phd biochemistry

1. Composite regional center for skill Development, Rehabilitation & empowerment of
persons with disabilities (CRC) Gorakhpur
Evidence based recent research on play and children with CP
Dr. Jagroop Singh
Research Associate
Govt. Medical College Amritsar

2. Evidence Based Recent Research on Play and children with CP
CEREBRAL PALSY (CP)
In 1860, known as Cerebral Paralysis or Little s Disease
After an English surgeon wrote the 1st medical descriptions
William john little

3. CEREBRAL PALSY (CP)
Cerebral; latin Cerebrum
Affected part of brain
Palsy; Gr. Para – beyond,
lysis – loosening
Lack of muscle control

4. CEREBRAL PALSY (CP)
A motor function disorder
- Caused by permanent, non – progressive brain lesion
- Present at birth or shortly thereafter
Non – curable , life long condition
Damage doesn’t worsen
May be congenital or acquired

5. CEREBRAL PALSY (CP)
A Heterogenous group of movement disorder.
-An umbrella term
-Not a single diagnosis

6. CP AFFECTS

7. IN CP
Muscles are unaffected
Brain is unable to send the appropriate signals necessary to instruct muscles when to contract
and relax.

8. CAUSES
An insult or injury to the brain
- fixed, static lesions
- In single or multiple areas of the motor centers of the brain
- early in CNS deviation
Development malformations
-The brain fails to develop correctly
Neurological damage

9. Neurological damage
- Can occur before, during or after delivery
- Rh incompatibility, illness, severe lack of oxygen
-Unknown in many instances
Severe deprivation of oxygen or blood flow to the brain
- Hypoxic ischemic encephalopathy or intraportal asphyxia

10. RISK FACTORS
Prenatal factor
- Before birth
- Maternal characteristics
Perinatal factors
-At the time of birth to 1 month
Postnatal factors
- In the first 5 mos of life

11. Prenatal factors
Hemorrhage/bleeding
- Abruptic placenta
Infections
- Rubella, cytomegalovirus, toxoplasmosis
Environment factors
Maternal characteristics
- Age
- Difficulty in conceiving or holding a baby to term

12. Multiple births
History of fetal deaths/miscarriages
Cigrarette smoking more than 30 sticks per day
Alcoholism and drug addiction
Social status; mother with MR
Mother s medical condition

13. Perinatal factors
High or low BP
Umbilical cord coil
Breech delivary
Over sedation of drugs
Trauma ie. Forcepts or vaccum delivary
Complication of birth

14. Postnatal causes
Trauma, head injury
Infections
Lack of oxygen
Stroke in the young
Tumor, cyst

15. CP CASES

16. TYPES OF CP
According to;
Neurologic deficits
Type of movements involved
Area of affected limbs
Acc. To neurologic deficits;
Based on the
- Extent of the damage
- Area of brain damage

17. Each type involves the way a person moves
3 main types;
PYRAMIDAL
- Originates from the motor areas of the cerebral cortex
EXTRAPYRAMIDAL
- Basal ganglia and cerebellum
MIXED

18. 4 Main types
PYRAMIDAL 1. Spastic CP
EXTRAPYRAMIDAL 2. Athethoid CP
3. Ataxic CP
MIXED 4.Spastic & Athethoid CP
Spastic CP;
Increased muscle tone, tense and contracted muscles
Have stiff and jerky or awkward movements

19. -Limbs are usually underdeveloped
-Increased deep tendon reflexes
-Most common form 70 – 80% of all affected

20. Types of Spastic CP
According to affected limbs
@ Plegia or paresis – meaning paralyzed or weak;
-Paraplegia
-Diplegia
-Hemiplegia
-Quadriplegia
-Monoplegia – one limb (extremely rare)
-Triplegia – three limbs (extremely rare)

21. Diplegia/paraplegia
Both legs with slight involvement else where
Both legs

22. Diplegia
May also have contractures of hips and knees and talipes equinovarus (clubfoot)
Hemiplegia
Limbs on only one side
Hemiplegia on right side
Hip and knee contractures
Talipes equnius (tip toeing – sole permanently flexed)
Asteriognosis may be present (inability to identify objects by touch)

23. QUADRIPLEGIA

24. spastic Quadriplegia
Characteristic scissors positions of lower limbs due to adductor spasms

25. DYSKINESIA
Dyskinetic movement of mouth
Grimacing, drooling
Adductor spasm
Movement may become choreoid (rapid, irregular, jerky) and dystonic (disordered muscle tone,
sustained muscle contractions)
Especially when stressed and during the adolescent years.

26. ATAXIC CP
Poor balance and lack of coordination
Wide based gait
Depth perception usually affected
Tendency to fall and stumble
Inability to walk straight line
Least common 5 – 10% of cases

27. MIXED CP
A common combination is spastic
Spastic muscle tone and involuntary movements
25% of CP cases, fairly common

28. DEGREE OF SEVERITY
Mild CP 20% of cases
- Not require self help for assisting their impaired ambulation capacity
Moderate CP 50%
- Reqiure self help for assisting their impaired ambulation capacity
Severe CP 30%
- Totally incapacited and bedridden and they always need care from others

29. Signs and symptoms

32. Late infancy
Inability to perform motor skills as indicated;
- Control hand grasp by 3 months
- Rolling over by 5 months
- Independent sitting by 7 months
Abnormal developmental patterns;
- Hand preference by 12 months
- Excessive arching of back
-Log rolling
-Abnormal or prolonged parachute response

33. Abnormal developmental patterns after 1 year of age;
- ‘w sitting – knees flexed, legs extremely rotated
- Bottom shuffling – scoots along the floor
- Walking on tip toe or happing
Behavioral symptoms;
- Poor ability to concentrate
- Unusual tenseness
- Irritability

34. CEREBRAL PALSY
Main problems;
Mentation and thought processes are not always affected
Trapped in their bodies with their disabilities
Ability to express their intelligence may be limited by difficulties in communicating

35. ASSOCIATED PROBLEMS
Hearing and visual problems
Sensory integration problems
Failure to thrive, feeding problem
Behavioral/ emotional difficulties
Communication disorders
Bladder and bowel control problem, digestive problem
Skeletal deformities, dental problem
Mental retardation and learning disabilibities in some

36. DIAGNOSIS
A useful diagnosis is when the specific type, affected limb, severity and cause, if known are
identified.
Physical evalution, interview
MRI, CT scan EEG
Laboratory and radiologic work up
Assessment tools
i.e. Peabody development motor skills, Denver test II

37. DENVER TEST II
Developmental screening test
Cover 4 general functions;
- Personal social i.e. smiling
- Fine motor adaptive i.e. grasping & drawing
- Language i.e. combining words
- Gross motor i.e. walking
- Ages covered; from birth to 6 years

38. ASSESSMENT
Subjective – interview
a. history taking
Include all that may predispose an infant to brain damage or CP
Risk factors
Psychosocial factors
Family adaptation

39. b, child s health history
Often admitted to hospitals for corrective surgeries and other complications.
Respiratory status
Motor function
Presence of fever
Feeding and weight loss
Any changes in physical state

40. 2. OBJECTIVE – Physical examination
CRITERIA
P osturing/poor muscle control and strength
O ropharyngeal problems
S trabismus/squint
T one
E volutional maldevelopment
R eflexes

41. Posturing/poor muscle control and
strength
Test hand strength by lifting the child off the ground while the child holds the nurses hands
Observe for presence of limb deformity, as decreased use of extremity leads to shortening
Upon extension of extremities on vertical suspension of the infant,
If infant backbend backwards like and arch may indicate CP is severe

42. Oropharyngeal problems
Speech,
Swallowing breathing
Drooling,
Feeding poorly

43. EVOLUTIONAL MAL DEVELOPMENT
Delay in motor skills
Such as rolling over, sitting, crawling, and walking
Size for age
Persistence of primitive reflexes or parachute reflex fail to develop

44. Treatment
No treatment to cure cerebral palsy
Brain damage cannot be corrected
Crucial for children with CP;
Early identification
Multidisciplinary care ; and
Support

45. Nonphysical therapy
The earlier we start, the more improvement can be made

46. A. General management
Proper nutrition and personal care
B.Pharmacologic
Intrathecal, baclofen
Control muscle spasms and seizures
Delivered directly to the spinal fluid
Using a pump to avoid brain effects
GLYCOPYRROLATE – Control drooling

47. Pamidronate – may help with osteoporosis
C. surgery
To loosen joints
Relieve muscle tightness
Straightening of different of leg muscles
Improve the ability to sit, stand and walk

48. Selective posterior rhizotomy
Is used to improve spasticity ( muscle stiffness) in cerebral palsy. In some cases nerves need to be
severed to decrease muscle tension of inappropriate contractions.

49. Procedure
A major operation, takes approximately four hours to complete
The sensory nerve fibers in the spinal cord, usually between the bottom of the rib cage and the
top of the hips are divided
The nerve fibers are then stimulated and the responses of the leg muscles are observed
Those that have an abnormal or excessive response are severed
Those with a normal response are left intact
Intensive rehabilitation is required after the surgery, usually up to six weeks, followed by
physical therapy on an ongoing basis

50. D. Physical aids
Orthosis, braces and splints
- Keep limbs in correct alignment
- Prevent deformities
Positioning devices
Enable better posture
Walkers, special scooters, wheelchairs
- Make it easier to move about

51. E. Special education
To meet the child s special needs
Improve learning
Vocational training can help prepare young adults for jobs

52. F. Rehabilitation Services
Speech and occupational therapies may improve the ability to speak, and perform activities of
daily living and to do some suitable works to have their own income.

53. G. Family Services
Professional support helps a patient and family cope with cerebral palsy
Counselors help parents learn how to modify behaviors
Caring for a child with cerebral palsy can be very stressful
Some families find support groups helpful

54. Other treatment
Therapeutic electrical stimulation,
Acupuncture
Hyperbaric therapy
Massage therapy might help

55. II. Physical therapy
The ultimate long term goal is realistic independence
To get there we have to have some short term goals
Those being a working communication skills and above all friends

56. A. sitting
- Vertical head control and control of head and trunk
B. standing and walking
- Establish an equal distribution of weight on each foot, train to use steps or inclines
C. prone development
D. supine development
- Head control on supine and positions

57. PLAY
Range of voluntary intrinsically motivated activities normally associated with pleasure and
enjoyment
Also known as work of the children/daily work of a child
Act as a tool assessing stress

58. CRITERIA
Voluntary
Internally motivated
Unique to each child
Active with motion and cognition

59. CONTENT OF PLAY
This involves physical, mental, emotional and spiritual aspects of the play along with the social
relationships
It follows a directional trend of simple to complex

60. THE CHARACTERISTICS OF PLAY
Play is child chosen
Play is child invented
Play is pretend but done as if the activites were real
Play focuses on the doing (process, not product
Play requires active involvement
Play is pleasurable
Play is marked by flexibility

61. VALUES OF PLAY
Physical value
Intellectual value
Moral value
Creative value
Therapeutic value
Socialization

62. TYPES OF PLAY
Social affective play
Play with objects
Play with language
Skill play
Play with motion and interaction
Play with nature
Play with social material explore, relation between objects, actions, and people
Play with child s interest and skills

63. Play with rules
Play with animals
Play with technology
Cooperative play
Medical play

64. TOY
Definition;
The word toy comes from an old English term that means tool
Toys are tools for a child
Toys are valuable teaching tools

65. TYPES OF TOYS
Soft and cuddling toys
Manipulation/small motor skill toys
Large motor skill toys
Dramtic play

66. The most important things that parents
can provide are;
Time
Space
Materials
Caring adults

67. THANK YOU