensive muscles
 Use positions to improve functional voluntary
movement of limbs
Mother & child
relationship
 Activities should be done on mother's
lap, close to body & face so that her
touch & stroking & talking to baby not
only help motor development but also
body image, movement enjoyment by baby
& demonstrate love & security
 Weaning of child to a PT should be
carefully done after mother-child bonding
& confidence is established
 Introducing more than one therapist
or developmental worker may be
disconcerting to child & even parents
 Not to overload with exercises, but
rather use corrective movements &
postures within ADL of child
Feeding & respiration
 Position in a propped up sitting for feeding
 For greater hip stability & symmetry
during feeding position in a high chair with
adaptation
 Head & neck position should be in neutral
rotation & slight flexion to facilitate
swallowing
 Deep respiration can be facilitated before
feeding by applying pressure in the thorax
or the abdominal area
Facilitate sensory-motor
development (body image)
 Reaching, rolling, sitting, crawling &
transitional movements like standing &
pre walking are facilitated
◦ Promotes spatial perception, body awareness
& mobility, facilitate play, social interaction
& exploration of environment
 Use of equipments that facilitates
function when impairment is preventing
development E.g. sitting on adapted
chair
 Practice midline play, reach for
feet, suck on fingers
 Do not give too many stimuli at once
 Carefully introduce different surfaces
for child to roll on, creep, crawl, & walk
on with bare feet
 Always give child time to experience
tactile & auditory stimuli & let him reach
& find out about himself whenever
possible
Improve proprioceptive &
vestibular function
 They are compensatory stimuli for visual
impairment & also develop body image
 Touch, pressure & resistance can be
correctly given to stimulate movement
giving clues as to direction & degree of
muscle action.
 Do not use Rx with handling or other
proprioceptive stimuli from behind as
leaning back will facilitate extensor
thrusts
Visual development
 Can be easily integrated with methods for
head control, hand function & all balance &
locomotor activities
 Relate appropriate level of visual ability with
child's motor programme.
 Also one may have to accept unusual head
position & other patterns which make it
possible for the child to use residual vision
 Use favorite toys or colors to facilitate
visual function
Language development
 Talk & clearly label body parts used
 Delay is normal for a child who cannot yet
understand meaning of sounds, words &
conversation
 Use simple & easy words with appropriate
examples & models
 Communication is also fostered through
motor actions, touch & body language
relevant to sign system of a child
Facilitating motor
development
 Postural stability of the head when
◦ lying prone (0-3 months)
◦ on forearms (3 months)
◦ on hands and on hands and knees (6
months),
◦ during crawling, half-kneeling hand
support (9-11 months)
◦ in the bear-walk (12 months) in normal
developmental levels.
 Acceptance of prone position.
◦ Accustom child to prone
 on soft surfaces, sponge rubber, inflatable
mattress, in warm water, over large soft
ball, over your lap
 rock and sway a baby held in prone
suspension.
 Postural stability of the shoulder girdle
◦ weight on forearms (3 months),
◦ on hands (6 months),
◦ on hands & knees & arms held stretched forward
along the ground to hold a toy at 5-6 months also
include postural stability.
 Pivot prone with arms held extended in air
activates stabilizers (8-10 months).
 Maintenance of half-kneeling lean or upright
kneeling (lean on hands) or grasp a support -
9-12 months stimulates shoulder girdle
stability
 Postural stability of pelvis
◦ On knees with hips at right angles (4
months)
◦ on elbows & knees & on hands and knees
(4-6 months),
◦ on half-kneeling and upright kneeling
with support (9-12 months) in normal
motor levels.
Maintaining an upright
position
 Use of adapted chairs & standing
frame
 Use of orthosis can be delayed until
some voluntary movement is gained
 Sitting on swiss ball, vestibular board
etc can be given to improve
challenges
PRESCHOOL PERIOD
 Main aim is to reduce the primary
impairments & prevent the
secondary impairments
Increase force generation
(strengthening)
 Creating demands in both concentric &
eccentric work
◦ Transitional movements against gravity, ball
gymnastics etc.
 If a child has some voluntary control in
muscle group, capacity for strengthening
exists
 Use of electrical stimulation or by
strengthening within synergistic
movement patterns
 Ambulatory children with CP have
capacity to strengthen
muscles, although poor isolated control
or inadequate length
 To participate in a strength-training
program, child must be able to
comprehend & to consistently produce
a maximal or near-maximal effort
Reduce spasticity
 Positioning in anti synergistic pattern
 Stretching of tight structures
 MFR
 ROM exercise
 Rhythmic rotations
 Splinting & serial casting
 Dorsal rhizotomy
 Botox injection
Increase mobility &
flexibility
 ROM exercise
 Maintain length of muscle by regular
stretching & splinting
◦ Prolonged stretching of 6 hours a day with
the threshold at which the muscle began to
resist a stretch
 Strengthening exercise of prime
movers of a joint
Prevent deformity
 Serial Casting techniques
 Orthosis & night splints
 Lycra splinting & taping techniques
◦ Skin reactions should be carefully
assessed
 Allignment of the body in a variety
of positions in which they can
optimally function, travel & sleep
Improve physical activity
 Exercise should be intensive, challenging &
meaningful & involve integration of skills into
function
 Movement should be goal oriented & interesting to
maintain motivation
◦ Kicking a soccer ball
 Feedback is important & feedforward is also
considered
 CIMT also improves function in hemiplegic CP
 Oromotor rehabilitation should also be provided
Improve ambulatory
capacity
 Weight bearing, promoting
dissociation, & improving balance
 Walkers & crutches may be used
◦ Posterior walkers encourages more upright
posture during gait
 Treadmill training or body weight
support treadmill training
 Adapted tricycle, wheelchair or
motorized wheelchair may improve
mobility in more disabled children
Improve play
 Play is the primary productive activity of
children it should be motivating &
pleasurable
 Motivates social skills, perception
conceptual, intellectual & language skills
 Appropriate toys & play methods should
be suggested
 Parents should encourage to let children
enjoy their typical play activities s/a
rolling downhill or getting dirty
SCHOOL AGE & ADOLESCENCE
Improve activity, mobility &
endurance
 Gait training can be continued throughout
school age with other conjunction s/a
spasticity mgt
 Architectural modification may be
required s/a ramps or rails
 Orthosis increases energy expenditure
 Regular exercise, proper diet & nutrition &
participation in recreational activities is
encouraged
School & community
participation
 Positioning, lifting & transfer techniques
should be taught to the school personnel
 Opportunities should be given to
participate in community & recreational
activities
 Adapted games & athletic competition &
team participation improves self esteem
 Introduce to Community fitness program
 Barriers s/a transportation, finances,
time preferences & involvement,
interest should also be considered
carefully
 Injury prevention will limit impairment
& disability
TRANSITION TO
ADULTHOOD
Improve functional skills
 Maintain & improve cardiovascular fitness
 Weight control, maintain integrity of joints &
muscles, help prevent osteoporosis
 Fitness clubs, swimming, wheelchair aerobics
& adapted sports are options
 Disability certificate should be provided to
reimburse handicap facilities & compensations
 Introduce to help lines & community care
centers
Transition planning
 Vocational training & occupational
training should be provided
 Living arrangement, personal mgt
including birth control, social skill &
household management should be made
available
 Continuation of professional health
service should be done
Characteristics Score 0 Score 1 Score 2 Acronym
Skin color/
Complexion
Blue or pale all
over
Blue at extremities
body pink
(acrocyanosis)
No cyanosis-
body & extremities
pink
Appearance
Pulse rate Absent <100 ≥100 Pulse
Reflexirritability
No response to
stimulation
grimace/feeble cry
when stimulated
cry or pull away
when stimulated
Grimace
Muscle tone None some flexion
flexed arms & legs
that resist extension
Activity
Breathing Absent
weak, irregular,
gasping
strong, lusty cry Respiration
Apgar score
Scoring
 Test is done at 1 & 5 min after birth, & repeated later if
score is/ & remain low
◦ 3 & below- critically low,
◦ 4 to 6 - fairly low
◦ 7 to 10- generally normal.
 A low score on 1 minute -requires medical attention
 If score remains below 3 at times s/a 10, 15, or 30
min, there is a risk that child will suffer longer-term
neurological damage.
 Purpose of Apgar test is to determine quickly whether a
newborn needs immediate medical care or not & not
designed to make long-term predictions
 A score of 10 is uncommon due to prevalence of transient
cyanosis, & is not substantially different from a score of 9.
◦ Transient cyanosis is common, particularly in babies born at
high altitude.

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Cerebral Palsy: PT assessment and Management

  • 2. Definition  It is defined as a group of disorders resulting from permanent non progressive cerebral dysfunction developing before maturation of CNS affecting the locomotor system  It is non-contagious motor conditions that cause physical disability in human development
  • 3.  Although brain lesions that result in CP are not progressive, clinical picture of CP may change with time  In addition to primary impairments in gross & fine motor function, there may be associated problems with cognition, seizures, vision, swallowing, s peech, bowel-bladder, & orthopedic deformities
  • 4. Criteria of diagnosis ◦ Neuromotor control deficit that alters movement or posture ◦ Static brain lesion ◦ Acquisition of brain injury either before birth or in first years of life
  • 5. History  Formerly known as "Cerebral Paralysis,“ ◦ First identified by English surgeon William Little in 1860. (Little’s disease) ◦ Believed that asphyxia during birth is chief cause  In 1897, Sigmund Freud, suggested that difficult birth was not the cause but only a symptom of other effects on fetal development  National Institute of Neurological Disorders & Stroke (NINDS) in 1980s suggested that only a small number of cases of CP are caused by lack of oxygen during birth
  • 6. Epidemiology  The incidence of CP is about 2 per 1000 live births  The incidence is higher in males than in females  Other associated problems include ◦ Mental disadvantage (IQ < 50): 31% ◦ Active seizures: 21% ◦ Mental disadvantage (IQ < 50) and not walking: 20% ◦ Blindness: 11%
  • 7.  During past 3 decades considerable advances made in obstetric & neonatal care, but there has been no change in incident of CP  The population of children with CP may be increasing due to premature infants who are surviving in greater numbers, higher incidence  in normal-weight term infants (3), and longer survival  overall.
  • 8. Causes of CP  Prenatal (70%)  Peri-natal (5-10%)  Post natal
  • 9. Prenatal  Maternal infections E.g. rubella, herpes simplex  Inflammation of placenta (chorion amnionitis)  Rh incompatibility  Diabetes during pregnancy  Genetic causes  Exposure to radiations  Maternal jaundice
  • 10. Peri- natal  Prematurity- immature respiratory & cardiac function  Asphyxia  Maconeum aspiration  Birth trauma  Disproportion  Breech delivery  Rapid delivery  Low birth weight  Coagulopathy
  • 11. Post natal  Brain damage secondary to cerebral hemorrhage, trauma, infection or anoxia  Motor vehicle accidents  Shaken baby syndrome  Drowning  Lead exposure  Meningitis  Encephalitis
  • 12.  Additional risk factors for CP include ◦ Kernicterus ◦ methyl mercury exposure ◦ genetic causes
  • 13. Classification of CP  Depending on the topographical distribution ◦ Monoplegic ◦ Diplegic/ Paraplegic ◦ Triplegic ◦ Hemiplegic ◦ Tetraplegic / Double hemiplegia
  • 14.  Monoplegia is one single limb being affected.  Diplegia: LE affected, with little to no upper-body spasticity. ◦ The most common form of spastic forms ◦ Most people with spastic diplegia are fully ambulatory, but are "tight" & have scissors gait ◦ Flexed knees & hips to varying degrees, & moderate to severe adduction are present ◦ Often nearsighted & intelligence is unaffected ◦ In 1/3rd of spastic diplegics, strabismus may be present
  • 15.  Hemiplegia ◦ The most ambulatory of all forms, although they generally have dynamic equinus on affected side  Triplegia: three limbs affected usually both LL & one UL  Quadriplegia: all four limbs more or less equally affected. ◦ Least likely to be able to walk ◦ Some children also have hemiparetic tremors (hemiballismus), & impairs normal movement
  • 16.  Depending on tone or movement patterns (physiologic) ◦ Spastic ◦ Athetoid/ dyskinetic ◦ Ataxic ◦ Flaccid/ Hypotonic ◦ Mixed
  • 17. Spastic CP  It is the most common type of CP, occurring in 70% to 80% of all cases.  The cerebral cortex is affected  Moreover, spastic CP accompanies any of the other types of CP in 30% of all cases  It can be monoplegia, diplegia, triplegia, hemiplegia or quadriplegia.
  • 18. Athetoid/ dyskinetic CP  It is mixed muscle tone  Often show involuntary motions  The damage occurs to extrapyramidal motor system & pyramidal tract  It occurs in 10% to 20% of all cases  In newborn infants, high bilirubin levels in blood, if left untreated, can lead to brain damage in certain areas (kernicterus).  This may also lead to Athetoid CP
  • 19. Ataxic CP  It is caused by damage to cerebellum  They are least common types of CP, occurring only in 10% of all cases  Some of these individuals have hypotonia and tremors
  • 20. Hypotonic CP  Hypotonic CP have musculature that is limp, and can move only a little or not at all (Floppy child)  The location of damage is wide spread in the CNS  Although physical therapy is usually attempted to strengthen muscles it is not always fundamentally effective.
  • 21. Mixed CP  Signs & symptoms of spastic CP is seen with any other type of CP ◦ Most commonly mixed with Athetoid
  • 22.  Depending on functional level (Gross Motor Function Classification System) ◦ It classifies acc. to age categorized activity level
  • 24. pathology  Periventricular leukomalacia (PVL) is the most common finding in CP  Corticospinal tract fibers to LL are medial to those of UL in periventricular white matter. ◦ Thus children with PVL typically have spastic diplegia (common type of CP)
  • 25.  Bilirubin encephalopathy in basal ganglia is seen in athetoid CP following a diagnosis of kernicterus  Focal cortical infarcts involving both grey & white matter are found in patients with hemiparesis, & are typically related to MCA strokes  Brain malformations can be found on neuroimaging in approximately 10% of children
  • 26. Signs & symptoms (spastic)  Hypertonia  Exaggerated reflexes & +ve barbinskis  Clonus  Poor voluntary movement  Scissoring gait  Low intelligence & loss of memory  Epilepsy  Synergistic pattern  Contracture, deformity & wasting ◦ Adduction & IR of shoulder ◦ Flexion of elbow & pronation of forearm ◦ Wrist flexion & thumb inside hand ◦ Flexion & adduction of hip ◦ Knee flexion ◦ PF of ankle
  • 27. Extrapyramidal CP  May affect limb, face, tongue & speech  Characterized by continuous muscular worm like movement  Postural instability  Decreased movement in prone position  Fluctuation of tone from high to low  Reflexes are usually normal & muscles are able to contract  Decreased stability  Difficulty to look up  Emotional liability  Arms are more affected  Sucking & feeding problems  Delayed head & trunk control  May be either quadriplegic or rarely hemiplegic  Subtypes - dystonic, athetoid, choroid, h emiballismic, rigid
  • 28. Ataxic / hypotonic  Inco-ordination  Intension tremor  Hypotonia  Nystagmus  Diminished reflexes  Speech, visual, hearing & perceptual problems  Joint hypermobility  Dysmetria  Incontinence  Postural instability  Gait disturbances  Imbalance & lack of trunk control  Unsteadiness 
  • 29. risk babies  Biological risk  Established risk  Environmental & social risk
  • 30. Biological risk  Birth weight of 1500g or less  Gestational age of 32 weeks or less  Small for gestational age (less & 10th percentile of weight)  Ventilator requirement for 36 hours or more  Intracranial hemorrhage  muscle tone abnormalities  Recurrent neonatal seizures (3 or more)  Feeding dysfunction  Symptomatic (TORCH)  Meningitis  Asphyxia with apgar score <3 in 1 min after birth or <6 in 5 min after birth
  • 31. Established risk  Hydrocephalus  Microcephaly  Chromosomal abnormalities  Musculoskeletal abnormalities (CDH, AMC, limb deficiencies)  Multiple births more than twins  Brachial plexus injuries  Myelodysplasia  Congenital myopathies  Inborn errors of metabolism  HIV infection
  • 32. Environmental/ social risk  Single parent  Parental age less than 17  Poor quality infant parent attachment  Maternal drug or alcohol abuse  Behavioral state abnormalities (lethargy, irritability)
  • 33. Detection of risk babies  Principles ◦ There should be definite objective ◦ Some form of action should be possible if the test is positive ◦ The population should be defined ◦ Test should be sensitive ◦ Test should be specific ◦ Screening should start at foetal life & continue into early childhood  Some test are for all children but some are for those who are known to be at risk
  • 34. Prenatal screening  Routine check up for mother during pregnancy is beneficial for the mother & the foetus  Health education ◦ Diet advice (avoid tobacco & alcohol) ◦ Exercise on prescription ◦ Sleep & working habits
  • 35.  Clinical examination ◦ Breast condition ◦ Height of uterus ◦ Position of foetus ◦ BP ◦ Samples of blood & urine  For special test condition sought are ◦ Phenylketonuria ◦ Glycosuria ◦ Albuminuria ◦ Rh incompatibility ◦ Congenital syphillis ◦ Rubella, AIDS ◦ Neural tube defect
  • 36.  Special test for screening ◦ USG from 8-12 weeks  For the assessment of the gestational period  Congenital abnormalities in various organ defect ◦ Amniocentesis from 16-18 weeks of pregnancy  To find chromosomal defect, if the test is positive terminate pregnancy ◦ Chorionic villus sampling technique in 8-11 weeks of pregnancy  For chromosomal study
  • 37. Post natal screening  Starts in the immediate neonatal period & during the first two years ◦ To find biochemical defects ◦ Hearing & visual problems
  • 38.  Clinical methods (at birth) ◦ Examination of weight, height, head circumference ◦ Gestational age ◦ Musculoskeletal defects ◦ Testicular descent ◦ At 6 weeks repeat test
  • 39.  Chemical methods ◦ Blood sample from heel prick at 2-5 days of age & repeated where necessary  Respiratory conditions, cardiac pathology, haemoglobinopathies can be detected  Neuromuscular pathologies (cpk level)  Metabolic disorders  Gene abnormalities
  • 40.  Electronic scanning ◦ USG, CT Scan, MRI  To find out AVM, hemorrhage, cyst, leucodystrophies etc
  • 41. Diagnosis  The diagnosis of CP depends on patient's history & on the basis of significant delay in gross & fine motor function, with abnormalities in tone, posture, & movement on neurological examination.  Once diagnosed with CP, further diagnostic tests are optional.
  • 42.  MRI is preferred over CT due to diagnostic yield & safety.  The CT or MRI also reveals treatable conditions, such as hydrocephalus, AVM, subdural hematomas etc.  Diagnosis, classification, & treatment are often based on abnormalities in tone  Apgar scores have sometimes been used as one factor to predict whether or not an individual will develop CP
  • 43. Diagnostic tools  Movement Assessment of Infants (MAI): able to predict CP at 4 months (identifies motor delay)  Alberta Infant Motor Scale (AIMS) is able to predict CP at 6 months (Identifies motor delays & measures changes in motor performance over time)  Bayley scale is able to predict CP at 1 year (Identifies devt delay in gross & fine motor, & cognitive domains)
  • 45. Drugs  Oral medications such as baclofen, diazepam, and trihexyphenidyl as well as therapeutic botulinum toxin (Botox)  Children with dystonic CP have dopa- responsive dystonia, with improved motor function using levodopa  Children with basal ganglia/thalamic injury from perinatal asphyxia may develop improved expressive speech & hand use with trihexyphenidyl
  • 46. Surgery  Dorsal rhizotomy reduces spasticity  Joint & Tendon release most often performed on hips, knees, & ankles.  The insertion of a baclofen pump usually during young adolescence. ◦ usually placed in left abdomen - a pump that is connected to spinal cord, ◦ sends bits of Baclofen to relax muscle  Bony correction E.g. femur (termed femoral anteversion or antetorsion) & tibia (tibial torsion). 2ndary complication caused by spastic muscles generating abnormal forces on bones
  • 47. Prognosis  CP is not a progressive but the symptoms can become more severe over time  Prognosis depends on intensity of therapy during early childhood  Tend to develop arthritis at a younger age than normal because of pressure placed on joints by excessively toned & stiff muscles
  • 48.  Intellectual level among people with CP varies from genius to intellectually impaired ◦ (it is important to not underestimate a person with CP and to give them every opportunity to learn)  The ability to live independently with CP varies widely depending on severity of each case. ◦ Some individuals with CP are dependent for all ADL. ◦ Some can lead semi-independent lives, needing support only for certain activities. ◦ Still others can live in complete independence.
  • 49.  Persons with CP can expect to have a normal life expectancy  Survival is associated with the ability to ambulate, roll, & self-feed  As the condition does not directly affect reproductive function, some have children & parent successfully  There is no evidence of increased chance of a person with CP having a child with CP
  • 50. Notable persons  Abbey Curran, American beauty queen with CP who represented Iowa at Miss USA 2008 and was the first contestant to compete with a disability
  • 52. Pt assessment  Subjective Examination: ◦ Obtained from parents especially mother or from relatives and through case-sheet. ◦ General details includes  Name  Age & Sex  Address  When did the mother first noticed the dysfunctions ◦ Siblings having same type of symptoms
  • 53. PT assessment  History ◦ Review of complications of pregnancy & delivery, birth weight, gestation, any neonatal & perinatal difficulties, feeding problems, and other health- related problems ◦ Developmental milestones
  • 54.  Prenatal History ◦ Age of mother ◦ Consanguity marriage ◦ Any drugs taken during pregnancy ◦ Any trauma & stress ◦ Any addiction – smoking or alcoholism ◦ History of TORCH infection ◦ History of previous abortions, still born or death after birth ◦ Multiple pregnancies ◦ Status & cast of the mother
  • 55.  Perinatal History ◦ Place of delivery ◦ History preterm or post-term delivery ◦ History of asphyxia at birth ◦ History of prolonged labour pain ◦ Type of delivery (Forceps, vacuum delivery) ◦ Presentation of child (Breech) ◦ Condition of mother at the time of delivery
  • 56.  Postnatal History ◦ Delayed birth cry ◦ Weight of the child at birth ◦ History of trauma to brain during the first 2 years of life ◦ History of neonatal meningitis, jaundice, hypoglycemia, Hydrocephalus or Microcephaly ◦ Nutritional habits of the child (malnutrition), Feeding difficulties ◦ Any medical, surgical or physiotherapy treatment taken before ◦ What treatment was used? ◦ Was the treatment effective or not? ◦ What was the ability level of child at that time? ◦ What obstructs the child from progress? ◦ Apgar Score from the case-sheet
  • 57. 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 ◦ What motivates his action – particular situation, person or special plaything  Communication of the child ◦ With the parents ◦ Whether child initiates or responds with gestures, sounds, hand or finger pointing, eye pointing or uses words and speech
  • 58.  Other observations ◦ Involuntary movements ◦ Deformities & contracture ◦ Scar may be present ◦ Trophic changes may also be seen due to poor positioning ◦ Postural faults ◦ Gait abnormalities ◦ Use of external appliances
  • 59.  Attention span ◦ What catches child’s attention ◦ For how much time child’s attention is maintained on particular thing ◦ How does parent assist him to maintain attention ◦ What distracts the child ◦ Does child follows suggestions to move or promptings to act
  • 60. ◦ 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?  With assistance, child makes any effort to go in that position  Symmetry of the child (actively or passively maintained)  If involuntary movements present, then in which positions these movements are decreased or increased
  • 61. ◦ Postural control & alignment  How much parental support is given  Postural stabilization and counterpoising in all postures  Proper & equal weight bearing  If the child’s center of gravity appears to be unusually high, resulting in floating legs and poor ability to raise head against gravity  Fear of fall in child due to poor balance
  • 62. ◦ Use of limbs & hands  Limb patterns in changing or going into position as well as using them in position ◦ 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, tremors or spasms, which interfere with actions, are present
  • 63. ◦ Sensory aspects  Observe child’s use of vision, hearing, of touch, smell and temperature in relevant tasks  Does child enjoys particular sensations  Whether child enjoys being moved or having position changed ◦ Form of Locomotion  How child is carried  Any use of wheelchair or walking aids  Which daily activities motivates child to roll, creep, crawl, bottom shuffle or walk
  • 64. ◦ Deformities  Any part of body, which remains in particular position in all postures & in the movements  The positional preferences typically seen in spastic cerebral palsies are for mid positions of body –  In the UL  Shoulder protraction or retraction, adduction and internal rotation, Elbow flexion, Forearm pronation, Wrist & Fingers flexion  In the LL  Hip semi-flexion, internal rotation and adduction, Knee semi-flexion, Ankle plantar flexion, Foot pronation or supination, Toes flexion  Athetoid or dystonic posturing usually incorporates extremes of movement such as total flexion or extension  Windswept Deformity of hip – One hip flexed, abducted and externally rotated; other hip flexed, adducted and internally rotated and in danger of posterior dislocation
  • 65.  Higher cognitive function ◦ Drowsy & lethargic ◦ Decrease in intellectual function ◦ Mental retardation (mild to profound) ◦ Attention deficit & easily distractible ◦ Poor memory ◦ Poor comprehension of speech & language
  • 66.  Cranial nerve integrity ◦ Strabismus or squint (Occulo motor nerve) ◦ Visual defects (optic nerve) ◦ Auditory defects (auditory nerve) ◦ Feeding & swallowing problems (lower cranial nerves) etc.
  • 67.  Special senses ◦ Visual & auditory defects ◦ Tactile & vestibular hyposensitivity or hypersensitivity
  • 68. On examination  Sensory Assessment ◦ It is difficult to assess sensation in babies and young children with severe multiple impairments. ◦ If any hearing or visual or psychological abnormalities are present then assessment done by specialist is required
  • 69.  Motor integrity ◦ Abnormalities of tone  Spasticity, hypotonicity, dystonia etc ◦ Muscular weakness ◦ Loss of voluntary control ◦ Decreased co ordination
  • 70.  Reflex integrity ◦ Abnormal DTR ◦ Abnormal Superficial reflexes ◦ Abnormal primitive reflexes may be persistent  ATNR, Extensor thrust, gallant reflex etc
  • 71.  ROM & flexibility ◦ Decreased in the ROM of the involved limbs ◦ Tightness & contracture in hip adductors, hamstrings, calf are very common
  • 72.  Anthropometric measurement ◦ Height or length decreased (growth retardation) ◦ Weight – decreased (thin & lean) or obese ◦ Head circumference – decreased (growth retardation or microcephaly), increased (hydrocephalus)
  • 73. ◦ 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 Weight kg Pounds At birth 3.25 7 3-6 months Age in months +9/2 Age in months + 11 1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17 7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
  • 74. Weight kg Pounds At birth 3.25 7 3-6 months Age in months +9/2 Age in months + 11 1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17 7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5  Weight
  • 75.  Head circumference of the child - ◦ The tape is used to measure occipitofrontal head circumference from external occipital protuberance to glabella Head cicumference Cm At birth 35 3 months 40 1 yr 45 2 yrs 48 12 yrs 52
  • 76. Developmental milestones  Age Developmental Milestones  4 to 6 weeks Social smile  3 months Head holding  6 months Sits with support  7 months Sits without support  5 to 6 months Reaches out for bright object & gets it  6 to 7 months Transfers object from one hand to other  6 to 7 months Starts imitating cough  8 to 10 months Crawls
  • 77.  10 to 11 months Creeps  9 months Standing holding furniture  12 months Walks holding furniture  10 to 11 months Stands without support  13 months Walks without much of a support  12 months Says one word with meaning  13 months Says three words with meaning  15 to 18 months Joints 2 or 3 words into sentence
  • 78.  13 months Feeds self with spoon  15 to 18 months Climbs stair  15 to 18 months Takes shoes and socks off  24 months Puts shoes and socks on  24 months Takes some clothes off  3 to 4 years Dresses self fully  2 years Dry by day  3 years Dry by night  3 years Knows full name and sex  3 years Rides tricycle
  • 79.  Joint Range of Motion (active & passive) ◦ Active head and trunk flexion, extension, rotation observed during head raise in prone, supine, sitting, standing developmental channels ◦ Active shoulder elevation, abduction, rotation, flexion and extension movements are observed during functional examination of creeping, reaching and other arm movements ◦ Active elbow flexion and extension observed during child’s reach to parts of body or toys ◦ Active wrist and hand movements will be observed during function development ◦ Active hip flexion and extension will be observed during all functions ◦ Active knee flexion and extension seen with active hip flexion extension ◦ Foot movements are also check during functional development
  • 80.  Posture ◦ Poor posture in all types of CP ◦ Kypho-Scoliosis, knock knee & flexion deformity & inverted flat foot are commonly seen
  • 81.  Balance & gait ◦ Compromised static & dynamic balance ◦ Balance severely affected in athetoid & ataxic CP ◦ Independent walking is rarely achieved by spastic quadriplegic & athetoid CP,  few diplegic CP can walk with aids,  hemiplegic CP can achieve independent walking
  • 82.  Bowel & bladder involvement ◦ If the child is able to communicate & understand, training can be helpful ◦ In profound MR and those unable to communicate have dependent functions
  • 83.  Functional capacity ◦ Varies from complete dependence to complete independent
  • 85. INFANCY (FIRST STAGE – BIRTH TO 3 YEARS)
  • 86. PT aims  Family education  Handling & care  Promote infant & parent interaction  Encourage development of functional skills & play  Promote sensory motor development  Establish head & neck control  Attain & maintain upright position
  • 87. Family education  Educate families about CP  Provide support in their acceptance of child  Goal setting & programming should be done with family  Be realistic about the prognosis & efficacy of PT while remaining hopeful  Honesty & commitment towards child  Listening to parental concerns & recognizing personal values & strength
  • 88. Handling & care  Promote parents ease, skill & confidence in handling child  Positioning, feeding & carrying techniques should be taught  Promote symmetry, limit abnormal posturing & facilitate functional motor activity  Use variety of movement & posture to promote sensory function  Include position to allow lengthening of spastic or hypoextensive muscles  Use positions to improve functional voluntary movement of limbs
  • 89. Mother & child relationship  Activities should be done on mother's lap, close to body & face so that her touch & stroking & talking to baby not only help motor development but also body image, movement enjoyment by baby & demonstrate love & security  Weaning of child to a PT should be carefully done after mother-child bonding & confidence is established
  • 90.  Introducing more than one therapist or developmental worker may be disconcerting to child & even parents  Not to overload with exercises, but rather use corrective movements & postures within ADL of child
  • 91. Feeding & respiration  Position in a propped up sitting for feeding  For greater hip stability & symmetry during feeding position in a high chair with adaptation  Head & neck position should be in neutral rotation & slight flexion to facilitate swallowing  Deep respiration can be facilitated before feeding by applying pressure in the thorax or the abdominal area
  • 92. Facilitate sensory-motor development (body image)  Reaching, rolling, sitting, crawling & transitional movements like standing & pre walking are facilitated ◦ Promotes spatial perception, body awareness & mobility, facilitate play, social interaction & exploration of environment  Use of equipments that facilitates function when impairment is preventing development E.g. sitting on adapted chair
  • 93.  Practice midline play, reach for feet, suck on fingers  Do not give too many stimuli at once  Carefully introduce different surfaces for child to roll on, creep, crawl, & walk on with bare feet  Always give child time to experience tactile & auditory stimuli & let him reach & find out about himself whenever possible
  • 94. Improve proprioceptive & vestibular function  They are compensatory stimuli for visual impairment & also develop body image  Touch, pressure & resistance can be correctly given to stimulate movement giving clues as to direction & degree of muscle action.  Do not use Rx with handling or other proprioceptive stimuli from behind as leaning back will facilitate extensor thrusts
  • 95. Visual development  Can be easily integrated with methods for head control, hand function & all balance & locomotor activities  Relate appropriate level of visual ability with child's motor programme.  Also one may have to accept unusual head position & other patterns which make it possible for the child to use residual vision  Use favorite toys or colors to facilitate visual function
  • 96. Language development  Talk & clearly label body parts used  Delay is normal for a child who cannot yet understand meaning of sounds, words & conversation  Use simple & easy words with appropriate examples & models  Communication is also fostered through motor actions, touch & body language relevant to sign system of a child
  • 97. Facilitating motor development  Postural stability of the head when ◦ lying prone (0-3 months) ◦ on forearms (3 months) ◦ on hands and on hands and knees (6 months), ◦ during crawling, half-kneeling hand support (9-11 months) ◦ in the bear-walk (12 months) in normal developmental levels.
  • 98.  Acceptance of prone position. ◦ Accustom child to prone  on soft surfaces, sponge rubber, inflatable mattress, in warm water, over large soft ball, over your lap  rock and sway a baby held in prone suspension.
  • 99.  Postural stability of the shoulder girdle ◦ weight on forearms (3 months), ◦ on hands (6 months), ◦ on hands & knees & arms held stretched forward along the ground to hold a toy at 5-6 months also include postural stability.  Pivot prone with arms held extended in air activates stabilizers (8-10 months).  Maintenance of half-kneeling lean or upright kneeling (lean on hands) or grasp a support - 9-12 months stimulates shoulder girdle stability
  • 100.  Postural stability of pelvis ◦ On knees with hips at right angles (4 months) ◦ on elbows & knees & on hands and knees (4-6 months), ◦ on half-kneeling and upright kneeling with support (9-12 months) in normal motor levels.
  • 101. Maintaining an upright position  Use of adapted chairs & standing frame  Use of orthosis can be delayed until some voluntary movement is gained  Sitting on swiss ball, vestibular board etc can be given to improve challenges
  • 103.  Main aim is to reduce the primary impairments & prevent the secondary impairments
  • 104. Increase force generation (strengthening)  Creating demands in both concentric & eccentric work ◦ Transitional movements against gravity, ball gymnastics etc.  If a child has some voluntary control in muscle group, capacity for strengthening exists  Use of electrical stimulation or by strengthening within synergistic movement patterns
  • 105.  Ambulatory children with CP have capacity to strengthen muscles, although poor isolated control or inadequate length  To participate in a strength-training program, child must be able to comprehend & to consistently produce a maximal or near-maximal effort
  • 106. Reduce spasticity  Positioning in anti synergistic pattern  Stretching of tight structures  MFR  ROM exercise  Rhythmic rotations  Splinting & serial casting  Dorsal rhizotomy  Botox injection
  • 107. Increase mobility & flexibility  ROM exercise  Maintain length of muscle by regular stretching & splinting ◦ Prolonged stretching of 6 hours a day with the threshold at which the muscle began to resist a stretch  Strengthening exercise of prime movers of a joint
  • 108. Prevent deformity  Serial Casting techniques  Orthosis & night splints  Lycra splinting & taping techniques ◦ Skin reactions should be carefully assessed  Allignment of the body in a variety of positions in which they can optimally function, travel & sleep
  • 109. Improve physical activity  Exercise should be intensive, challenging & meaningful & involve integration of skills into function  Movement should be goal oriented & interesting to maintain motivation ◦ Kicking a soccer ball  Feedback is important & feedforward is also considered  CIMT also improves function in hemiplegic CP  Oromotor rehabilitation should also be provided
  • 110. Improve ambulatory capacity  Weight bearing, promoting dissociation, & improving balance  Walkers & crutches may be used ◦ Posterior walkers encourages more upright posture during gait  Treadmill training or body weight support treadmill training  Adapted tricycle, wheelchair or motorized wheelchair may improve mobility in more disabled children
  • 111. Improve play  Play is the primary productive activity of children it should be motivating & pleasurable  Motivates social skills, perception conceptual, intellectual & language skills  Appropriate toys & play methods should be suggested  Parents should encourage to let children enjoy their typical play activities s/a rolling downhill or getting dirty
  • 112. SCHOOL AGE & ADOLESCENCE
  • 113. Improve activity, mobility & endurance  Gait training can be continued throughout school age with other conjunction s/a spasticity mgt  Architectural modification may be required s/a ramps or rails  Orthosis increases energy expenditure  Regular exercise, proper diet & nutrition & participation in recreational activities is encouraged
  • 114. School & community participation  Positioning, lifting & transfer techniques should be taught to the school personnel  Opportunities should be given to participate in community & recreational activities  Adapted games & athletic competition & team participation improves self esteem  Introduce to Community fitness program
  • 115.  Barriers s/a transportation, finances, time preferences & involvement, interest should also be considered carefully  Injury prevention will limit impairment & disability
  • 117. Improve functional skills  Maintain & improve cardiovascular fitness  Weight control, maintain integrity of joints & muscles, help prevent osteoporosis  Fitness clubs, swimming, wheelchair aerobics & adapted sports are options  Disability certificate should be provided to reimburse handicap facilities & compensations  Introduce to help lines & community care centers
  • 118. Transition planning  Vocational training & occupational training should be provided  Living arrangement, personal mgt including birth control, social skill & household management should be made available  Continuation of professional health service should be done
  • 119. Characteristics Score 0 Score 1 Score 2 Acronym Skin color/ Complexion Blue or pale all over Blue at extremities body pink (acrocyanosis) No cyanosis- body & extremities pink Appearance Pulse rate Absent <100 ≥100 Pulse Reflexirritability No response to stimulation grimace/feeble cry when stimulated cry or pull away when stimulated Grimace Muscle tone None some flexion flexed arms & legs that resist extension Activity Breathing Absent weak, irregular, gasping strong, lusty cry Respiration Apgar score
  • 120. Scoring  Test is done at 1 & 5 min after birth, & repeated later if score is/ & remain low ◦ 3 & below- critically low, ◦ 4 to 6 - fairly low ◦ 7 to 10- generally normal.  A low score on 1 minute -requires medical attention  If score remains below 3 at times s/a 10, 15, or 30 min, there is a risk that child will suffer longer-term neurological damage.  Purpose of Apgar test is to determine quickly whether a newborn needs immediate medical care or not & not designed to make long-term predictions  A score of 10 is uncommon due to prevalence of transient cyanosis, & is not substantially different from a score of 9. ◦ Transient cyanosis is common, particularly in babies born at high altitude.