Recent advances in management of CP

1. INTERVENTIONS TO IMPROVE BALANCE IN
CHILDREN WITH CEREBRAL PALSY

2. INTRODUCTION
DEFINITION
“Cerebral palsy describes a group of permanent disorders of the development
of movement and posture, causing activity limitations that are attributed to
nonprogressive disturbances that occurred in the developing fetal or infant
brain. The motor disorders of CP are often accompanied by disturbances of
sensation, perception, cognition, communication and behavior as well as
seizures and secondary musculoskeletal problems.

3. INCIDENCE
• 3/1000 live births Indian incidence.

4. CAUSES
PRENATAL
• Maternal infection during 1st
and 2nd trimester
(toxoplasmosis, rubella,
cytomegalovirus)
• Vascular events (such as
MCA infarct)
NATAL
• Obstructed labor
• Antepartum hemorrhage
• Cord prolapse
• Severe hypoglycemia
• Untreated jaundice
POSTNATAL
• Infection (meningitis)
• CVA
• Shaken baby syndrome
• Toxicity such as alcohol

5. Permanent static lesion
Cerebral motor cortex
CEREBRAL PALSY
Irreversible cell death
Hypoxic event
Hyperbilirubinaemia
Basal ganglia injuryIrreversible cell death
Periventricular
Leukomalacia
Before/ within 2 years Immediate
PATHOPHYSIOLOGY

6. CLASSIFICATION
Cerebral Palsy
Dyskinetic CPSpastic CP Ataxic CP Hypotonic CP
Diplegic
Hemiplegic
Quadriplegic
Athetoid
Dystonic

8. COMMON IMPAIRMENTS
Seizures
Learning
Bowel and Bladder
CommunicationFeeding/
eating
Behavior
Vision Hearing
Movement

9. DIAGNOSIS AND PROGNOSIS
• Neuroimaging of the brain, such as cranial ultrasound , computed
tomography (CT), and magnetic resonance imaging (MRI), can show
the location and type of brain damage.

10. SPASTICITY & MUSCLE WEAKNESS
STRETCHING , STRENGTHENING
Mobility for children with CP is greatly impacted by both muscle weakness
and spasticity. Strength training can increase the muscle strength in CP, and
may improve endurance , cardiovascular health, weight management,
maintenance of bone mass, self perception and gait function.
MANAGEMENT

11. PAIN , EDEMA & MUSCLE STRENGTHENING
ELECTRICAL STIMULATION
• FES (Functional Electrical Stimulation)
• NMES (NeuroMuscular Electrical Stimulation)

12. JOURNAL /
IMPACT FACTOR
Clinical paediatrics
AUTHOR /
TITLE
Ya-Chao Qi et al 2018.
Therapeutic Effect Evaluation Of NMES With Or Without Strengthening Exercise On Spastic
CP.
METHOD 100 children with spastic CP were randomly divided into a treatment group (NMES+
strengthening; n=50) and a control group (only NMES; n=50)
OUTCOME
MEASURES USED
Comprehensive Spasticity Scale (CSS)Score, GMFM
CONCLUSION NMES combined with strengthening exercise was more effective than NMES alone in the
recovery of spastic CP.

13. JOURNAL /
IMPACT FACTOR
Journal of Physical Therapy Science
0.271 (2015)
AUTHOR /
TITLE
Abeer Flemban et al. 2018.
Effect of combined rehabilitation program with botulinum toxin A injections on gross motor
function scores in children with spastic cerebral palsy
METHOD 46 ambulatory children with spastic diplegia (age= 25-154 months) were recruited. Group I
(n=18) and (n= 28). After baseline assessment , all children received botulinum toxin type A
injection (6 units/kg ) in to lower limb muscles. A second botulinum toxin was given 6 months
later. The ankles were placed in plaster cast for 2 weeks after the first injection and an orthosis
was prescribed after cast removal. Group 2 received 2 weeks of intensive physiotherapy. The
gross motor function scores for the 2 groups were recorded at the baseline, 4 , 6 and 52 weeks.
OUTCOME
MEASURES USED
GMFM
CONCLUSION The addition of the 2 weeks physiotherapy programme after the initial botulinum toxin type A
injections produced significantly greater improvements in gross motor function score
GROSS MOTOR FUNCTION

14. JOURNAL/
IMPACT FACTOR
Journal of Complementary Alternative Medical Research
1.868 (2018)
AUTHOR /
TITLE
Alaa N. Kora et al 2018.
Muscle Inhibitory Vs Functional Corrective Kinesio Taping on Gross Motor Functional Abilities in
Children with Spastic Cerebral Palsy
METHOD 32 children with spastic CP were selected from the Outpatient Clinic Of The Faculty Of Physical
Therapy University Cario University. Age group= 2 - 4 years. Muscle inhibitory and functional
corrective kinesio taping application in addition to physical therapy for 3 months.
OUTCOME
MEASURES USED
Peabody Developmental Motor Scales (PDMS) was used to assess gross motor functional abilities
CONCLUSION Muscle inhibitory and functional corrective kinesio taping applications both can be used for
increasing the gross motor functional abilities in children with spastic cerebral palsy

15. UPPER EXTREMITY FUNCTION
• mCIMT: Utilize less intensive means of constraint such as glove or a
mitten rather than a cast for the affected upper extremity that is
easier to manage and better tolerated in children.
• Mirror Therapy
• Virtual Reality (VR)

16. JOURNAL /
IMPACT FACTOR
Journal of Hand Therapy
1.04 (2017/2018); 1.159 (2016)
AUTHOR /
TITLE
Rathinam C et al 2018.
Effectiveness of virtual reality in the treatment of hand function in children with
cerebral palsy: A Systematic Review.
METHODS A International prospective register of systematic reviews (PROSPERO)- registered
literature search carried out in August 2015 in MEDLINE, CINHAL, ERIC,
HealthSTAR, AMED, BNI, Embase, PsychINFO, PEDro, Cochrane Central
Register,DARE, OT seeker, REHABDATA, HaPI, CIRRIE, and Scopus. PRISMA
guidelines were followed. Only randomized controlled trials (RCTs) were included,
and their methodological qualities were examined using the Cochrane
collaboration’s risk of bias (RoB) tool. A narrative synthesis was performed
CONCLUSION The role of VR improve hand function in children with CP is unclear due to
limited evidence; use as an adjunct has some support.

17. JOURNAL /
IMPACT FACTOR
Developmental Neurorehabilitation
1.239
AUTHOR /
TITLE
Ozgun Kaya Kara et al 2019.
Combined Effects Of Mirror Therapy And Exercises On The Upper Extremities In
Children In With Unilateral Cerebral Palsy : A RCT
METHODS 30 children were included either in experimental group or control group . All
participants were evaluated with the Quality Of Upper Extremity Skill Test
(QUEST) , Canadian Occupational Therapy Performance Measure (COPM), and
a Hand Held Dynamometer (HHD) to measure isometric muscle strength.
CONCLUSION Mirror therapy combined with power and strength exercises is a promising
intervention approach to improve activity performance and upper limb function
in children with USCP

18. GAIT TRAINING
• Treadmill training/ Robotic Gait Training
Functional treatment in which patients practice walking on a treadmill
to improve their ability to walk at home and in the community. On the
basis of task specific approach to motor learning.
Reciprocal treadmill walking may be partially controlled by the spinal
cord and can be stimulated in the absence of higher brain centre
control.

19. JOURNAL /
IMPACT FACTOR
The Tohoku Journal of Experimental Medicine
1.56 (2018)
AUTHOR /
TITLE
Chunhee Cho et al 2016 .
Treadmill training with Virtual reality improves gait, balance , and muscle strength
in children with Cerebral Palsy RCT.
METHOD 18 with spastic CP were randomly divided into virtual reality treadmill training
(VRTT) group (9 subjects , mean age, 10.2 yrs) and treadmill training (TT) group (9
subjects, mean age, 9.4 years). The group performed their respective programs as
well as conventional physical therapy 3 times/ week for 8 weeks.
OUTCOME
MEASURES USED
Muscle strength = digital manual muscle tester ;Gross motor function = GMFM;
Balance = PBS; Gait speed = 10 MWT ; Gait endurance = 2 MWT
CONCLUSION VRTT programs are effective for improving gait, balance, muscular strength, and
gross motor function in children with CP.

20. JOURNAL /
IMPACT FACTOR
Clinical Rehabilitation
2.93 (2017/2018); 2.823 (2016)
AUTHOR /
TITLE
Ahmed M Elnahhas et al 2019.
Effects of backward gait training on balance, gross motor function, and gait in
children with CP : a systematic review.
METHOD RCTs were included if they involved any form of backward gait training for child
ren with CP . 2 authors independently screened articles, extracted data and assessed
the methodological quality using PEDro scale, with any confliction resolved by the
third author. Modified Sackett Scale was used to determine the levels for each
outcome.
CONCLUSION In children with CP, there is moderate evidence that backward gait training
improves balance, gross motor function, step length and walking capacity. More
high quality studies are needed.
BALANCE TRAINING

21. JOURNAL /
IMPACT FACTOR
Paediatric Physical Therapy
0.863 (2020); 1.02 (2019); 1.536 (2018)
AUTHOR /
TITLE
Hsieh- Chun Hseih et al 2018.
Effect of a gaming platform on balance training for children with CP RCT.
METHOD Intervention group (n=20) received 12 weeks of playing personal computer (PC)
games using the platform, and the control group (n=20) played the same games
using a computer mouse. Age group 7-9 years.
OUTCOME
MEASURES USED
Center of pressure sway, Berg Balance Scale (BBS),Fullerton Advanced Balance
Scale (FAB) and Timed Up and Go (TUG) test scores.
CONCLUSION Balance training using a PC gaming platform may improve exercise compliance
and enhance recovery of balance in children with CP.

22. JOURNAL / IMPACT
FACTOR
Journal Of Back And Musculoskeletal Rehabilitation
0.814 (2019)
AUTHOR /
TITLE
Bulent Elbasan et al 2018.
Effects of NeuroMuscular Electrical Stimulation and KinesioTapping applications in
children with CP on postural control and sitting balance RCT.
METHOD 45 children in 3 groups, between the ages 5-12 years were included in the study. Group I
received NDT; Group II NDT + NMES; and group III received NDT+NMES+KT for 6
weeks.
OUTCOME
MEASURES USED
Sitting function evaluated by the sitting section of (GMFM); and postural control
assessed with Seated Postural Control Measure (SPCM).
CONCLUSION Implementation of the NMES and KT additionally to NDT improves the sitting posture,
postural control, seating function and gross motor function in children with CP.

23. JOURNAL /
IMPACT FACTOR
The Journal of Physical Therapy Science
1.21 (2016); 1.38 (2017); 0.74 (2018/2019)
AUTHOR /
TITLE
Seung Min Nam et al 2016.
The effects of a multisensory dynamic balance training on the thickness of lower limb
muscles in ultrasonography in children with spastic diplegic CP RCT.
METHOD 15 children diagnosed with Spastic diplegic CP were randomly divided in to balance training
group and control group. The experimental group only received a multisensory dynamic
balance, while the control group performed general physiotherapy focused balance and
muscle strengthening exercise based NDT. Both group therapy session for 30 minutes/day, 3
times a week for 6 weeks. The ultrasonographic muscle thickness were obtained in order to
compare and analyse muscle thickness before and after in each group. Age group= 14-17 yrs.
CONCLUSION A multisensory dynamic balance training can be recommended as a treatment method for
patients with spastic diplegic CP.

24. JOURNAL /
IMPACT FACTOR
Clinical Rehabilitation
2.93 (2017/2018); 2.823 (2016)
AUTHOR /
TITLE
Wanees M. Badawy et al 2016.
Comparing the effects of aquatic and land based exercises on balance and
walking in spastic diplegic CP children RCT.
METHOD 30 children with spastic diplegia of both sexes (19 boys; 11 girls) with GMFCS
(II-III) and age ranged between 6-9 years were included in this study. Children
were randomly assigned in to 2 equal groups ; Aquatic intervention (AQ) group
and land based exercise (LB) group. Evaluation for each child in both groups
was done before and after 12 successive weeks of treatment.
OUTCOME
MEASURE
Balance parameter were evaluated using biodex balance system TM, gait
parameters were evaluated using biodex gait trainer II TM.
CONCLUSION The aquatic therapy is beneficial to improve balance control and walking
performance in spastic diplegic CP children.

25. NINTENDO WII BALANCE BOARD
WEEHAB SOFTWARE
• The balance board and Wiimote interfaces are paired via bluetooth with a
normal Windows desktop or notebook allowing for a full suite of
application development on the windows platform.
• This allows WeeHab software to receive data from the Balance Board
and Wiimote, enabling their use for rehabilitation activities .
• Along with the Wii gaming peripherals, the WeeHab system consists of a
computer equipped with Bluetooth, a large LCD screen for displaying
visual feedback, and webcams for recording audio and video data.

26. WEEHAB CAPABILITIES
• It can monitor the center of pressure of a subject standing on the balance
board, providing visual feedback as to how his/her weight is distributed.
FEEDBACK AND BALANCE ASSESSMENT
• It provides feedback to both therapist and patient during the course of
rehabilitation, objectively displaying the patients performance.
BALANCE WEEHAB ACTIVITIES
• 3 most common activities performed using WeeHab system are: Sit – stand
Transition, Weight shifting, Stepping.

28. SNOWBOARD PENGUIN SLIDE SUPER HULA HOOP
DEEP BREATHING
NINTENDO WII BALANCE BOARD EXERCISES

29. DOES NINTENDO WII BALANCE BOARD
IMPROVE BALANCE? : A RANDOMIZED
CONTROL TRIAL
Gatica Rojas et al
JOURNAL : European journal of physical and rehabilitation medicine
YEAR: 2017
Impact Factor: 1.56

30. OBJECTIVE
• Primary aim was to compare the effect of Nintendo Wii balance board
(Wii therapy) and standard physiotherapy (SPT), on the performance of
standing balance in children and adolescents with CP.
• Secondary aim was to determine the post-treatment effectiveness of Wii-
therapy and SPT.

31. • Sample size: 16.
• Age group: 7-14 years (children with congenital SHE (Spastic HEmiplegia)
and SDI (Spastic DIplegia) CP.
• Study design: matched-pairs (type of CP and age) randomized controlled
trial.
• Study setting: outpatient rehabilitation center for children and adolescents
with neurological disorders in the city of Talca, Chile.
• Interventions: Wii and SPT (Standard Physical Therapy) interventions were
delivered.
• Duration: 6 weeks.
METHODOLOGY

32. INCLUSION CRITERIA EXCLUSION CRITERIA
CP type SHE (Spastic HEmiplegia) and SDI (Spastic
DIplegia)
Full-scale intelligence quotient (FSIQ) <80
Level I or II of the Gross Motor Function
Classification System (GMFCS) 21 or Expanded and
Revised Gross Motor Function Classification System
(GMFCS-ER) 22
Patients with other neurological disorders, such as
epilepsy
Males and females aged between 7 and 14 years. Patients with uncorrected vision and hearing disorders
Previous surgeries in lower limb over the last 18 months
or application of Botulinum Toxin-A in the lower limb
over the past 10 Months
Participants with access to a Nintendo Wii at home

33. Wii - Therapy SPT
18 sessions delivered at a frequency of three times per week over 6 weeks
Wii Fit Plus with the Nintendo Wii
Balance Board for 30 minutes,
divided into three series.
Stretching, flexibility, strengthening,
and balance exercises for 40 minutes
in each session.
Third series involved deep breathing in the
Yoga game with eyes open and closed. For
those participants who were not able to
perform the first two series of games, less
challenging games, such as the Run Plus and
Heading Football, were used
First two series, the Snowboard, Penguin
Slide and Super Hula Hoop games were
used. Between the first and the second series
of exercises, there was a 1-2-minute break,
where the children sat on a chair until they
had recovered
INTERVENTIONS

34. OUTCOME MEASUREMENT
• Standing still under 2 visual conditions: eyes open and eyes closed (EO; EC)
– AMTIOR6-7 force plate (Watertown, MA, USA) at 200 Hz.
• Momentum and force data, CoP sway , (SDML),(SDAP),(VML),(VAP) –
AMTI NetForce software

35. PSYCHOMETRIC PROPERTIES
• GMFCS - Gross Motor Function Classification
RELIABILITY: 0.96
VALIDITY: 0.80
• FSIQ - Full Scale Intelligence Quotient
RELIABILITY: 0.93
VALIDITY: 0.75

36. STATISTICAL METHODS
• Descriptive statistics were calculated for all demographic and clinical measures, and
unpaired t-tests and χ² tests were used to compare these measures between the
participants in each intervention group.
• Assumptions of normality and homogeneity of the outcome measures were assessed
using Shapiro-Wilk and Levene tests.
• The Mann-Whitney Test was used to determine differences between the effects of the
therapies in the 6th week.
• Friedman’s one-way ANOVA with post hoc pairwise comparisons (Wilcoxon Signed-
Ranks Test) was used to determine the effect over time for each type of therapy and
subtypes of CP (SHE and SDI).
• For all analyses, a P≤0.05 was considered statistically significant. All statistical
analyses were performed using IBM-SPSS 20.0 (SPSS Inc., Armonk, NY, USA).

37. FLOW CHART OF
PARTICIPANTS
RESULTS

42. DISCUSSION
• Significant effects of Wii on posturographic measures of balance were found only
for the SHE group. It has been suggested that SHE patients are better able to use
proprioceptive and somatosensory information arising from the unaffected limb,
which may have been enhanced (sensory up-weighting) by the Wii-therapy.
• Therefore, the improvement in the balance performance for SHE during EC for
both CoPSway and SDAP may be due to proprioceptive stimuli generated during
Wii-therapy.
• Wii-therapy was better able to improve standing balance than a SPT intervention,
especially in SHE, and that these positive effects wane within 2-4 weeks
postintervention.

43. CONCLUSION
• Wii-therapy over a period of 6 weeks significantly improved standing
balance in children and adolescents with CP. These improvements
were significantly greater than in SPT, which did not improve balance
over a similar period.
• Further analysis found that significant improvements in balance
control only occurred in SHE and that positive effects wane 2-4 weeks
after the end of the intervention.

44. LIMITATIONS
• Sample size reduction when performing post hoc analysis on CP subtypes (SDI
and SHE) was a limitation.
• Inclusion of children with mild levels and without the intellectual disability,
limits the generalizability of these results to CP populations with severe
intellectual disability.
• Absence of information concerning the number of repetitions used for the
stretching, flexibility, strength and balance exercises for SPT group.
• Other aspects of balance control were not assessed (dynamic balance).
• It should also consider children with CP with greater motor disabilities, such as
GMFCS/GMFCS-ER levels III, IV, V.

45. PEDro SCORES
• Eligibility criteria were specified : Yes
• Subjects were randomly allocated into groups: Yes
• Concealed allocation : Yes
• The groups were similar at baseline regarding the most important prognostic indicators: Yes
• There was blinding of all subjects: No
• There was blinding of all therapist who administered the therapy: No
• There was blinding of all assessor who measured at least one key outcome: No
• Measures of at least one key outcome were obtained from more than 85% of the subjects initially
allocated to the group: Yes
• All subjects for whom outcome measures were available received the treatment or control
condition as allocated or, where this was not the case, data for at least one key outcome was
analysed by “intention to treat “ : Yes
• The results between group statistical comparisons are reported for at least one key outcome : Yes
• The study provides both point measures and measures of variability for at least one key outcome:
Yes
SCORE = 7/10

46. COMPARISON WITH SIMILAR STUDIES

47. JOURNAL /
IMPACT FACTOR
Paediatrics International
1.362
AUTHOR /
TITLE
Devrim Tarakci et al 2018.
Effects of Nintendo Wii Fit video games on balance in children with mild CP
METHODS RCT involved 30 ambulatory paediatric patients (5-18 yrs) with CP. Participants were
randomized either to conventional balance training (control group) or to Wii Fit Balance
based video games training (Wii group). Both group received NDT treatment during 24
sessions. In addition the control group conventional balance training in each session, the
Wii group played Nintendo Wii Fit games such as ski slalom, tightrope walk and soccer
heading on balance board.
OUTCOME
MEASURES USED
Functional Reach Test (forward and side ways), sit-stand test and Timed Get Up and Go
test, Nintendo Wii Fit balance , 10 MWT, 10 step climbing test and WeeFIM (Wee
Functional Independence Measure)
CONCLUSION Wii Fit balance based video games are better at improving both static and performance
related balance parameters when combined with NDT treatment in children with mild CP.

48. JOURNAL /
IMPACT FACTOR
Peer Journal
2.118 (2017); 2.353 (2018)
AUTHOR /
TITLE
Julien Tripette et al 2017
The contribution of Nintendo Wii Fit series in the field of health: Systematic review
and meta analysis.
METHODS A systematic literature review was undertaken. The MEDLINE database and games
for Health Journal published content were explored using the search term ”Wii-Fit”.
Included articles were required to have measurements from Wii Fit activities for at
least one relevant health indicator.
OUTCOME
MEASURE
Activity specific balance confidence score, Berg Balance Score (BBS) and Timed Up
and Go Test (TUG)
CONCLUSION Wii Fit has the potential to be used as rehabilitation tool in different clinical
situations.

49. JOURNAL /
IMPACT FACTOR
Developmental Neurorehabilitation
1.239
AUTHOR /
TITLE
Sajan JE et al 2017.
Wii based interactive video games as a supplement to conventional therapy for
rehabilitation of children: a pilot RCT
METHOD 10 children with CP in both control and intervention groups. IVG using Wii, given as
a supplement to conventional therapy for 45 minutes/ day, 6 days a week for 3
weeks. Control group received conventional therapy alone. Age group 5-20 years.
OUTCOME
MEASURES USED
PBS, static posturography , QUEST, TVPS (Test for Visual- Perceptual Skills).
CONCLUSION Wii based IVG may be offered as an effective supplement to conventional therapy
in the rehabilitation of the children with CP.

50. JOURNAL /
IMPACT FACTOR
Games for Health Journal
1.782 (2019)
AUTHOR /
TITLE
Songul Atasavun Uysal S et al 2016.
Effects of Nintendo Wii training on occupational performance, balance, and
daily living activities in children with Spastic Hemiplegic CP : A single blind
and RCT
METHOD 24 children aged 6-14 years, level I/II GMFCS . The children were recruited in 2
groups: intervention (n=12) and control group (n=12). Both groups continued
their traditional physiotherapy program twice a week, 45 minutes / session,
whereas the participants in the intervention group, group additionally , were
trained with NW, 2 /week for 12 weeks for 30 minutes.
OUTCOME
MEASURES USED
Activity performance analysis = (Canadian Occupational Performance
Measure)COMP; PBS; PEDI
CONCLUSION NW contributed to the implementation of occupational performance, daily
activities, and functional balance.

51. JOURNAL /
IMPACT FACTOR
International Journal of Therapies and Rehabilitation Research.
1.378
AUTHOR /
TITLE
Urgen MS et al 2016.
Investigation of the effects of the Nintendo Wii Fit training on balance and
advanced motor performance in children with spastic hemiplegic CP : A RCT.
METHOD 30 children with spastic hemiplegic CP who were 7-14 years of age, had GMFCS
I and II regularly participated in routine physiotherapy program twice a week.
Children were randomly assigned either to Nintendo Wii Fit training (twice a
week + physiotherapy program) or the control group.
OUTCOME
MEASURES USED
GMFM, GMPM, TUG, PBS, PEDI.
CONCLUSION Nintendo Wii Fit training may effect on advanced motor skills and improve
balance of children with spastic hemiplegic CP with physiotherapy.

52. JOURNAL /
IMPACT FACTOR
Journal of Physical Therapy Science
1.21 (2016); 1.38 (2017); 0.74 (2018/2019)
AUTHOR /
TITLE
Tai-Yen Hsu et al 2016.
Effects of Wii-Fit balance game training on the balance ability of students with
intellectual disabilities.
METHODS 24 students with intellectual disabilities were selected and randomly divided in
to Wii Fit balance game training, physical education and sedentary activity
group. The Wii Fit balance game training group received two 40 minutes Wii Fit
balance game training sessions per week for total of 8 weeks. Age group 17-18
years
OUTCOME
MEASURE
Kruskal Wallis one way analysis of variance and Wilcoxon signed ranking test
were used to compare difference.
CONCLUSION Wii Fit balance game training can improve static balance and lower extremity
muscle strength in students with intellectual disabilities.

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