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Cerebral Palsy: Definition
Cerebral palsy is a static encephalopathy
Encephalopathy = Brain Injury that is non-
progressive disorder of posture and movement
Often associated with epilepsy, speech
problems, vision compromise, & cognitive
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
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
Types of Cerebral Palsy
Quadriplegia, hemiplegia, diplegia
Combination of any two types of CP
Early stages of the Spastic, Dyskinetic and
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
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,
Natal (During the time of Delivery)
Anoxia, Asphyxia, Birth Trauma such as
Dispropotion , Forceps, Rapid or Breech
Postnatal (After Delivery)
Trauma to Skull, Kernictures (Jaundice after
birth), Infections, Vascular complications such
as Thrombosis, Embolism, Haemmorhage
CT Scan / MRI Scan
Remember that motor developmental
progression is from….
Head to Toe
1.Assessment of higher functions
Orientation-Normal (except in MR cases)
Speech- Dysarthria , Aphasia
Vision-Squint or Blindness
Learning – May be lost
Memory-will be impaired in most of the
Emotional State- Apathic , Frightened
2.Assessment of Muscular System
Tone – Spastic
Mixed (depends on the type of
Muscle Power- Assessed by MRC Grading
Girth Of the Muscle- Its is usually reduced
due to DISUSE .
3.Assessment of Sensory System
1.Spinothalamic sensations are Normal
2.Posterior column is involved.
So Joint position sense, Vibration sense
are usually affected
4.Assessment of Reflexes
Deep Tendon Reflex – exaggerated in
Neonatal reflexes – Delayed or Absent
Superficial reflexes may be affected in
5.Assessment of Chest
6.Assessment of limbs
1.Alteration of Tone in both upper and
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
9.Assessment of Balance
10.Assessment of Posture
Three types of posture are usually seen
according to the type of CP. They are
11.Assessment of compound
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 Adductors
13.Assessment of Other Problems
1.Ortho Problems-Stiffness, Pain & Deformity in
2.Pressure sores – Ulcers over the Bony
Cerebral Palsy: Management
Neurologic and Physiatric
OT and PT
Rhizotomy, Baclofen pumps, Botoxin
Different approaches to
W M Phelps-diagnosed five types of CP
Specific combinations of muscle education &
bracing were prescribed for different types of
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
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
Various primitive reflexes of infancy should also
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
The key points are usually head&
neck,shoulder & pelvic girdles.
All-day management –should supplement
treatment session.parents &others are advised
on daily management & trained to treat the
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 observed with functional activities as
walking ,feeding, playing sports. These patterns
are spiral (rotational)& diagonal.
The movements patterns consist of the following
(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.
1. Irradiation-this is the predictable overflow of
action from one muscle group to another within
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 &
Vital functions-A developmental sequence
of respiration, sucking, swallowing,
phonation, chewing & speech is followed.
Reflex creeping&Other Reflex
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
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
For improvement of functional mobility and
appearance after conservative therapy has
Correction of contractures – Tenotomy
Correction of deformities from muscle
imbalance Eg. Tendon transfer
Correction of functional handicaps of
hands and feet – Arthrodesing operations
Stretching is the activity of gradually applying tensile
force to lengthen, strengthen, and lubricate muscles,
often performed in anticipation of physical exertion and
to increase the range of motion within a joint. Stretching
is also believed to help to prevent injury to tendons,
ligaments and muscles by improving muscular elasticity
and reducing the stretch reflex in greater ranges of
motion that might cause injury to tissue.
These exercises are done to increase the power &
strength of the muscle. They usually done as
Resisted Exercises both Manually and Mechanically.
The patient is made to move from one side to another
side by his side. This is known as rolling
The child is made to move on his four limbs
Standing with support
Initiating auditory-verbal therapy as early
as possible is essential because the child's
greatest capacity for learning language
auditorily, occurs during the first two to
three years of life. In order to effectively
learn spoken language, a child's hearing
and listening skills must be stimulated
during this critical time.
Parents are the major influence in a young
child's 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
Proper neural development of oral
movements and oral sensory function is
vital for providing the foundation for good
speech production and mature feeding
Oral Sensitivity (based on these domains -
Temperatures, Textures, Tastes)
Hypersensitivity - Over-sensitive
Hyposensitivity - Under-sensitive
Position of the jaw and presence/absence of stability or weakness
during oral sensory-motor activities, such as chewing.
Position and action/movement of the lips during oral sensory-
motor activities, such as drinking, sucking, chewing or blowing.
Position and action/movement of the tongue during oral sensory-
motor activities, such as chewing, drinking, sucking or blowing.
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
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 don't have any teeth, move your tongue
tip up to your gum where your top teeth would
Open mouth as wide as possible maintaining
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
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
Relax and Repeat 5 to 10 times.
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
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.
Range of Motion
1. Jaw Opening
2. Side-to-Side Movement
3. Increasing Circular Jaw Movement
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
Hold for 5 seconds.
Relax and Repeat 5 times.
3. Lip Retraction and Protrusion
Smile then pucker your lips. Use exaggerated
Relax and Repeat 5 times.
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.
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
In physical therapy ,attention must be
given to the flexors & extensors muscles
of the neck & shoulders.
3.Develop a Breathing Rate of Less Than
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
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
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 &
Having the child imitate a prolonged sigh, a
prolonged phonation, babbling or sustained
blowing will help him develop controlled,
5.Counteract Abdominal Movements Which
are Asynchronous with Thoracic
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
This helps in stronger voices & longer
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
Correction Of Phonatory Errors
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
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
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 &
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
5. Counteract Undesirable postural
The postural pattern interfere with laryngeal
function. as the child phonates, he extends
the leg, arch the back and throw back his
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
Before going for articulatory correction the
therapist should be sure that the child has
sufficient control over speech breathing
The patterns of neural organization as in
sucking and swallowing must also be
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
Bilabial consonants may be added by rapidly
vibrating the lips with the therapist’s or parent’s
2. develop sucking, swallowing and
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
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
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
The therapist should help the child about
his awareness of his movement of the
By using the mirror the child can see the
movement of his mandible moves with his
Stabilization of the mandible with small
object placed between the molars, aids
the child in developing free tongue
Team Approach To
A comprehensive management plan will
pull in a combination of health
professionals with expertise in the
physical therapy to improve walking
and gait, stretch spastic muscles, and
occupational therapy to develop
compensating tactics for everyday
activities such as dressing, going to
school, and participating in day-to-day
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
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
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