2. Cerebral Palsy
Divya Arora
Actor , Director
 Dr .Batra’s Positive
health Award .
 work with Hrithik Roshan
in Guzaarish movi .
 Tara Movi

3.  What is Cerebral Palsy (CP) ??
Cerebral Palsy (CP) Describe a
of The
.
The motor disorder of CP are often accompanied by distrubances of
sansation ,perception ,cognition ,communicatiom and behaviour , by
epilepsy and by secondary musculoskeletal problem .

4.  What are the cause of cerebral palsy ??
• In many childern , the . risk factors
must be distinguished from causes .
1. Prenatal Cause
2. Perinatal Cause
3. Postneonatal Cause

5. Prenatal Perinatal Postneonatal
Responsible for approximately 75
% of all cases of CP and Incude -
Brain Malformatio
Meternal Infection (most common
TORCH - Toxoplasmosis , rubella
,cytomegalovirus ,herpes simplex
virus )
Genetic
Vascular events such as medial
cerebarl artery occlusion
metabolic condition
toxin
etc .
Responsible for approximately 10-
15 % of all cases of CP and
Result From Problem during
Labour and Delivery such as -
Antepartum haemorrhage or cord
prolpse ,compromising the fetus ,
neonatal encephalopathy
difficulty with initiating and
maintaining respiration , seizures
,low birth weight , etc .
minor perinatal events where the
baby recover rapidly do not result
in CP .
(Occurring after 28 days of life )
10% cases of all CP .
include -
meningitis
accident
non accidental injuries
etc .

6. Cerebal Palsy classified by -
1. Tropographical Distribution
2. Motor Type
3. Severity of Motor Disorder (Describe in examination)

7. Tropographical Distribution

8. Motor Type
1. Spastic Cerebral Palsy (Most Common Type)
2. Dyskinetic Cerebral Palsy ( Dystonia + Athetoid)
3. Atexic Cerebarl Palsy (Second Most Common Type)
4. Mixed Type

9. Case Presentation

10.  The Male child was apparently normal before one year after which
mother noticed that the child not attend the age appropriate
milestone. child didn't attend neck holding even after a 1 year and
the lower Limb become stiff .
 mother compare the child growth with neighbours child of some
age and found her baby has not attend the milestone only after
1.5 year child attend neck holding but not a attend sitting position
but the lower Limb become a more stiff so she went to the nearly
Hospital where child was diagnosed as a case of the Global
developmental delay and refer to the higher centre there
pediatrician was diagnosis case of ..................... and refer to the
physiotherapist .

11. Assessment
• Subjective Assessment -
• Objective Assessment -
• Examination -
• Management -

12.  Name of physiotherapist -______________________
GSCPT No - _________________Date - __________
• Child Name - ?
• Father Name - ?
• Mother Name -?
• Gender - Male
• Child Age - 1.5 Y
• Both parent Age - ?
• Address -?
• Contact Number - ?
Both Mother and father -

13. • Occupation - both parent
• Socioeconomical Condition - poor
Good / fair / Poor (Its help to determine treatment plans )
• Referred by - pediatrician
Name - Dr ..
Hospital Name -
Number -

14. • Chief Complain -
“ her Child did’t attend the neck holding and lower limb gradually
become stiff then after 1.5 child attend the neck holding but not got
a sitting postion and lower limb become more stiff when She was
Compared to the neighbors child ”

15. History
1. Talking to the child
2. Talking to parents (Mother)
• “You can do anything with children if you only play with
them.”

16.  Talking to parents (Mother)
• Ask if they have an infant medical record book—this contains information
about height and weight percentiles, immunizations, development, and
illnesses in the first few years of life .
 Prenatal History
• Age of Mother - ?? (<20 yr or >30 yr - high risk of the Pregnancy )
• H/o marriage in Blood Relationship
• H/o Drugs taken During Pregnancy
• H/o of Truma or Stress
• H/o Any addiction
• H/o Fever

17. • H/o Genetic Origin
• H/o Abortion , Still born ,Death after the birth
• H/o Multiple Pregnancy
• H/o Radiation exposure
• H/o Jaundice
• H/o Metabolic disorder (gestational diabetes)
• H/o Maternal Hypoxia ??? (Eclampsia ,traumatic injury)
 Perinatal History
• Place of Delivery ??

18.  H/o Premature delivery (Common)
• H/o Vacuum or C - delivery
• H/o Forceps delivery
• H/o Asphyxia at Birth or Birth Truma ( common )
• H/o Presentation of Child - breech Presentation
• H/o test tube baby
 Postnatal history
• H/o Delayed birth cry

19. • H/o Low Birth weight < 2.5 kg , very Low birth weight <1.5 kg , Extremely low
birth weight < 1 Kg .
• APGAR SCORE
• Need For O2 Supply / Ventilation (High Risk Baby)
 NICU Stay
• H/o any truma to brain during the first 2 year of life
• H/o Infection (F)
• H/o Epilepsy ??
• Hydrocephalus / microcephaly
• H/o ICP ( headache , vomit )
• H/o Any change in performance, personality or behavior (e.g., aggression)?

20.  feeding history - ??
 Personal history - Sleep , Diet , Appetite ,Habite (Thumb sucking
)
 Surgical History - ??
 Drug History -??
 Other -
Respiratory History
CVS History
GI History

21. Objective Assessment
children cannot cooperate with a formal neurological
examination, so assessment is opportunistic—
observation becomes important.

22. On Palpation
• Tone - Hypertonic infant
‘ scissoring of lower limbs when the baby is picked up. Resistance
to movement of limbs. The baby will seem to move in one piece ’
• No Tenderness
• No Swelling
• No scar
• Temperature - may be cold the distal extremity ( Spastic muscles )
• Below the age 3 month or newborn baby so palpate the anterior
fontanel to identifiy the ICP .

23. Examination
 Developmental Assessment
Development is a continuous process, the rate of which varies considerably
among normal children.
 divided into four areas:
• Gross motor
• Fine motor and vision
• Speech and hearing
• Social
Delay in all four areas is usually abnormal, but delay in one area may not
be

25. • Warning Sign - 17 month (1.5 yr) child
not got a Setting postion
Persistent primitive reflexes.

27. • Gross Motor Developmental milestones is Affected .
(at the 6 month)

28.  Reflexes Examination -
May Be Persistent primitive reflexes
Spinal reflex -
1. Flexor Withdrawal -
2. Crossed Extension -
3. Traction -
4. Moro -
5. Startle -
6. Grasp -
Tonic / Brain stem reflex -
1. ATNR -
2. STNR -
3. Symmetrical tonic
labyrinthine -
4. Positive Supporting -
5. Associated reaction -

29. • Tendon reflexes can be elicited by tapping the tendon
with a finger -
Hyperreflexia due to spasticity (Affect the Lower extremity)

30.  Cranial nerves examination -
It is not possible to systematically examine cranial nerves in children
• I (olfactory): very difficult
• II (optic): Ask the parents - can the child see? ( Pupils: Check for
size, shape, and reaction to light )
• III, IV, VI (eye movements): Gain the infant’s visual attention with
an object and move it back and forth. Watch for the range of ocular
movements as the child tracks the object. Pendular nystagmus may
indicate a visual defect.

31. • V (trigeminal): rooting reflex
• VII (facial): Facial palsy will become apparent when the child cries.
Asymmetry will be more obvious. Does the child close both eyes?
• VIII (vestibulocochlear): Formal hearing tests are performed at
birth.
• IX, X: swallowing
• XI (accessory): neck and shoulder movements
• XII (hypoglossal): tongue movement

32.  Sensation
This is difficult to assess. Only response to pain can be
confidently elicited in young children .

33. Motor -
Passive ROM -
ROM Abnormal
Hip Flex -
Exte -
Abd -
add -
knee Flex -
Exte -
Ankle PF -
DF -
May be afected .

34. • Tone - hypertonia
( Adductors of hip , extensors of knee , and calf mus .)
Attitude of limb - scissoring of lower limbs
• Spasticity - Present ( may be gread 3 - Marked increase in tone,
passive movements difficult)

35. Anthropmetric examination
height - may be reduced bcz of spasticity
HEIGHT CENTIMETERS
AT BIRTH 50
AT 1 to 2 Yr 75
2 to 12 Yr (Age in Yr * 6) + 77

36. Weight of Child - depend on the patient ( Average 11 kg)
Weight Kg
At birth 3.25
3 to 12
months
(age in month +9)/2
1 to 6 Yr (age in Yr * 2) + 8
7 to 12 Yr (age in Yr * 7) +5 / 2

37.  Head circumference of child - at occipitofrontal head
circumference from external occipital protuberance to the glabella
.
 Its normal in the case .
Head circumference Centimeter
At Birth 32 - 35
1 to 3 monthh 39
4 to 6 month 42
6 to 12 month 46 -47
2 Yr 48 - 49
3 Yr 50 - 51
4 Yr 52 -53
Adult 53 - 56

38. Severity of Motor Disorder - Scale
• The
Provide Information About The based
on the and Their need for
.
• There are Five levels within the GMFCS -
I. Level 1 + 2 - walk independently
II. Level 3 - need walking frames or elbow crutches
III. Level 4 + 5 - require a wheelchair
 GMFCS level Provide Guidance regarding prognosis for motor development .

40. GMFCS score - Level 4
“ require a wheelchair ”

41. Other examination
( in case its not requiired )
 Abdomen and gastrointestinal system
 Cardiovascular system
 Orthopedic (Club Foot , DDH)
 Respiratory system
etc .

42. Investigation -
MRI ( Periventricular leukomalacia ) lesion (may be)

43. www.drawittoknowit.com (Pathology)

45. “Pediatrics is a specialty bound by age and not by
system.”
Management of Cerebral Palsy

46. Its Multidisciplinary Approach ,
 PHYSICIAN
 ORTHOPEADIC SURGEON
 PHYSIOTHERAPIST
 OCCUPATION THERAPIST
 SPEECH PATHOLOGIST
 ORTHOTICS AND PROSTHETICS
 PSYCHOLOGIST
 SOCIAL WORKER

47. Problem List -
not got a Setting postion
scissoring of lower limbs due to spasticity

48. PT MANAGEMENT
Aims -
 Improve Functional Ability
 Reduce the Spasticity
 Improve Mobility and flexibility
 Improve Activity / Mobility / Endurance
 Prevent the Contracture / Deformity

49. Plans
• Passive Movement , Active Assisted Movement , Active Movement , Resisted
motion followed according to the child’s capability
• Streching (PNF)
• Synergistic motion which involves resistance to a muscle group in order to
contract an inactive muscle group in the same synergy
• Relaxation techniques
• Reciprocation is training movement of one leg after the other in a bicycling
pattern in lying, crawling, knee walking and stepping.
• Balance- Training of sitting balance and standing in braces
• Ambulation Training
• Skills of daily living such as feeding, dressing, washing and toileting
• Approaches

50. Approaches

51. SENSORY STIMULATION FOR ACTIVATION AND INHIBITION
(Margaret Rood,1962)
• Main features are:
1. Afferent stimuli - Techniques of stimulation such as troking, brushing,
icing, heating, pressure, slow and quick muscle stretch, joint retraction and
approximation, muscle contractions are used to activate, facilitate or inhibit
motor response.
2. Muscles are classified- ‘light work muscle action’ or ‘heavy work muscle
action.’
3. Reflexes - tonic labyrinthine, tonic neck, vestibular are used in therapy.

52. REFLEX CREEPING AND OTHER REFLEX REACTIONS (Vaclov
Vojta, 1984, 1989)
• Reflex creeping - The creeping patterns involving head, trunk and limbs
are facilitated at various trigger points or reflex zones.
• Reflex rolling - Also used with special methods of triggering.
• Sensory stimulation- Touch, pressure, stretch and muscle action against
resistance are used in many of the triggering mechanisms or in facilitation of
creeping.
• Resistance is recommended for action of muscles.

53. • Other -
 NEUROMOTOR DEVELOPMENT
 NEURODEVELOPMENTAL TREATMENT WITH REFLEX
INHIBITION AND FACILITATION (Bobath)
 SYNERGISTIC MOVEMENT PATTERNS( Brunnstrom)
 PROGRESSIVE PATTERN MOVEMENTS