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Cerebral palsy
- 1. CEREBRAL PALSY Devendra singh ,MPT (NEURO
- 2. LEARNING OUTCOMES At the end of the session the students are able to describe the: Etiology Pathology Classifications Primary impairments Physical therapy Examination Diagnosis Intervention DEVENDRA SINGH 2
- 3. CONTENTS Definition Etiology Pathology Classifications Primary impairments Physical therapy Examination Diagnosis Intervention DEVENDRA SINGH 3
- 4. GROWING INTO DEFICIT DEVENDRA SINGH 4
- 5. DEFINITION “CP is an umbrella term covering group of nonprogressive but often changing motor impairment syndromes that may or may not involve sensory deficits, that are caused by a nonprogressive defect, lesion or anomaly of the developing brain” DEVENDRA SINGH 5
- 7. “Cerebral palsy is a movement and postural disorders caused by permanent, nonprogressive damage of a developing brain” DEVENDRA SINGH 7
- 10. ANTENATAL Vascular events Maternal infections 1st and 2nd trimesters Rubella, cytomegalovirus, Toxoplasmosis Less common Metabolic disorders Maternal ingestion of toxins Rare genetic syndrome DEVENDRA SINGH 10
- 11. PERINATAL Problem during labor and delivery Obstructed labor Antepartum hemorrhage Cord prolapse Neonatal encephalopathy Other neonatal causes Hypoxic ischemic encephalopathy Neonatal stroke Severe hypoglycemia Untreated jaundice Severe neonatal infections DEVENDRA SINGH 11
- 12. POSTNATAL Metabolic encephalopathy Storage disorders Intermedullary metabolism disorders Metabolic metabolism disorders Miscellaneous disorders Toxicity – alcohol Infections Meningitis, septicemia, malaria Injuries CVA, following surgery for any congenital malformations Near drowning Trauma Motor vehicle accident Child abuse such as shaken baby syndrome DEVENDRA SINGH 12
- 13. PATHOLOGY Intraventricular hemorrhage (IVH) Bleeding into ventricles in and around Periventricular intraventricular hemorrhage (PIVH) DEVENDRA SINGH 13
- 16. PATHOPHYSIOLOGY OF CEREBRAL PALSY Cause Deficit Intraventricular hemorrhage Spastic diplegia Hypoxic – ischemic injury Spastic quadriplegia Spastic hemiplegia Selective neuronal necrosis of the cerebellum Ataxia Status marmoratus (hypermyelination in basal ganglia) Athetosis DEVENDRA SINGH 16
- 18. CLASSIFICATION Muscle tone Topographic Intellectual disability (Severity) DEVENDRA SINGH 18
- 19. MUSCLE TONE Spastic 70% Hypotonic Dyskinetic ( Athetoid –Chorea) 20% Ataxic 10% Mixed DEVENDRA SINGH 19
- 23. INTELLECTUAL DISABILITY (IQ) IQ Disability 50-55 to 70 Mild 35-40 to 50-55 Moderate 20-25 to 35 – 40 Severe <20-25 Profound DEVENDRA SINGH 23
- 24. EARLY MARKERS OF CP SLOW head growth Poor head control Eye – roving eyes, poor hand regard, persistent squint. Ear – lack of auditory response Irritability, seizures, poor suck, poor quality of sleep. Extreme sensitivity to light Scissoring of lower limbs Toe walking Abnormal tone Persistence of primitive reflexes or failure to acquire postural reflexes Stereotypic abnormal movements Lack of alertness
- 25. CLINICAL CLASSIFICATION OF CP Spastic-hypertonicity with poor posture control Dyskinetic/athetoid- abnormal involuntary movement/slow wormlike writhing Ataxic- wide-based gait Mixed-type/dystonic- combination of spasticity and athetosis
- 27. CLINICAL MANIFESTATIONS Delayed gross motor development A universal manifestation of CP The discrepancy between motor ability and expected achievement tends to increase as growth advances. Delayed development of ability to balance slows milestones Delay in all motor accomplishments
- 28. NEUROLOGY CHAPTER OF IAP
- 29. CLINICAL MANIFESTATIONS Abnormal motor performance Preferential unilateral hand use may be apparent at 6 months. Hemiplegia, abnormal crawling or asymmetrical crawl; spasticity may cause child to walk and stand on toes Dyskinetic CP or uncoordinated or involuntary movements (writhing tongue, fingers, and toes; facial grimacing), poor sucking and feeding, persistent tongue thrust; head staggering, tremor on reaching, truncal ataxia.
- 32. ALTERATIONS IN MUSCLE TONE Increased or decreased resistance to passive movement (abnormal muscle tone). Opisthotonic postures or exaggerated back arching, feel stiff on dressing. Difficulty diapering due to spastic hip adductor muscles and lower extremities When pulled to a sitting position, child may extend the entire body and be rigid at hip and knee. This is an early sign of spasticity.
- 34. ABNORMAL POSTURES Children with spastic CP have abnormal posture at rest or when position is changed Infantile lying prone may have hip higher than trunk with legs and arms drawn in. Persistent infantile resting and sleeping position is a sign of spasticity. Hemiparetic child may rest with affected arm adducted and held against torso, with the elbow pronated and slightly flexed and the hand closed.
- 36. REFLEX ABNORMALITIES Persistence of primitive infantile reflexes (one of the earliest signs of CP) Tonic neck reflex Hyperactivity or moro, plantar, palmar grasp Hyperreflexia, ankle clonus, stretch reflexes can be elicited from any muscle group.
- 37. ASSOCIATED DISABILITIES AND PROBLEMS Intellectual impairment 70% w/in normal limits; wide range Tests should be carried out over a period of time. Children with athetosis and ataxia more intelligent. Speech difficulties (not a sign or MR)- child has motor and sensory defects ADHD- (may occur)-poor attention span, marked distractibility, hyperactive behavior
- 38. ASSOCIATED DISABILITIES Seizures- generalized tonic-clonic;more in postnatally acquired hemiplegia Drooling- may occur and lead to wet clothing/skin irritation Feeding- alterations in muscle tone lead to difficulties chewing, swallowing, talking, etc. Address nutritional concerns. Coughing, choking may lead to aspiration. Altered respiratory patterns may lead to inadequate gas exchange.
- 39. MOTOR IMPAIRMENT Orthopedic complications Unilateral or bilateral hip dislocations, scoliosis, joint contractures due to unbalanced muscle tone. Decreased Mobility difficulties with toileting may lead to constipation Difficult chewing bulky foods may lead to constipation May need stool softeners or laxatives
- 40. ASSOCIATED PROBLEMS Dental carries Improper dental hygiene Congenital enamel defects (hyperplasia of primary teeth) high carbohydrate intake and retention Dietary balance with poor nutritional intake Inadequate fluoride Difficulty in mouth closure and drooling Spastic or clonic movements cause gagging or biting on toothbrush
- 41. ASSOCIATED PROBLEMS Oral hypersensitivity causes resistance to good hygiene Gingivitis is secondary to poor hygiene Dental health further complicated by anti-seizure meds
- 42. ASSOCIATED PROBLEMS Nystagmus and diplopia common May need surgery or corrective lenses May be due to sensoneural involvement Infants lying flat too long may have otitis media which may leads to conductive hearing loss
- 43. DIAGNOSTIC STUDIES Physical Assessment Observe LBW, preterm, and those with low Apgar scores at 5 minutes. Observe infants who have seizures, intracranial hemorrhage, metabolic disturbances
- 47. SPASTIC CEREBRAL PALSY (HYPERTONIA)Neuromotor system Decreased stiffness in neck and trunk Increased stiffness in extremities, distal>proximal; varies with type , extent, and location of the lesion Difficulty grading between co activation (CA) and reciprocal inhibition (RI), times with excessive amounts of either CA or RI Difficulty initiating certain muscle groups (hip extensors and Triceps) Difficulty sustaining certain muscle groups ( thoracic extensors and abdominals) Difficulty terminating certain muscle groups ( hip flexors, adductors and internal rotators) Activation of muscles tends to be in small ranges Difficulty with eccentric control (quadriceps) DEVENDRA SINGH 47
- 48. Musculoskeletal system Limited range of motion of certain muscles (soft tissue shortening) Other muscles are over lengthened (the antagonists) Decreased ability to generate force in certain muscles, also in spastic muscles Strength of poor grade High risk for scoliosis At risk for hip subluxation and /or dislocation DEVENDRA SINGH 48
- 49. Sensory/ perceptual system Decreased tactile and proprioceptive awareness Difficulty discriminating different kinds of touch Decreased kinesthesia throughout the body Decreased vestibular registration Decreased body awareness Vision used more in an upward gaze, sometimes asymmetrically DEVENDRA SINGH 49
- 50. Cardiovascular and respiratory systems Poor cardiovascular fitness due to decreased mobility Reduced breath support with flared ribs and tight rectus abdominus Gross motor impairments Limited independent mobility on the floor or in vertical May use assistive device for mobility Poor sitting balance with spastic quadriplegia Poor higher level balance skills DEVENDRA SINGH 50
- 51. Fine motor impairments Decreased use of hands due to use for stability and for assistive device for mobility Poor grasp and release and decreased in hand manipulation with spastic quadriplegia Oral motor impairments Usually noted more with spastic quadriplegia May have drooling , poor articulation May have difficulty feeding DEVENDRA SINGH 51
- 52. Associated Deficits Feeding and speech impairments Breathing inefficiency Visual impairments Hearing impairments Mental retardation Seizures DEVENDRA SINGH 52
- 53. ASSESSMENT Movement Postural control Postural tone Musculoskeletal Gait Fine motor and adaptive skills Speech and language abilities DEVENDRA SINGH 53
- 55. MANAGEMENT OF SPASTICITY: Proper P.T. given regularly considerably reduces spasticity and improves function. (i) Drugs: Baclofen - acts at the level of spinal cord neurons and enhances GABA activity. It is commonly used in a starting dose of 1.25 - 2.5 mg BD orally and increased gradually upto a maximum of 30 mgm/day, monitored by a clinical response. It is not recommended in children with seizures as it may provoke them.
- 56. Surgery: Surgery is useful in some children with spasticity, especially where mainly the lower limbs are involved. Tendon lengthening and transfer and arthrodesis are some of the procedures commonly performed. Generally multilevel surgery is required and is done after 8 years of age. Simultaneous availability of intensive physiotherapy is essential.
- 57. Dorsal rhizotomy which involves selective resection of posterior nerve roots from L 2_ to S 2 It may be helpful in children with severe lower limb spasticity, with sufficient trunk control and some form of forward locomotion. Its advantage must be weighed carefully against the sensory losses that may occur after the procedure.
- 58. Relief of athetosis and dystonia - is difficult occasionally levo-dopa for severe athetosis and carbamezepine for dystonia may be helpful. Thalamotomy for athetoid CP, stereotactic dentatomy and chronic cerebellar stimulation via implanted electrode .
- 59. ORTHOPEDIC SURGERY Spine Hip Knee Ankle and foot DEVENDRA SINGH 59
- 60. LOWER EXTREMITY ORTHOSIS Inhibitive casts Dynamic ankle foot orthosis Articulating AFO Floor reaction orthosis Supra malleolar orthosis Shoe inserts DEVENDRA SINGH 60
- 61. PHYSICAL THERAPY INTERVENTION Therapeutic exercise Neuro developmental therapy Sensory integration Electrical stimulation Conductive education Alternative intervention DEVENDRA SINGH 61
- 62. EQUIPMENTS USED Mats Benches Balls and bolsters Adaptive equipments DEVENDRA SINGH 62
- 63. LATER STAGE Pre school School Adolescents Adult with CP Home management DEVENDRA SINGH 63
- 65. REFERENCES Tecklin, J.S. (1999) Pediatric Physicaltherapy. 3rd edn. Philadelphia: Lippincott, Williams & Wilkins. Campbell, S.K., Palisano, R.J. and Vander Linden, D.W. (2006) Physicaltherapy for Children. 3rd edn. St.Louis: Saunders Elsevier. DEVENDRA SINGH 65