Cerebral Palsy: Definition Cerebral palsy is a static encephalopathy Encephalopathy = Brain Injury that is non- progressive disorder of posture and movement Variable etiologies Often associated with epilepsy, speech problems, vision compromise, & cognitive dysfunction
Cerebral Palsy: Prevalence 2-4/1000; 7-10,000 new babies each yr 150 years ago described by Dr. Little an orthopedic surgeon and known as Little’s Disease During past 3 decades considerable advances made in obstetric & neonatal care, but unfortunately there has been virtually no change in incident of CP
Cerebral Palsy: Classification Various classifications of Cerebral Palsy Physiologic Topographic Etiologic
Types of Cerebral PalsySpastic (70%) Quadriplegia, hemiplegia, diplegiaAthetoid (15%) Choreoathethoid, DystonicAtaxic (5%)Mixed (10%) Combination of any two types of CPHypotonic Early stages of the Spastic, Dyskinetic and Ataxic forms
CP Spastic Hemiplegic Clinical features are those of pyramidal release involving one side of the body Posture and gait Tone & Deep tendon reflexes Contractures and Deformities Wasting of affected limbs Note any facial muscle weakness Cortical sensory loss Visual field defect Speech defects
Ataxic Cerebral Palsy Rare form of CP Hypotonic and hyporeflexic in infancy Ataxic – Titubation( a tremor of the head and sometimes trunk, commonly seen in cerebellar disease ) Intention tremors and Incoordination Mental deficit is Mild Nystagmus is uncommon
Causes of Cerebral Palsy 90% of the causes are Idiopathic Prenatal (Before delivery) Maternal Infection, Genetic, Developmental, Vascular problems Natal (During the time of Delivery) Anoxia, Asphyxia, Birth Trauma such as Dispropotion , Forceps, Rapid or Breech delivery Postnatal (After Delivery) Trauma to Skull, Kernictures (Jaundice after birth), Infections, Vascular complications such as Thrombosis, Embolism, Haemmorhage
Diagnosis Medical History CT Scan / MRI Scan
Cerebral Palsy: Clinical Presentation Remember that motor developmental progression is from…. Head to Toe
On Examination 1.Assessment of higher functionsOrientation-Normal (except in MR cases)Speech- Dysarthria , AphasiaVision-Squint or BlindnessLearning – May be lostMemory-will be impaired in most of the casesEmotional State- Apathic , Frightened
Contd….2.Assessment of Muscular System Tone – Spastic Flaccid Rigid Mixed (depends on the type of CP) Muscle Power- Assessed by MRC Grading Girth Of the Muscle- Its is usually reduced due to DISUSE .
Contd….3.Assessment of Sensory System 1.Spinothalamic sensations are Normal 2.Posterior column is involved. So Joint position sense, Vibration sense are usually affected
Contd….4.Assessment of Reflexes Deep Tendon Reflex – exaggerated in spastic CP Neonatal reflexes – Delayed or AbsentSuperficial reflexes may be affected in spastic CP.5.Assessment of Chest Normal .6.Assessment of limbs1.Alteration of Tone in both upper and Lower limb.
Contd….7.Assessment of Co-ordination In co-ordination is seen in Athetoid, Ataxic & Mixed type.8.Assessment of Spine Spinal deformity – Scoliosis or Lardosis is seen9.Assessment of Balance Affected.
Contd….10.Assessment of Posture Three types of posture are usually seen according to the type of CP. They are 1.Flexion posture 2.Extension Posture 3.Adduction Posture11.Assessment of compound movements Affected
Contd….12.Assessment of Gait Scissoring gait – The patients try to catch their own centre of Gravity. This is due to weakness of Abductors and Spasm of Adductors13.Assessment of Other Problems 1.Ortho Problems-Stiffness, Pain & Deformity in Joints 2.Pressure sores – Ulcers over the Bony prominence
Cerebral Palsy: Management Neurologic and Physiatric OT and PT Speech Adaptive equipment Surgical Rhizotomy, Baclofen pumps, Botoxin
Different approaches to Neuromuscular education W M Phelps-diagnosed five types of CP Specific combinations of muscle education & bracing were prescribed for different types of CP. Muscles were assessed,classified as spastic,weak,normal or atonic & re-education was given based on their condition. In this system muscles antagonistic to spastic ones are activated.
Neuro developmental treatment with Reflex inhibition & facilitation (NDT) Berta Bobath- This technique is based on the inhibition of tonic reflexes,such as symmetrical& asymmetrical tonic neck reflexes,tonic labyrinthine reflex. Ones the reflex patterns of abnormal tone are inhibited the child is said to have been prepared for movements. Various primitive reflexes of infancy should also be inhibited.
Features of the approach are Reflex inhibitory patterns- Selected to inhibit abnormal tone associated with abnormal movement patterns & abnormal posture. Sensory Motor Experience- The reversal of these abnormalities gives the child the sensation of more normal tone. Sensory stimuli are also used for inhibition & facilitation & voluntary movement. Facilitation Techniques For Mature Postural Reflex.
` Key points of control Are used to attempt to change the patterns of spasticity so the child is prepared for movements. The key points are usually head& neck,shoulder & pelvic girdles. Developmental Sequences All-day management –should supplement treatment session.parents &others are advised on daily management & trained to treat the children.
Proprioceptive neuromuscular Facilitation (PNF) Herman Kabat,with Margret Knott & Dorothy Voss- Developed a system of movement facilitation techniques &methods for inhibition of hypertonus. The main features are : Movements patterns (called mass movements patterns)- Patterns observed with functional activities as walking ,feeding, playing sports. These patterns are spiral (rotational)& diagonal. The movements patterns consist of the following components-
(1) Flexion or Extention (2) Abduction or Adduction (3) Internal or External rotation Sensory (afferent) stimuli: Those muscle group working in synergy with rotational& diagonal patterns were identified & with a combination of touch & pressure, traction & compression. stretch , proprioception ,auditory& visual stimuli are given to muscles to contract against resistance.
Special Techniques 1. Irradiation-this is the predictable overflow of action from one muscle group to another within a synergy. 2. Rhythmic stablizations-which use stimuli alternating from the agonist to its antagonist in isometric muscle work. 3. Stimulation of reflexes- such as the mass flexion or extension. 4. Repeated contractions- of one pattern using any joint as a pivot. 5. Reversals-from one pattern to its antagonist.
6. Relaxation techniques- such as contract-relax & hold-relax. Ice treatment are used for relaxation of hypertonus.
Sensory Stimulation for Activation & Inhibition It is a sensory approach in which Rood’s technique-By Margret Rood muscles are classified according to their function & the appropriate stimuli for their action are given. The various nerves & sensory receptors are described & classified into types, location, effect, response, distribution & indication.
Techniques of stimulation, such as stroking, brushing (tactile) icing, heating (temp.) pressure, bone pounding, slow & quick muscle stretch, muscles contractions (proprioception) are used to activate, facilitate or inhibit motor response. Sensory motor technique uses a series of eight clearly defined developmental patterns which children learn in sequence.
These patterns are spine withdrawal, rolling over, pivot prone, neck co- contraction, elbow weight bearing, all four weight bearing, standing upright & walking. Vital functions-A developmental sequence of respiration, sucking, swallowing, phonation, chewing & speech is followed.
Reflex creeping&Other Reflex Reactions By Vaclav Vojta- Trigger points are points on the body which facilitate movement patterns involving the head,trunk & limbs. These reflex zones ( 9 in number) are activated with sensory stimuli & creeping is seen as a response to this triggering.
Sensory integration treatment approach Developed by A.J.Ayers The goal of this technique is to teach the children how to integrate all their sensory feedback & then produce useful & purposeful motor response. Activities like catching a ball in different position uses integration of visual, vestibular & joint proprioception feedback system at the same time.
Theory of this system is that sensory input followed by appropriate motor function will contribute to the improved development of higher cortical motor sensory function.
Orthopaedic Management For improvement of functional mobility and appearance after conservative therapy has failed Correction of contractures – Tenotomy Correction of deformities from muscle imbalance Eg. Tendon transfer Correction of functional handicaps of hands and feet – Arthrodesing operations
Gentle StretchingStretching is the activity of gradually applying tensileforce to lengthen, strengthen, and lubricate muscles,often performed in anticipation of physical exertion andto increase the range of motion within a joint. Stretchingis also believed to help to prevent injury to tendons,ligaments and muscles by improving muscular elasticityand reducing the stretch reflex in greater ranges ofmotion that might cause injury to tissue.
Strengthening exercisesThese exercises are done to increase the power & strength of the muscle. They usually done as Resisted Exercises both Manually and Mechanically.
Rolling Contd…..The patient is made to move from one side to another side by his side. This is known as rollingCrawling The child is made to move on his four limbsStanding with supportPosture CorrectionGait Training
Speech Rehabilitation VERBAL APPROACH- Initiating auditory-verbal therapy as early as possible is essential because the childs greatest capacity for learning language auditorily, occurs during the first two to three years of life. In order to effectively learn spoken language, a childs hearing and listening skills must be stimulated during this critical time.
Parent-Centered Modeling Parents are the major influence in a young childs development, acting as primary role models and the most effective teachers. For this reason, the verbal approach is parent-oriented. The verbal therapist develops a working partnership with parents to teach speech and language to the child at home
Oral Sensory motor facilitation techniques Proper neural development of oral movements and oral sensory function is vital for providing the foundation for good speech production and mature feeding patterns.
Oral Sensitivity (based on these domains - Temperatures, Textures, Tastes) Hypersensitivity - Over-sensitive Hyposensitivity - Under-sensitive
Jaw Stability Position of the jaw and presence/absence of stability or weakness during oral sensory-motor activities, such as chewing. Lip Function Position and action/movement of the lips during oral sensory- motor activities, such as drinking, sucking, chewing or blowing. Tongue Function Position and action/movement of the tongue during oral sensory- motor activities, such as chewing, drinking, sucking or blowing.
TONGUE EXERCISES Range of Motion 1. Tongue Extension Protrude tongue between lips. Sticking out tongue as far as you can. Hold tongue steady and straight for 3 to 5 seconds. Relax and Repeat 5 times.
2. Tongue Retraction Retract tongue, touching the back of your tongue to the roof of your mouth (as if producing the /k/). Hold for 1 to 3 seconds. Relax and Repeat 5 times. 3. Tongue Extension and Retraction Combine the two procedures above, holding each position for 1 to 3 seconds. Relax and Repeat 5 times. .
4. Tongue Tip Up Place tongue on alveolar ridge, (the area behind your top teeth.) If you dont have any teeth, move your tongue tip up to your gum where your top teeth would be. Open mouth as wide as possible maintaining tongue contact. Hold for 3 to 5 seconds. Relax and Repeat 5 times
5. Tongue Elevation Along The Palate Tongue tip to alveolar ridge, (The area behind your top teeth.) Move tongue front to back along the roof of your mouth. Relax and Repeat 5 times. 6. Tongue Side To Side Tongue tip to left side of mouth, hold for 3 to 5 seconds. Tongue tip to right side of mouth, hold for 3 to 5 seconds. Relax and Repeat 5 to 10 times.
Tongue Resistance: 1. Tongue Push Forward Stick out your tongue as far as you can. Put something flat (back of a spoon or a tongue depressor) against your tongue Push against your tongue with the flat object at the same time as you push against the flat object with your tongue Hold for 1 to 2 seconds. Repeat 5 times. 2. Tongue Push Up Push down on your tongue with the flat object, while, at the same time, you push up with your tongue. Hold 1 second. Repeat 5 times.
JAW EXERCISES Range of Motion 1. Jaw Opening 2. Side-to-Side Movement 3. Increasing Circular Jaw Movement
LIP EXERCISES Range of Motion: 1. Lip Retraction Smile. Hold for 5 seconds. Relax and Repeat 5 times. 2. Lip Protrusion Pucker your lips as if you were going to give someone a kiss. Hold for 5 seconds. Relax and Repeat 5 times. 3. Lip Retraction and Protrusion Smile then pucker your lips. Use exaggerated movements. Relax and Repeat 5 times.
Lip Closure: 1. Lip Press Press lips tightly together for 5 seconds. Relax and Repeat 5 times. 2. Lip Press on Tongue Depressor Tightly press lips around tongue depressor, while the clinician tries to remove it. Perform for 3 to 5 seconds. Relax and Repeat 5 times.
Compensatory Techniques: Correction of Respiratory errors: Attention should be given to the development of speech- breathing patterns before the child is a year old. The following techniques are used for improvement of breathing patterns for speech :- 1.Break Up Persistent Tonic Reflex Patterns Abnormal distribution of muscle tone is found in abdominal, thorax & neck muscles of CP Children.When strong tonic reflexes persist they should be weakened or broken up through systematic use of such techniques as reflex inhibition or sensory facilitation.
2.Facilitate Developmental Sequences Which Lead To Good Sitting Posture Many of the cerebral palsied children seem to collapse on sitting because much of the weight of the trunk and head bears down on the abdominal areas, thus interfering with function of the diaphragm & abdominal musculature. The back is rounded & the head is flexed so that the chin rest on the chest.
In this position elevation of the rib cage for inhalation is difficult. Therefore taking the child through the developmental sequences leading to unsupported sitting with good posture is basic fo developing speech breathing. 3.Maintaining Proper Postural Relationships between Abdomen, Trunk, Neck & Head.
Seating in a properly fitted & adjusted relaxation chair will help the child maintain a more satisfactory postural relationship between head & neck, trunk & abdominal areas. In physical therapy ,attention must be given to the flexors & extensors muscles of the neck & shoulders.
3.Develop a Breathing Rate of Less Than 30 Cycles/minute Several procedure are suggested for imposing a slower rest-breathing rate on child. A) Crossing the child’s forearm across his chest & pressing them tightly enough against his thorax to encourage a deeper exhalation.For inhalation the pressure is released.
The therapist times his movement of pressure & relaxation of pressure to control the normal breathing pattern. B) With the child lying on his back, flex the knees & press the front portion of the upper legs against the abdomen by flexing the hips.Quickly extend the legs at the hips, thus releasing the pressure on the abdominal area. This pattern of movements should be repeated at a rate corresponding to the normal breathing rate i.e. about 20 cycles/ minute.
Some CP children seem to have difficulty in learning to inhale quickly and then produce the controlled, prolonged exhalation required for continuous speech (as in yawning & crying).It is difficult to modify these breathing patterns for speech production. Momentary interference with inhalation-by holding a tissue over the nose & mouth-will cause the child to breath deeply when the interference is removed.
Producing deep inhalation on a reflex basis is only a first step. Next learning is to hold the inhaled air until given a signal to exhale. At first the exhalation will be rapid & uncontrolled. Having the child imitate a prolonged sigh, a prolonged phonation, babbling or sustained blowing will help him develop controlled, prolonged phonations.
5.Counteract Abdominal Movements Which are Asynchronous with Thoracic Movements Sometimes CP children are unable to produce prolonged exhalations because the abdominal- diaphragmatic movements are antagonistic to the thoracic movements. Because of this asynchrony the child will be able to produce phonation of short duration.
To overcome this difficulty, a corset or girdle is wrapped around which extends from lower border of sternum to the ileac crest. This helps in stronger voices & longer exhalations.
6.Functional Techniques for Developing Control of Respiration Many techniques & pieces of equipments have been developed to encourage the child to produce prolonged exhalations such as sustained blowing or sustained phonations.
Correction Of Phonatory Errors1.Encouraging Vocalization: Parents should learn not to respond to the crying so quickly so that the child get sufficient practice to use his larynx. Laughing also exercises larynx. For “quite babies “ positioning is useful in facilitating vocalization.
2.Coordinate Phonation with exhalation Audible sigh on the exhalation. After the child learned to hold a deep inhalation ,he should be taught to phonate a vowel sound on the exhalation. If the child has difficulty initiating phonation, different techniques for breaking up the laryngeal block should be tried.
Positioning may also be used to good advantage. 3.Develop Prolonged Phonation without Undesirable Tension: Before encouraging the child to develop longer phonation, the therapist should be sure that the child inhales sufficiently immediately before beginning phonation.
The therapist should be sure that the child has learned to hold the inhaled air & to coordinate phonation with exhalation. 4.Develop Variation of Loudness & pitch: Practice in producing tones at different levels of loudness & pitch levels helps the child to increase his laryngeal function
Only a little imagination is required to think of many ways to motivate the child to vary the loudness, pitch or inflection patterns of his voice.For example- whispering, ordering like police man, cheering at something or singing.
5. Counteract Undesirable postural pattern: The postural pattern interfere with laryngeal function. as the child phonates, he extends the leg, arch the back and throw back his head. These can be detected by placing one’s hand against the soles of the child’s feet, on his shoulders or behind his head
The therapist must learn how to feel these changes in flexors and extensor tone. When increase in extensor tone or associated with phonation, he should use appropriate reflex –inhibiting postures or appropriate sensory stimulation for activation and inhibition of selected muscle group.
CORRECTION FOR ARTICULATORY ERRORS Before going for articulatory correction the therapist should be sure that the child has sufficient control over speech breathing and phonation. The patterns of neural organization as in sucking and swallowing must also be developed. 1.Encourage and facilitate babbling
While an infant is crying it is possible to produce approximation of the lips by placing the hand beneath the mandible and gently elevating it. Repetition of this technique enables the child to hear and feel the consonantal modification of his vocalization. Bilabial consonants may be added by rapidly vibrating the lips with the therapist’s or parent’s fingers.
2. develop sucking, swallowing and chewing patterns Attention should be given to the develop of sucking, swallowing and chewing patterns in CP children. The mother can use several techniques which facilitate maturation of oral activities.
When spooned foods are added to the child’s diet, it is to be placed in the front of the mouth, thus encouraging the child to develop the tongue movements which are essential for the first stage of chewing and swallowing. Touching the child’s lips spoon will make him aware of his lips and thus facilitate and maintenance of lip closure.
3. Improving the Function of the Lips, Mandible and Tongue as articulators The therapist should help the child about his awareness of his movement of the various articulators. By using the mirror the child can see the movement of his mandible moves with his tongue movement.
Stabilization of the mandible with small object placed between the molars, aids the child in developing free tongue movements.
Team Approach To Rehabilitation A comprehensive management plan will pull in a combination of health professionals with expertise in the following: physical therapy to improve walking and gait, stretch spastic muscles, and prevent deformities;
occupational therapy to develop compensating tactics for everyday activities such as dressing, going to school, and participating in day-to-day activities; speech therapy to address swallowing disorders, speech impediments, and other obstacles to communication;
counseling and behavioral therapy to address emotional and psychological needs and help children cope emotionally with their disabilities; drugs to control seizures, relax muscle spasms, and alleviate pain; surgery to correct anatomical abnormalities or release tight muscles
braces and other orthotic devices to compensate for muscle imbalance, improve posture and walking, and increase independent mobility; mechanical aids such as wheelchairs and rolling walkers for individuals who are not independently mobile; and
communication aids such as computers, voice synthesizers, or symbol boards to allow severely impaired individuals to communicate with others.
The members of the treatment team for a child with cerebral palsy will most likely include the following: A physician, such as a pediatrician, pediatric neurologist, or pediatric psychiatrist, who is trained to help developmentally disabled children
An orthopedist, a surgeon who specializes in treating the bones, muscles, tendons, and other parts of the skeletal system. An orthopedist is often brought in to diagnose and treat muscle problems associated with cerebral palsy. A physical therapist, who designs and puts into practice special exercise programs to improve strength and functional mobility.
An occupational therapist, who teaches the skills necessary for day-to-day living, school, and work. A speech and language pathologist, who specializes in diagnosing and treating disabilities relating to difficulties with swallowing and communication.
A social worker, who helps individuals and their families locate community assistance and education programs. A psychologist, who helps individuals and their families cope with the special stresses and demands of cerebral palsy. In some cases, psychologists may also oversee therapy to modify unhelpful or destructive behaviors. An educator, who may play an especially important role when mental retardation or learning disabilities present a challenge to education.
Surgical options in CP Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle relaxant, into the fluid surrounding the spinal cord. Baclofen works by decreasing the excitability of nerve cells in the spinal cord, which then reduces muscle spasticity throughout the body. Because it is delivered directly into the nervous system, the intrathecal dose of baclofen can be as low as one one-hundredth of the oral dose. Studies have shown it reduces spasticity and pain and improves sleep.
Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving about difficult or painful. For many people with cerebral palsy, improving the appearance of how they walk – their gait – is also important.
Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of severe spasticity when all of the more conservative treatments – physical therapy, oral medications, and intrathecal baclofen -- have failed to reduce spasticity or chronic pain. In the procedure, a surgeon locates and selectively severs overactivated nerves at the base of the spinal column.