PHYSIOTHERAPY MANAGEMENT IN CEREBRAL PALSY.pptx

PHYSIOTHERAPY MANAGEMENT
IN CEREBRAL PALSY
STUTI GAIKWAD
MPT – 1ST
UNDER GUIDANCE OF
DR. SUVARNA GANVIR
PROFESSOR & HOD
DEPT OF NEUROPHYSIOTHERAPY
DVVPF’S COLLEGE OF PHYSIOTHERAPY

CONTENTS
• Definition
• Classification
• Pathology
• Clinical features
• Clinical Assessment
• Diagnostic criteria and tools
• Management Options
• Medical Management
• Surgical Management
• Physiotherapy Rehabilitation-INFANCY
• Physiotherapy Rehabilitation- SCHOOL AGE & ADOLESCENCE
• Deformities
• PROGNOSIS

S
DEFINITION : Disorders of the
development of movement and posture,
causing activity limitation, that are
attributed to non‐progressive
disturbances that
occurred in the developing foetal or
infant brain.
PREVALENCE :
• From regions in low-and middle-income
Countries (LMICs), birth prevalence for pre-/
perinatal CP was as high as 3.4 per 1000
(95% CI 3.0–3.9) live births.
• Following meta-analyses, birth prevalence
for pre-/perinatal CP in regions from high-
income countries (HICs) was 1.5 per 1000
(95% CI 1.4–1.6) live births, and 1.6 per
1000 (95% CI 1.5–1.7) live births when
postneonatal CP was included.
Treatment of Cerebral Palsy and Motor Delay- Sophie Levitt, Anne Addison, 6th Edition.
McIntyre, Sarah, et al. "Global prevalence of cerebral palsy: A systematic analysis." Developmental Medicine & Child Neurology (2022).
The motor disorders of cerebral
palsy are often accompanied by
disturbances
of sensation, perception, cognition,
communication and behaviour, by
epilepsy
and by secondary musculoskeletal
problems’ (Rosenbaum et al. 2007a).

PERINATAL CAUSES:Problems During Labor and
Delivery
Obstructed labor
Antepartum hemorrhage
Cord prolapse
Other Neonatal Causes
Hypoxic–ischemic encephalopathy
Neonatal stroke, usually of the middle cerebral artery
Severe hypoglycemia
Untreated jaundice
Severe neonatal infection
POSTNATAL CAUSES:
Metabolic Encephalopathy
Storage disorders
Intermedullary metabolism
disorders
Metabolic disorders
Miscellaneous disorders
Toxicity such as alcohol
Infections
Meningitis
Septicemia
Malaria (in developing countries)
Injuries
Cerebrovascular accident
Following surgery for congenital
malformations
Near-drowning
Trauma
Motor vehicle accident
Child abuse such as shaken baby
syndrome
PRENATAL CAUSES: Vascular events such as a
middle cerebral artery infarct
Maternal infections during the first and second
trimesters such as rubella, cytomegalovirus, and
toxoplasmosis
Less common: metabolic disorders, maternal
ingestion of toxins, and rare genetic syndromes
Pediatric Physical Therapy, Jan S. Tecklin, 5th Edition.

RISK FACTORS:LABOUR-
Likely Causes of Perinatal
Asphyxia
Prolapsed cord
Massive intrapartum hemorrhage
Prolonged or traumatic delivery
due to cephalopelvic
disproportion
or abnormal presentation
Large baby with shoulder
dystocia
Maternal shock from a variety of
causes
Events Associated with Causal
Factors
Prolonged second-stage labor
Emergency Cesarean section
Premature separation of placenta
Abnormal fetal position
In Preterm, Can Include:
Meconium-stained fluid
Tight nuchal cord
RISK
FACTORS:PRET
ERM INFANTS-
Patent ductus
arteriosus
Hypotension
Blood transfusion
Prolonged
ventilation
Pneumothorax
Sepsis
Hyponatremia
Total parenteral
nutrition
Seizures
Parenchymal
damage with
appreciable
ventricular
dilatation
RISK FACTORS:BIRTH &
NEWBORN PERIOD-Decreased
birth weight
Decreased age at birth (length of
gestation is the strongest
determinant)
Poor intrauterine growth in
moderately preterm but not in the
very preterm infant
Low placental weight
Low Apgar scores (scores of 0 to 3
at 5 minutes have an 81-
fold increased risk of cerebral
palsy)
Neonatal seizures
Sepsis
Respiratory disease
RISK FACTORS
DURING
PREGNANCY:
Preeclampsia in term
infants but not in
preterm infants
Multiple pregnancies
associated with:
Preterm delivery
Poor intrauterine growth
Birth defects
Intrapartum
complications
Pediatric Physical Therapy,
Jan S. Tecklin, 5th Edition.

Rosenbaum P. Proposed definition and
classification of cerebral palsy, April
2005. Dev Med Child Neurol.
2005;47:571-6.

FUNCTIONAL CLASSIFICATION
Paulson, A.; Vargus-Adams, J. Overview of Four Functional Classification Systems Commonly Used
in Cerebral Palsy. Children 2017

PATHOLOGY
• The most common abnormality on neuroimaging is periventricular leukomalacia (PVL), upto 56% of
all cases of CP demonstrate abnormalities in this location. Occurs commonly in premature infants. It
is a common outcome of intraventricular hemorrhage.
• Children with PVL typically have spastic diparesis. One large study found that PVL was present in
71% of the children with diparesis, 34% of those with hemiparesis, and 35% of those with
quadriparesis.
• Deep grey matter lesions to the basal ganglia and thalamic region are mainly associated with
dystonic CP. in approximately 12% of children.
• Large numbers of children acquired athetoid CP following a diagnosis of kernicterus, due to
concentrated damage to the basal ganglia with bilirubin encephalopathy.
• Focal cortical infarcts involving both the grey and white matter are found almost exclusively in
patients with hemiparesis. In a group of children with hemiparetic CP, 27% were found to have a
focal infarct on imaging.
• Infection and ischemia are two of the more common causes of generalized encephalomalacia.
• Multiple MRI findings including multiple cysts, cortical thinning, white and grey matter loss, and
microcephaly.
• Children with diffuse brain lesions or anomalies typically demonstrate spastic quadriparesis and are
at high
risk for additional medical and cognitive problems.
Pediatric Rehabilitation: Principles &
Practice, 4th Edition, Michael Alexander
& Dennis Matthews

IMPAIRMENTS ADDRESSED MOST OFTEN
• Muscle Tone and Extensibility
• Muscle Strength
• Skeletal Structure
• Selective Control
• Postural Control
• Pain
• Fatigue
• Gait
• Respiratory system
• Genitourinary system
• Sensory system
• Balance
• Coordination
• Infantile reflexes.
• Self care activities
Campbell’s Physical therapy For Children,Robert Palisano,5TH Edition

DIAGNOSTIC TOOLS
• Magnetic resonance imaging (MRI) and Computed tomography (CT) help in identifying the
extent and site of the neurological lesions , brain scans locate lesions in the white matter that
are described as periventricular leukomalacia.
• Genetic and metabolic testing should be targeted based on history or MRI findings.
• Psychological tests, Vision evaluation, Audiometric tests
• Electroencephalography (EEG).
• Neurological condition in infants admitted to a NICU is virtually always evaluated by imaging
of the brain, in particular, by cranial ultrasound (cUS) and MRI. Neonatal cUS is especially
applied in preterm infants.
• The most predictive patterns are (1) white matter injury (cystic periventricular leukomalacia or
periventricular hemorrhagic infarctions) (56%), (2) cortical and deep gray matter lesions (basal
ganglia or thalamus lesions, watershed injury [parasagittal injury], multicystic
encephalomalacia, or stroke) (18%), and (3) brain maldevelopments (lissencephaly,
pachygyria, cortical dysplasia, polymicrogyria, or schizencephaly) (9%)
William Jr et al ; mijna algra et al, sept 2014-FrontiersinNeurology | Neuropediatrics

MANAGEMENT
Physical Therapy
Occupational therapy
Speech therapy
Orthopedic Interventions.
Neuromedical and Neurosurgical interventions.
Stem cell therapy.
Current diagnosis & Treatment-Pediatrics,Willliam JR, Myron Levin,22ND Edition

MEDICAL MANAGEMENT
In the case of generalized spasticity,
The main drugs used include for
treatment baclofen – an analogue are
gamma-aminobutyric acid
(GABA),acting on the spinal cord, and
benzodiazepine derivatives, such as
diazepam, clonazepam or tetrazepam.
In the case of focal spasticity,one of the
basic therapies is intramuscular
administration of botulinum toxin type A
(botulin).
Sadowska et al, com Neuropsychiatric
Disease and Treatment 2020

SURGICAL MANAGEMENT
• In the case of patients for whom the medical treatment has proved ineffective neurosurgical operations
are performed, among others:
Sadowska et al, com Neuropsychiatric Disease and Treatment
2020
continuous
intrathecal infusion
of baclofen
through a pump
selective dorsal rhizotomy:
cutting of 50–75% of the
dorsal (afferent) nerve fibres
on L1-S1 level; this
treatment has a permanent
and irreversible effect,
reducing spasticity solely in
the lower limbs
selective peripheral
neurotomy: cutting some of
the fibres of the peripheral
nerve innervating a particular
muscle/group of muscles; it
only affects the spasticity of
the muscle innervated by the
cut nerve fibres.

ORTHOPEDIC INTERVENTIONS.
• The types of OS in CP include release and lengthening of musculotendinous unit, tendon
transfers, osteotomies, and arthrodesis.
• The concept of “surgical dose” in OS for CP, whereby the surgical intervention should match
the severity of dysfunction, is relevant.
The usual response of
many
orthopedic surgeons is
to perform tenotomies
of adductor
longus and brevis (with
or without obturator
neurectomies)
and Z lengthening of
the tendoachilles
1. A Japanese orthopedic surgical
approach called orthopedic selective
spasticity-control surgery (OSSCS)-
selective reduction of a specific
muscle’s spasticity, dystonia and
athetosis, and improvement of
antigravity posture control and
movement.
2. Single-event multilevel lever arm
restoration and antispasticity surgery
(SEMLARASS) is an advancement
of the concept of OSSCS
Newer
Orthopedic
Surgery
Approaches
Deepak sharan et
al, 2017, Indian
Journal of
Orthopaedics

INFANCY – FIRST STAGE- BIRTH TO 3 YEARS
• GOALS:
1. Family Education
2. Providing opportunities for optimal sensorimotor experiences and skills in enhanced environments.
3. Handling and positioning of infants.
4. The development of well-aligned postural stability coupled with smooth mobility to allow the
emergence of motor skills
5. Intensive, repetitive, task-specific intervention should be incorporated into practice.
6. Clearly written, illustrated, and updated home programs can be beneficial.
7. The therapist should work to ensure that no one position dominates daily activity.
8. The frequency of intervention should be tailored to meet the needs of a family.
9. Forms of communication (gesture, speech, and the use of alternative forms of communication with
pictures, signs, or electronic aids)
Campbell’s Physical therapy For Children,Robert Palisano,5TH Edition

FAMILY EDUCATION
• Knowing the hopes and expectations of a child and parents are and what they already know and can do
• build confidence in their skills to help their child
• aid their well‐being so that their own adjustment is promoted
• enjoy home therapy and not become stressed by the programme.
• Using small interactive groups with subgroups allows new parents to learn from experienced parents and
more positive attitudes are facilitated.
• setting goals and deciding on how to achieve them can increase children’s goal attainment, parental
feelings of competency.
• Educate about the realistic prognosis and the effect of physiotherapy while being hopeful.
Treatment of Cerebral Palsy and Motor Delay- Sophie Levitt,
Anne Addison, 6th Edition.

HANDLING AND POSITIONING OF INFANTS
• Activities such as prone positioning, promoting head control, weight bearing.
• Encouraging sitting and standing, and midline hand activities provide enhanced perceptual-motor
experiences to promote abilities including strength, postural control, hand activity, and social interaction.
• Focus on the development of well-aligned postural stability coupled with smooth mobility to allow the
emergence of motor skills - reaching during play, object interaction, and optimal transitional movements
and postures.
• Attain optimal mobility to facilitate play, language development, social interaction, and exploration of
the environment.
• Help Promote ease and confidence in the handling and caring of infants with these problems.
• Include positions that promote the full lengthening of spastic or hypoextensible muscles, and to use
positions that promote active, functional movement.

PARENT–CHILD INTERACTION
• Enabling a parent to position a child well, to handle them, and to cuddle and play with them modifies the
child’s neurological symptoms, improves motor function and daily care, and even prevents some
deformities; it also enhances their communication and the quality of their relationship.
Treatment of Cerebral Palsy and Motor Delay- Sophie Levitt, Anne
Addison, 6th Edition.

SENSORIMOTOR DEVELOPMENT
• Ayres’ theory describes SI as “an approach used to enhance the brain’s ability to organize sensory input
for use in functional behaviors.
• Use firm pressure when toweling dry after the bath.
• Provide a swinging motion to the infant or child every time you pick him or her up.
• “Dance” with the infant or young child on your shoulder or in your arms when passing between rooms.
• Encourage floor play with rolling over, pushing up, and moving extremities.
• Propose play activities requiring use and strength of the hands such as play dough, silly putty, playing in
wet sand, and so on.
• Provide opportunities for “heavy” work such as pushing a laundry basket of clothes or books, pushing
the grocerycart or carrying selected “heavier” groceries into the house or pantry, pushing the chair under
the classroom table, and replacing the toys that are heavier during classroom clean-up.
• Select equipment on the playground that provides movement to the child such as sliding boards, seesaws,
merrygo- rounds, jungle gyms, and so on, according to his or her capabilities and available safety
features

Warutkar VB, Kovela RK. Review of Sensory Integration
Therapy for Children With Cerebral Palsy. Cureus. 2022 Oct
26;14(10).

DEVELOPMENTAL TRAINING
• Some children will move through the typical developmental sequence of rolling, sitting, crawling,
standing, and prewalking skills, whereas other children will be limited in their gross motor trajectories
and require environmental adaptations.
• Different positions for the chosen activity may be used by a parent or carer to assist their own
management of an individual.
• Therapy plans become involved with simultaneous use of each developmentalchannel of prone, supine,
sitting, standing, and walking as well as hand function. There is also crossing of channels when a child
goes in and out of various postures.
• Each component needs practice within each channel. Postural mechanisms such as stabilisation on
forearms or hands can later be used in sitting, standing, and when using walkers.
• Managing gravity can be used to activate and strengthen particular muscle groups.
• Atypical postures are modified or changed by activating specific motor patterns.

PRONE DEVELOPMENT
• Postural stability of the head:
• Postural stability of the trunk:
• Postural stability of the shoulder girdle:
• Postural stability of the pelvis:
• Counterpoising limb movements:

Head control. Train the following aspects of head control:
• raising the head (righting)
• holding the head steady (postural stability)
• turning the head from side to side (postural adjustment for this movement).
Treatment of Cerebral Palsy and Motor Delay- Sophie
Levitt, Anne Addison, 6th Edition.

SUPINE DEVELOPMENT
• Postural stabilisation of the head.
• Postural stability of the shoulder girdle.
• Postural stability of the pelvis.
• Counterpoising the limbs in the air.
• Rising reactions and actions.
• Tilt reactions and saving reactions.

DEVELOPMENT OF SITTING
• Postural stability of the head
• Postural stability of the shoulder girdle
• Postural stability of the head and the trunk
• Postural stability of the pelvis
• Counterpoising (postural adjustments) for movements of head, for lifting to the vertical
• Righting (rising) reactions and actions
• Tilt reactions
Treatment of Cerebral Palsy and Motor Delay- Sophie Levitt, Anne Addison, 6th
Edition.

DEVELOPMENT OF STANDING
AND WALKING
• Antigravity support or weight bearing.
• Postural stability of the head and trunk.
• Postural stability of the pelvic girdle.
• Counterpoising or postural adjustment in the standing position holding on and removing one hand (Fig. 9.123),
holding on lifting an arm overhead, holding on, trunk turn, and also bend down to reach a toy with one hand.
• Control of anteroposterior weight shift of the child’s centre of gravity to initiate walking.
• Control of lateral sway from one foot to the other.
• Rising reactions and actions.
• Tilt reactions in standing are anteroposterior and lateral and later diagonal.
• Perturbations of a child in standing.
• Saving from falling.

AIMS:
• Develop postural mechanisms.
• Correct atypical postures and movements as much as possible in the context of standing and stepping.
• Bone density problems need early use of appropriate standing and walking frames.

DEVELOPMENT OF HAND FUNCTION
AIMS:
• Establish head control (stability and movement) for hand/eye coordination.
• Establish postural stability and weight shift of head, shoulder girdle, trunk, and pelvis in many gross motor activities in
prone, supine, sitting, standing, and stepping.
• Develop particular stabilisation of the whole body, shoulder girdle stabilization on arm/forearm support, and wrist
stabilisation with fine motor activity.
• Decrease manual or other supports in developmental stages, especially in sitting, standing, and upright kneeling,so
anticipatory postural control is associated with arm and hand function.
• Develop saving reactions in the arms.The upper limbs are thrown into various patterns involving active contractions of
the muscles in synergies (patterns) to save and prop the child as they fall off balance.

TECHNIQUES FOR CARRYING THE CHILD
CORRECTLY 1. To stimulate head
control.
2. To correct any atypical
postures.
3. To suggest easier ways
for a parent/carer
to carry a child with
cerebral palsy.

FUNCTIONS IN DAILY LIFE
Communication:
• Follow the general guide of developmental levels and individual assessment by speech and language
therapists and psychologists.
• Provide frequent opportunities for each individual child to initiate communication in any way that is
possible.
• Respond positively to all attempts at communication by a child, even when they do not appear to be
deliberate.
• Give time and more occasions for a child’s attempts to express his or her levels of communication.
• Speak slowly and distinctly but not with exaggerated articulation that sounds like ‘baby talk.
• Say names of familiar objects used during feeding, washing, dressing, and playing, say what they are
used for, and demonstrate and name parts of the body, and talk about the child’s own experiences.
• Children need to be able to see your face in a good light during speech.
• A multidisciplinary team (MDT) approach is essential, with the physiotherapist and occupational
therapist being present to establish effective communication with the materials or technology.

SELF‐CARE: SELF‐CARE TASKS (DRESSING, TOILETING, FEEDING, ETC.).
ACTIVITIES
• Children take an active role in most of their self‐care when they achieve components of vertical head
control, and adequate trunk and pelvic control to maintain upright sitting without specialist equipment.
• Food via a percutaneous endoscopic gastrostomy or jejunostomy. However, if this type of medical
intervention is required, the importance of positioning remains paramount for many children because of
reflux and discomfort. upright head posture is essential for feeding. Training self‐feeding begins with
finger feeding so that the child feels their own fingers on their mouth and learns to take in a small amount
of food.
• Feeding with a spoon follows, with the adult guiding hand to mouth and if needed supporting the child in
an effective sitting position.

• Bilateral hand use is also required in the development of skills.
• dressing may also present a functional opportunity in which a child can develop their language, including their
understanding of the names of body parts/clothes (nouns) and prepositions.
• Dressing practice should be carried out when the child needs to get dressed or changed.
• Start by completing each stage of a task except for the final one, which the child should do.
• Vary stable positions for dressing to discover the easiest one for the child.
• Type of clothing: loose‐fitting garments, large sleeves and arm holes, elastic necks. The child is held flexed for and
waistbands, large buttons, zips with zip‐pulls, and Velcro fastenings can all be used effectively to reduce the motor
demands required.
• When a child has unilateral involvement of the upper limbs, teach them to dress the affected arm first.
SOPHIE
LEVITT

Development of play:
• Play is usually a synonym for exploration and experimentation and, as described above, is extremely important in the
development of skills.
• Give helpful positioning, guidance, and support to use existing abilities to enjoy learning from play.
• Select objects and toys in a size that can be handled and those that can be understood, but especially those that interest an
individual child.
• Show the children how to use toys, but, wherever possible, see if they can find things out for themselves.
• Do not interfere with any child who is concentrating on a play activity unless absolutely essential.
Strengthening:
• Strengthening can improve motor skill or function
when the child has some voluntary control in a muscle group.
SOPHIE LEVITT
Pediatric Physical Therapy, Jan S. Tecklin, 5th
Edition.

REDUCE SPASTICITY :
• Positioning in antisynergistic pattern.
• Stretching.
• MFR.
• ROM exercise
• Splinting & serial casting
• Dorsal rhizotomy
• Botulinum injection.
MANAGING DEFORMITY:
• Explain the importance of the postural
management programme to parents and
carers.
• Monitor posture and movement
throughout the lifespan of a person.
• Treat pain due to deformities.
• Improve postural alignments and symmetrical weight bearing both
actively and with orthoses.
• Strengthen muscles using gravity for Assistance.
• Use interesting playful activities to motivate actions and as much
mobility.
• Ice treatments (cryotherapy) to decrease spasticity.
• Prolonged stretch to spastic muscles in
correct positions in plasters or moulded
orthoses and postural equipment.
• active and full ROM of antagonists
to hypertonic muscles.
SOPHIE
LEVITT

VISUAL DEVELOPMENT :
• Integrated with methods for head control, hand function, and locomotor activities.
• An assessment of the developmental use of residual vision is given by the developmental paediatrician and
specialist teacher and relates to vision available for exploration and learning (Sonksen 2016). This will help in
planning the motor activities.
• Unusual head movements and other patterns might have to be accepted for making use of the residual vision.
• Use of favorite toy and color.
LANGUAGE DEVELOPMENT :
• Talk and clearly label body parts used.
• Use simple and easy words with appropriate examples.
• Also aided with help of motor actions.
SOPHIE
LEVITT

SCHOOL AGE & ADOLESCENCE
ACTIVITY, MOBILITY,
ENDURANCE:
Gait training,
Architectural
modification,Orthosis,Re
gular exercise, proper
diet & nutrition.
SCHOOL &
COMMUNITY
PARTICIPATION:
Positioning,lifting &
transfer teachniques
taught to school
personnel, Oppurtunities
should be given, adapted
games & competitions &
team participation
encouraged, community
fitness program,Injury
prevention.
IMPROVE
FUNCTIONAL
SKILLS:
cardiovascular
fitness,weight
control,maintain
integrity of joints
&muscles,
swimming,
wheelchair
aerobics.
TRANSITIONAL
PLANNING:
Vocational training,
occupational
training,living
arrangement, social
skill& household
management,
professional health
service be made
available.
SOPHIE
LEVITT

PROGNOSIS
• Children with hemiplegic and ataxic CP are more likely to walk, whereas those with dyskinetic and
bilateral CP are less likely to do so. Cognitive functioning, visual and hearing impairments, and epilepsy
are also predictors of walking ability for all types of CP. Independent sitting by 24 months remains the
best predictor of ambulation for 15 meters or more with or without assistive devices by age 8 years.If
independent sitting is not achieved by age 3, there is very little chance of achieving functional
independent walking.
SOPHIE
LEVITT

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