Cerebral palsy is a group of disorders caused by non-progressive brain damage early in development resulting in abnormal movement and posture. It is characterized by increased muscle tone or spasticity, exaggerated reflexes, weakness, and delayed development. Common types include spastic diplegia, hemiplegia, and quadriplegia. Treatment is multidisciplinary and aims to improve motor function, prevent complications, and manage associated issues like epilepsy, cognitive impairment, and speech or feeding difficulties.

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Cerebral palsy
Definition: The term cerebral palsy includes a group of permanent disorders that result from
non-progressive fetal of infantile brain damage during the early development and are
characterized by abnormalities of movement and posture. ( United cerebral palsy research and
education foundation, April 2006)
Etiology:
A. Prenatal
 Maternal deficiencies: Fe, I2, poor nutrition
 Maternal infection: TORCH, UTI, Chorioamnionitis
 Maternal disease: DM, HTN, Hyperthyroidism
 Teratogens: Drugs, radiation, smoking, alcohol
 Congenital malformation
 Fertility problem: Advanced age at conception, secondary infertility,
contraceptive failure
 Abdominal trauma
B. Perinatal
 IUGR
 LBW (< 2.5 kg)
 Prematurity (< 32 weeks gestation)
 Birth asphyxia
 Premature separation of placenta
 Maternal bleeding 2nd
or 3rd
trimesters
 Intravetricular haemorrhage
 Hyperbilirubinemia
 Hypoglycemia, dyselectrolytemias
 Sepsis, pneumonia, meningitis
 Abnormal fetal presentation
 Meconium staining or aspiration
C. Postnatal
 CNS infection: meningitis, encephalitis
 Seizures
 Head injury
 Hyperpyrexic damage
 Stroke
 Periventricular leukomalacia (PVL)

2. 2
 Coagulopathies
Classification:
A. Physiological
1. Spastic
2. Dyskinetic
 Dystonic
 Athetoid/Choreoathetotic
3. Ataxic
4. Mixed
5. Hypotonic
B. Topographic
1. Diplegic
2. Hemiplegic
3. Quadriplegic
4. Monoplegic
Spastic:
 Commonest (70-80%)
 Hypertonia
 Slow restricted movement
 Hyper-reflexia
 Babinski sign-positive
 Clonus
 Persisted primitive reflexes
Spastic diplegia:
 Most common in preterm babies
 Bilateral spasticity of LL & UL (LL>UL)
 Increased adductor tone
 A scissoring posture of the lower extremities
 Feet equinovarus in position
 Tip toe walking
 Crouched gait (Flexed hip and knee with excessive ankle dorsiflexion in stance phase)
 Walking is significantly delayed
 Seizure is uncommon
 Mentation usually preserved

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 Strabismus in ¾ th patient
Spastic hemiplegia:
 Usually seen in term or near-term babies
 Both upper and lower limbs of one side affected
 Weakness of hand and foot dorsiflexors is evident
 Arms are more affected
 Walking is delayed until 18-24 months but is possible in all patients
 Gait: Spastic
 Early feature: Reduced hand regard, persistent fisting
 Late feature: Absent pincer grip, presence of apraxia
 Seizure in 33% patient (High risk of occurance)
 Mental retardation in 25% patient
Spastic quadriplegia:
 All 4 limbs and trunk involved
 Marked mental retardation
 Seizures (common)
 Only 10% learn to walk
 Swallowing and speech difficulty
 Absent bowel bladder control
Dystonic:
 Hypokinesia
 Hypertonia
 Results in stiff movement
Athetoid:
 Involuntary, uncontrolled, slow, writhing and jerky movement
 Caused by damage to the extrapyramidal system
 Hyperkinesia
 Hypotonia
 Tremor
 Contractures are unusual as muscle tone is not increased
Ataxic:
 Due to cerebellar damage

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 Hypotonia
 Incoordinated movements
 Intention tremor,
 Nystagmus
 Gait: Wide based, imbalanced
 Delayed language skill
Mixed:
 A combination of spasticity with dyskinesia is the commonest type
Hypotonic:
 It is usually a phase, lasting several years during early childhood, before the features of
spasticity become obvious
Associated deficits:
 Mental Retardation: Spastic quadriplegia & hemiplegia are mostly affected
 Epilepsy: Spastic quadriplegia & hemiplegia are mostly affected
 Visual Deficits: Strabismus, refractory error, amblyopia, visual field defect
 Hearing Impairment: Sensory neural impairment is the commonest, conductive defect
from various infections or ototoxic drugs
 Language Disorders: It include aphasia, dysarthria. Hemiplegic CP with involvement of
dominant hemisphere lead to aphasia. Most athetoids and 50% of spastic diplegics have
some dysarthria.
 Behavioral problems: It may include attention deficit or hyperactivity disorder,
depression, anger, anxiety etc.
 Gastrointestinal Problems: GERD, constipation
 Oromotor Problems: Difficulty in swallowing, sucking, and chewing, poor lip closure,
decreased tongue movements etc.
 Growth retardation
Positive motor signs:
 Involuntary increase of muscle activity
 They include hypertonia and hyperkinesia
 Hypertonia: Spasticity, rigidity
 Hyperkinesia: Dystonia, chorea, athetosis, myoclonus, tremor, tics
Negative motor signs:
 Weakness

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 Reduced selective motor control
 Ataxia
 Apraxia
Functional classification:
1. Gross Motor Function Classification System (GMFCS)
2. Manual Ability Classification System (MACS)
3. Communication Function classification System (CFCS)
Gross Motor Function Classification System (GMFCS):
 Level 1: Walks without limitations
 Level 2: Walks with limitations
 Level 3: Walks using hand-held mobility device
 Level 4: Self-mobility with limitations, may use powered mobility
 Level 5: Transported in a manual wheelchair
Manual Ability Classification System (MACS):
 Level 1: Handles objects easily and successfully
 Level 2: Handles most objects but with somewhat reduced quality and/or speed of
Achievement
 Level 3: Handles objects with difficulty; needs help to prepare and/or modify activities
 Level 4: Handles a limited selection of easily managed objects in adapted situations
 Level 5: Does not handle objects with severely limited ability to perform even simple
Actions
Communication Function Classification System (CFCS):
 Level 1: Sends and receives information with familiar and unfamiliar partners effectively
and efficiently
 Level 2: Sends and receives information with familiar and unfamiliar partners but may
need extra time
 Level 3: Sends and receives information with familiar partners effectively, but not with
unfamiliar partners
 Level 4: Inconsistently sends and /or receives information even with familiar partners
 Level 5: Seldom effectively sends and receives information even with familiar partner
Primitive Reflexes:

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Primitive reflexes are brainstem-mediated, complex, automatic movement patterns that commence as
early as the twenty-fifth week of gestation, are fully present at birth in term infants.
Reflex Position Method Response Age at
Disappearance
Heel Supine Tapping on the heel
with a hammer, with
the hip and knee joint
flexed, and the ankle
joint in neutral position
Rapid reflex extension
of the lower extremity
in question
3 wk
Crossed
extensor
Supine Passive total flexion of
one lower extremity
Extension of the other
lower limb with
adduction and internal
rotation into talipes
equinus
6 wk
Asymmetric
tonic neck
reflex
Supine Rotation of the infant’s
head to one side for 15
sec
Extension of the
extremities on the chin
side and flexion of
those on the occipital
side
3 mo
Extensor
thrust
response
Supine Hip and knee flexed,
then the sole of the
foot is stimulated
Sudden reflex
extension of the leg
3 mo
Rooting Supine Touching the cheek or
mouth on one side
Turns head towards the
same side
4 mo
Galant Prone Scratching the skin of
the infant’s back from
the shoulder
downward, 2 to 3 cm
lateral to the spinous
processes
Incurvation of the
trunk, with the
concavity on the
stimulated side
4 mo
Reflex Position Method Response Age at
Disappearance
Palmar grasp Supine Placing the index finger
in the palm of the
infant
Flexion of fingers, fist-
making
6 mo
Moro Supine Sudden head extension
produced by a light
drop of the head
Abduction followed by
adduction and flexion
of upper extremities
6 mo
Primitive
neck-righting
Supine Head is turned towards
one side
Turning of the trunk
towards the same side
7 mo
Symmetrical
tonic neck
Supine 1. Moving the chin
down toward the
1. Flexion of the
upper extremities
11 mo

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reflex chest & then
2. Up toward the
back
& extension of the
lower extremities
2. Extension of the
upper extremities
& flexion of the
lower extremities
3.
Plantar grasp Supine Pressing a thumb
against the sole just
behind the toes in the
foot
Flexion of toes 15 mo
Postural reactions /reflexes:
Postural reactions are maturational motor skills that develop during the first year of life and
form the basis for attainment of functional motor skills. These reactions automatically provide
for maintaining the body in an upright position through changes of muscle tone, in response to
the position of the body and its parts. Postural reactions respond to more global stimuli than
primitive reflexes and last for a lifetime, in order to support movement and balance (Zafeiriou,
2004). The assessment of postural reactions is an important tool to assess the integrity of CNS
in children with cerebral palsy. It include
 Righting reactions
 Head righting: Prone and supine
 Body righting
 Protective reactions
 Equilibrium reactions
Mile stones of development:
 Social smile: 6 weeks
 Neck control: 3 months
 Sitting: 6 months
 Crawling: 9 months
 Stands by holding something, some start walking, say few words: 1 year
 Start and walk alone: 18 months
Early clinical feature:
History: H/O any significant prenatal, perinatal or postnatal event
 Abnormal obstetric history

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 Pre-term birth
 Very low birth weight
 Neonatal jaundice
Symptoms:
 Difficulty in sucking, swallowing (tongue pushes milk & food out, difficulty in closing his
mouth)
 Excessive drooling
 Sudden stiffening or fidgeting awkwardly
 Abnormal posture- child favoring one side of the body
 Floppiness- baby’s head flops & he cannot lift it, arms & legs hang down when he is held
in the air, baby moves too little
 Lack of alertness
 Poor quality of sleep- crying & irritable or may be very quiet & sleeps too much
 Seizures
Signs:
 Microcephaly
 Fisting after 2 months of age
 Delayed mile stones of development
 Persistent primitive reflexes. Persistence of any 2 of the following 5 reflexes after 12
months of age is a cause for concern:
 Primitive neck-righting
 Asymmetric tonic neck reflex
 Symmetric tonic neck reflex
 Extensor thrust response
 Moro reflex
 Increased tone, scissoring or assumption of equinus position of feet
 Visual problems:
 Persistent squint
 Recognizing objects
 Focusing for near objects
 Fast eye movements
 Visual field loss
 Loss of visual acuity
 No visual following and poor hand regard after 6 months of age
 Lack of auditory response: Do not turn head to noise after 6 months

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Diagnosis in later childhood:
 Neurological examination:
 Increased tone, brisk reflexes, a positive Babinski response and clonus
 Poor coordination
 Sensation is often not entirely normal and problems with stereognosis (as well as
with perception) may be important factors contributing particularly to upper
limb disability
 Since it is essentially a disorder of posture and movement, the child should be carefully
observed sitting, standing, walking and lying:
 Sitting posture:
 The child may find it difficult or impossible to sit unsupported
 Children with a hypotonic trunk may slump into a kyphotic posture
 Others may always ‘fall’ to one side
 The lower limbs may be thrust into extension
 Head control may be poor
 Standing posture
 In the typical case of a spastic diplegia, the child stands with hips flexed,
adducted and internally rotated, the knees are also flexed and the feet
are in equinus with scissoring posture
 With tight hamstrings, the pelvis may be tilted posteriorly obliterating the
normal lumbar lordosis and the child may have difficulty standing
unsupported
 Scoliosis: Common in quadriplegics and often associated with pelvic
obliquity
 Kyphosis and lordosis also occur
 Gait:
 Abnormal postures, fluidity of movement, balance and the ability to
start/stop easily may all become more noticeable during walking
 Clinical gait analysis:
o Each limb must be observed in both the stance and swing phases
of gait and in the coronal, sagittal and transverse planes
o In the spastic diplegia patients walk with narrow base combined
with the hip and knee flexion and foot equinus with scissoring of
legs, there is a strong tendency to fall.
 Computerized gait analysis:
o Kinematics (joint and limb segment movement), kinetics (joint
moments and powers), EMG (identification of the phases in which

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muscles are firing), pedobarography (foot pressures) and metabolic
energy analysis (assessment of the ‘cost’ of walking) are all part of
the analysis, as is a video recording which can be viewed from any
direction and at any speed.
 Contracture:
 Assess whether it is fixed or flexible
 Assess the degree of deformity
 Deformity at one level may be markedly affected by the position of the
joints above and below
 Silfverskiöld test: To determine which component gastrocnemius or
soleus is responsible for equinus.
 Bony deformity:
 Normal bone growth is influenced by muscle pull
 Persistent abnormal muscle pull may result in abnormal bone growth
 The normal degree of infant femoral neck anteversion persists and
sometimes even increases with growth rather than improving. Persistent
flexion and adduction of the hip, in addition to the persistent femoral
neck anteversion, leads to acetabular dysplasia and subluxation of the
joint.
 External tibial torsion may give rise to planovalgus deformity of the foot
 Shortening in the quadriceps may contribute to the patella alta
appearance and the development of patella–femoral pain
Common deformities in CP:
A. In upper limbs:
 Shoulder: Flexion, adduction, internal rotation
 Elbow: Flexion, pronation
 Wrist and fingers: Flexion
B. In lower limbs:
 Hip: Flexion, adduction, internal rotation
 Knee: Flexion or hyperextension
 Ankle and foot: Planter flexion, inversion, forefoot adduction

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Differential diagnosis:
 Intrauterine stroke
 Hereditary spastic paraplegia
 Motor delay without specific neurological signs
 Spinal cord injury
 Hydrocephalus
 Brain tumor
 Metabolic disease
 Spina bifida
Management:
Management protocol:
1. Aim of management
2. Counseling to parents
3. Formation of a rehabilitation team
4. Medical management
 Feeding, growth and nutrition
 Pulmonary management
 Neurological issues and management
 Genitourinary management
 Gastrointestinal management
 Musculoskeletal pain and osteopenia
 Management of hypertonia
5. Therapeutic management
 Childhood Disabilities and Education
 Therapy Interventions
 Stretching exercise
 Strengthening exercise
 Aerobic exercise
 Constraint-Induced Movement Therapy (CIMT)
 Functional Electrical Stimulation (FES)
 Robotic and Partial Body Weight Support Treadmill Training (PBWSTT)
 Durable Medical Equipment
 Management of Hypertonia
6. Orthopedic Management
 Hips
 Lower Limb

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 Upper Limb
 Spine
7. Complementary and Alternative Medicine
8. Transition to Adulthood and Aging with Cerebral Palsy
Aim of management:
 To develop independency in ADLs. Eg- ambulation, transfer, eating, dressing, personal
hygiene and communication
 To prevent deformity
 To improve psychosocial issues and ensure community participation
 To ensure participation in recreational activity
Counseling to parents:
 Explanation of the course of the disease
 Non-progressive
 Not a mental illness
 Not inherited
 Not contagious
 Holistic evaluation and care needed
 Not curable but management aims at minimizing the disability to improve their
quality of life
 Emphasize the need for long term treatment
 Provide encouragement to attain the goal
Formation of a rehabilitation team:
A. Medical team members
 Physiatrist (Team leader)
 Paediatrician
 Paediatric neurologist
 Orthopaedic surgeon
 Neorosurgeon
 Psychiatrist
 Ophthalmologist
B. Paramedical team members
 Physiotherapist
 Occupational therapist
 Speech therapist

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 Orthotist
 Rehabilitation nurse
 Biomedical engineer
 Recreational therapist
 Nutritionist
C. Others
 Parents
 Social worker
Medical management:
Feeding, Growth, and Nutrition:
 Regular monitoring of weight
 Adaptation with spoon or cup feeding
 Dysphagia is commonly observed in patients with CP. Thick food preparation is a simple
early solution. Moistening and softening solids can also make swallowing easier.
 To prevent aspiration: Proper positioning, modified feeding consistency
 NG tube feeding or grastostomy if needed
 Early on, children should receive nutritional counseling and supplemental caloric and
fluid intake if necessary
Pulmonary:
 Lung disease is an important cause of morbidity and mortality in CP.
 Prevention of pulmonary aspiration
 Control of sialorrhea with anticholinergic medications, botulinum injections into the
salivery gland, and sometimes surgery.
 Chest physiotherapy and bronchodilators can assist with decreased mucociliary
clearance
 Children with infections should be treated with tailored antibiotics based on sputum
cultures, and some will require prophylactic or cyclical antibiotic coverage
 Upper airway obstruction may require continuous positive airway pressure and/or
surgery. Lower airway obstruction may respond to a trial of bronchodilators and
pressure
 Children with CP frequently have sleep-disordered breathing. A history of snoring or
observed irregular breathing patterns with or without excessive daytime somnolence
should prompt the practitioner to investigate possible sleep apnea, which if untreated
can contribute to further morbidity

14. 14
 Preventative measures include immunizations since this population is at higher risk for
infections and complications
Neurologic Issues:
 Seizures occur most frequently in children with a quadriplegic or hemiplegic CP. If
present anti-epileptic drugs should be used.
 Cognitive impairment is seen more commonly in children with a quadriplegic CP. It may
consist of several issues like behavior, communication, attention, sensory perception
etc. Treatment options are:
 Making a team with medical professionals of different specialties to reach the
patient to his/her fullest potential. This can include-
 A Physiatrist
 A Psychiatrist
 A behavioral therapist
 A speech-language pathologist
 A physical therapist
 An occupational therapist
 Adoption of newer technology like
 Brain computer interface
 Transcranial magnetic stimulation
 Brain training through neurofeedback
 Hyperbaric oxygen therapy
 Galantamine with combination of resperidone drug have good result for
cognitive changes in CP patients
 Hearing problem:
 Conductive hearing loss:
 Treating the underlying infection and inflammation
 Hearing aids
 For more severe or recurring conductive hear loss: surgery
 Sensorineural hearing loss
 Hearing aids: Amplify sounds so that those nerve receptors that are not
damaged receive more sound
 Cochlear implant: It actually bypasses damaged inner ear nerves and uses
mechanical parts to collect, transmit, and convert sounds into electrical
impulses that are sent to the brain as sounds.
 Visual problem:

15. 15
 Visual stimulation therapy: High contrast colours or objects illuminated by
light in a darkroom. Recommended duration is less than 12 minutes, twice
per day, 5 days a week for one year.
 Corrective glasses
 Squint surgery
Genitourinary:
 Urinary incontinence:
 Clean intermittent catheterization
 Anticholinergic medication
 Urinary retention:
 Crede maneuver
 Valsalva maneuver
 Clean intermittent catheterization
 Eneuresis
 Restriction of fluid 1-2 hours before bedtime
 Avoidance of caffeinated and citrus beverages, chocolate
 Waking to urinate at regular intervals during the night
 Protection of bedding
 Night light
 Prevent constipation
 No punishment
 Recording of dry nights & motivation by rewarding dry nights
 Bladder training — delaying voiding for increasing periods when daytime
frequency symptoms are present
 Medication (not before 6 years of age): Desmopressin, imipramine, oxybutynin
Gastrointestinal:
 Gastroesophageal reflux disease
 PPI
 Liquid antacid
 Domperidone
 Constipation
 Gastro-colic reflex
 Recto-colic reflex
 Laxatives
Musculoskeletal Pain and Osteopenia:

16. 16
 Musculoskeletal pain
 Common sites include the hips, spine, knee, and foot and ankle complex
 With aging, patients may experience worsening pain associated with patella alta,
spondylolysis with spondylolisthesis, and degenerative hip conditions
 Treatment options include
 Adjustment of position for function within capabilities
 Strengthening program
 NSAIDs
 Trigger point injections
 Osteopenia
 Risk factors for osteoporosis include decreased weight bearing, use of
anticonvulsants, malnutrition, and decreased sunlight exposure
 Treatment options:
 Supplementation with calcium and vitamin D is routinely used to improve
bone density
 Bisphosphonates are effective in improving bone mineral density and is
usually reserved for children who have experienced a fragility fracture
Therapeutic interventions: The main goal of all therapies is to promote and facilitate
development in all domains of function.
 Stretching: Its goal is to reduce the risk of contracture development as a result of muscle
imbalances and hypertonicity. Sustained stretching can be achieved through the use of
positioning devices, orthoses, and serial casting.
 Strengthening exercise
 Aerobic exercise: Improvements in aerobic fitness were noted with 45 minutes four
times a week of “high-intensity” activities such as wheelchair sports, swimming, matt
exercises, or cycling. This benefit is not maintained if the activity is not maintained.
 Constraint-Induced Movement Therapy (CIMT): It is a treatment for hemiparesis to
improve motor function in the affected upper limb. In children with hemiplegic CP, the
unaffected limb is restrained with a removable cast, typically for 3 weeks, and the child
undergoes intensive, structured therapy in addition to daily activities and play.
 Functional Electrical Stimulation: Neuromuscular electrical stimulation (NMS) is the
application of an electrical current of sufficient intensity to elicit muscle contraction.
When applied during a functional activity, it is referred to as functional electrical
stimulation (FES).
 Robotic and Partial Body Weight Support Treadmill Training (PBWSTT): Its goal is to
achieve a more normalized gait pattern. The setting includes an overhead harness
system used to support the child’s body weight on a treadmill, while the therapist or a
robot facilitate the kinematic, kinetic, and temporal features of walking.

17. 17
 Motor strength training: To develop-
 Head control
 Rolling and twisting
 Gripping, reaching and hand-eye coordination
 Body control, sitting and balance
 Creeping and crawling
 Standing, walking and balance
 Communication and speech
 Early play activities and toys
Durable Medical Equipment:
 Equipment helpful for hygiene and day-to-day care:
 Bathing & toileting devices: Appropriate for specific age and functional needs
 Transfer aids
 Railings & other bed adjustments to prevent fall
 Mattresses with better pressure distribution
 Modifications to high chairs
 Positioning devices:
 For supported seating
 Corner seats: who lack postural control of the head, neck, or trunk.
 Preston feeder seats
 Rifton chairs: for feeding, speech therapy, active learning
 For supported standing
 Prone stander
 Supine stander
 Standing tables and frames
 Balancing devices
 Balance board
 Wobble board
 Rocking horse
 Gym ball
 Wheeled mobility
 Stroller mobility
 Manual wheelchair
 Powered wheelchair (Patients should be at least 24 months of age)
 Walking aids
 Walkers
 Anterior walker (Traditional)

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 Posterior walker (Promote trunk extension)
 Canes
 Crutches
 Orthoses:
 AFO
 Traditional solid AFOs
 Dynamic AFOs
 Spiral AFOs
 Articulating AFOs
 Floor reaction AFOs
 Supra-malleolar foot orthoses: Have trimlines that provide medio-lateral stability
but allow ankle dorsiflexion and planter flexion
 KAFO
 HKAFO
 Sitting, walking and standing hip (SWASH) orthoses
 TLSO
Management of Hypertonia:
 The most common forms of hypertonia observed in CP include spasticity, dystonia and a
combination of both.
 Oral Medications
 For generalized spasticity:
 Baclofen, diazepam, dantrolene sodium, tizanidine, clonazepam, and
clonidine
 For generalized secondary dystonia:
 Trihexyphenidyl hydrochloride, oral baclofen, and levodopa-carbidopa
 Chemodenervation
 Botulinum toxin:
 It works by blocking the presynaptic release of acetylcholine at the
neuromuscular junction.
 Appropriate for focal spasticity and/or dystonia, dynamic contracture
 Onset of action usually occurs within 24–72 hours, peak effect 4–6 weeks
 Effect lasts usually for 12 to 16 weeks and it is recommended that
injections be spaced a minimum of 3 months
 BTX-A injections combined with serial casting for dynamic equinus show
mixed results
 Phenol block:
 Phenol works by proteolytically causing neurolysis.

19. 19
 The use of phenol requires the injection to be placed selectively and the
nerve to be isolated by electrical stimulation with or without ultrasound
 Commonly injected nerves are the musculocutaneous, obturator and
sciatic nerve to the medial hamstring.
 In contrast to Botox, phenol is inexpensive and its results can last
between 6 and 18 months
 Combination of Botulinum toxin & Phenol:
 Can be used at the same time to maximize the dose and number of
muscles, treated by the finite amount of BTX
 Intrathecal Baclofen Therapy:
 It is most often used to treat children with generalized spasticity or generalized
moderate-to-severe dystonia
 ITB is delivered through a programmable pump placed subfascially in the
abdominal wall and connected to a catheter that is tunneled from the side of the
pump and inserted in the intrathecal space at a desired spinal level.
 This method allows the delivery of smaller doses of baclofen (micrograms)
intrathecally, thus reducing the side effect profile seen with the oral form of
baclofen
o (milligrams).
 The pump requires replacement every 6 to 7 years owing to battery life.
 Potential complications of ITB include infections, cerebrospinal fluid leaks, and
catheter problems such as disconnection, migration, or kinking.
 Abrupt withdrawal is a medical emergency and may present as increased tone,
spasms, diaphoresis, agitation, and pruritus.
 Deep Brain Stimulation:
 Deep brain stimulation (DBS) involves a stereotactic implantation of electrodes
into the basal ganglia and a programmable pulse generator implanted
subcutaneously in the infraclavicular region.
 DBS is the treatment of choice in primary dystonias. In CP, the majority of
persons have generalized secondary dystonia (typically quadriplegics with
GMFCS levels IV to V). ITB is the treatment of choice in this population; however,
in those who do not respond adequately to ITB, DBS should be considered.
 Selective Dorsal Rhizotomy:
 The surgical technique involves single or multilevel laminectomies exposing the
L1–S2 nerve roots and selectively cutting a percentage of the dorsal rootlets with
abnormal response with the aid of electrophysiologic monitoring. It is done to
reduce the excitatory input.

20. 20
 The ideal candidate for SDR is a child between the ages of 3 and 8 years old with
diplegic CP and predominantly spastic tone (typically GMFCS levels I to III), little
upper limb involvement, sufficient underlying strength, good selective motor
control, and minimal contractures.
 Positive outcomes of SDR include reduced spasticity, increased range of motion,
improved gait pattern and kinematics, increased speed, and decreased oxygen
cost, making gait more efficient.
 SDR plus physical therapy is more efficacious than physical therapy alone in
reducing spasticity
 Physical therapy:
 ROM exercise
 Stretching exercise
 Serial casting
 Orthoses
Orthopedic Management:
 The indications for surgery are:
1. A spastic deformity which cannot be controlled by conservative measures;
2. Fxed deformity that interferes with function; and
3. Secondary complications such as bony deformities, dislocation of the hip and joint
Instability
 Development of the CNS and the gait pattern matures around the age of 7–8 years and
thus many orthopaedic surgeons advocate delaying surgery until this age
 Upper-limb deformities are seen most typically in the child with spastic hemiplegia or
total body involvement and consist of elbow flexion, forearm pronation, flexion of the
wrist with clenched fingers and a flexed and adducted thumb (‘thumb-in-palm’
deformity).
 Elbow flexion deformity:
 Provided the elbow can extend to a right angle, no treatment is needed
Occasionally, to facilitate washing and dressing, it may be necessary to treat a
more marked flexion contracture by fractional lengthening of the biceps and
brachialis tendons with release of the brachialis origin.
 Forearm pronation deformity:
 Release of pronator teres may improve the position or the tendon can be
rerouted round the back of the forearm in the hope that it may act as a
supinator.
 Wrist flexion deformity:
 Wrist flexion is usually accompanied by ulnar deviation; it can be improved by
lengthening or releasing flexor carpi ulnaris and maintaining the position with a

21. 21
splint. If extension is weak, the released flexor tendon is transferred into one of
the wrist extensors where it acts more as a tenodesis than a true tendon
transfer.
 Flexion deformity of the fingers:
 Spasticity of the long flexor muscles may give rise to clawing. Highly selective
motor neurectomy has recently regained favour as a potential treatment for
spasticity while, for contractures, the flexor tendons can be lengthened
individually at the risk of provoking a swan neck deformity.
 Thumb-in-palm deformity:
 This is due to spasticity of the thumb adductors or flexors (or both), but later
there is also contracture of flexor pollicis longus.
 In mild cases, function can be improved by splinting the thumb away from the
palm, or by operative release of the adductor pollicis and first dorsal interosseus
muscles.
 Resistant deformity may need combined lengthening of flexor pollicis longus and
release of the thenar muscles, followed by tendon transfers to reinforce
abduction and extension
 Foot/ankle:
 Tibialis anterior is invariably weak and the patient develops an equinovarus foot
deformity.
 A dynamic varus deformity can be treated by a split tendon transfer to the outer
side of the foot (only half the tendon is transferred so as to avoid the risk of
overcorrection into valgus): both tibialis anterior and tibialis posterior tendon
transfers have been advocated depending perhaps on whether the surgeon feels
that the varus is originating from the hindfoot or the midfoot/forefoot.
 Most patients with cerebral palsy have a spastic diplegia where the lower limbs are
more affected than the upper limbs.
 Most children will walk but they are delayed in learning to master this; a child who is not
walking by the age of 6 or 7 years is unlikely to do so.
 Hip adduction deformity:
 Adductor release is indicated if passive abduction is less than 20 degrees on
each side.
 Hip flexion deformity:
 Operative correction is indicated if the hip deformity is more than 20–
30 degrees.
 In the walking child, it is important not to weaken hip flexion too much and thus
intramuscular lengthening of the psoas tendon at the pelvic brim is advocated.

22. 22
 In the non-walking child, psoas release at the level of the lesser trochanter is
allowed
 An associated fixed flexion deformity of the knee may require hamstring
lengthening as well.
 Hip internal rotation deformity:
 Internal rotation is usually associated with flexion and adduction. If so, adductor
release and psoas lengthening will be helpful (and perhaps also medial hamstring
lengthening)
 Hip subluxation:
 Adductor and psoas releases
 Femoral varus derotation (and shortening) osteotomy
 Hip dislocation:
 Open reduction
 Knee flexion deformity:
 Fractional lengthening of the hamstrings (medial more often than medial and
lateral combined)
 Scoliosis:
 Indications of surgery is a progressive curve of more than 40 degrees in a child
over 10 years
 Curve < 40 degree, apex of the curve above C8: Milwaukee brace
 Curve < 40 degree, apex of the curve at or below C8: Boston brace
Complementary and Alternative Medicine:
 Hyperbaric oxygen
 Adeli suit
 Patterning
 Electrical stimulation
 Threshold electrical stimulation
 Functional neuromuscular stimulation
 Conductive education
 Hippotherapy
 Craniosacral therapy
 Feldenkrais
Adulthood issues:
Common health conditions noted in adults with CP are-
 Pain

23. 23
 Secondary osteoporosis
 Dental problems
 Anxiety & depression
Brain-Computer Interfaces:
 A Brain-Computer Interface (BCI) is a technology which allows a human to control a
computer, peripheral or other electronic device with thought.
 It does so by using electrodes to detect electric signals in the brain which are sent to a
computer.
 The computer then translates these electric signals into data which is used to control a
computer or a device linked to a computer
 It works on phenomena of neuroplasticity that allows the brain to store new set of
information either by enabling creation of new connections between neurons or by
deletion of older connection due to damaged neurons.
 BCI is of 3 types:
1. Invasive: Electrodes are implanted directly into the grey matter of the brain by
neurosurgery
2. Partially invasive: Electrodes are implanted inside the skull over the surface of
the brain
3. Non-invasive: Electrodes are applied to the outside of the skull, just on the scalp
Neurofeedback (NFB ) training:
 The working process of NFB based on phenomena of neuroplasticity in which NFB
device measures the different brain waves such as alpha, beta, gamma and theta that
help in teaching the brain to make healthier patterns by rewarding the brain when it
does so. Once the healthier brain wave patterns are practiced it helps the brain to learn
and improve its own regulation.
 NFB helps in the improvement of concentration, attention, perception working memory
and cognition
Transcranial magnetic stimulation:
 Trasnscranial magnetic stimulation (TMS) is a technique for noninvasive stimulation of
the human brain by magnetic pulse through a coil put on the scalp [41]. It is widely used
in the field of human motor and cognitive functions.
 It is an approved tool by the Food and Drug Administration, USA for various neurological
and psychiatric diorders.
 TMS helps in the inhibition or excitation of neural pathways and neurons

24. 24
 TMS enhances the cognitive ability by cortical modulation and increases communication
efficiency within the neural networks of the brain for a cognitive level enhancement.
Administration of TMS appears to prevent excess neural excitability and correct frontal
dysfunction thereby improving cognitive performance
Hyperbaric oxygen therapy (HBOT):
 Hyperbaric oxygen therapy (HBOT) is the use of 100% oxygen in a pressurized chamber
to treat wounds in the brain of any duration in any location.
 In cerebral palsy, hypoxic brain injury is major cause of brain damage and impaired
cognitive functions.
 HBOT significantly improves the tissue oxygen concentration and affects both oxygen
and pressure sensitive genes.
 It also helps in initiating the vascular repair and improves cerebral vascular flow,
regeneration of axons, white matter, promotes blood brain barrier integrity and reduces
inflammation reaction
 These improved factors promote the neurogenesis of endogenous neural stem cell and
helps in cognitive enhancement in cognitive disabilities such as CP, Autism, dementia
Motor strength training:
1. Activities for head control
To encourage the child to raise her head when lying face
down, attract her attention with brightly colored objects
that make strange or pretty sounds.
If she does not lift her head, to help her, put her like this.
Press firmly on the muscles on each side of the backbone
and slowly bring your hand from her neck toward her
hips.
If the baby has trouble raising her head because of a
weak back or shoulders, try placing a blanket under her
chest and shoulders. Get down in front of her and talk to
her. Or put a toy within reach to stimulate interest and
movement.
If the child has trouble lifting her head when lying face
down, lay her against your body so that she is almost
upright. This way she needs less strength to lift her head.

25. 25
2. Activities to encourage rolling and twisting
3. Activities to help develop gripping, reaching, and hand-eye coordination
To help her develop head control when lying face up,
take her upper arms and pull her up gently until her head
hangs back a little, then lay her down again.
As your child develops better head control, play with him,
supporting his body firmly, but with his head and arms
free. Attract his attention with interesting objects and
sounds, so that he turns his head first to one side and
then to the other.
 Attract the child's attention by holding a rattle or toy
in front of her, then move the toy to one side, so the
child turns her head and shoulders to follow it.
 Encourage her to reach sideways for the toy, then
move the toy upward, so that she twists onto her
side and back.
 If she does not roll over after various tries, help her
by lifting her leg. If the child has spasticity, you may
need to help position this arm before she can roll
over.
 Also, help the child learn to roll from her back onto
her side. Again, have her reach for a toy held to one
side.
If she keeps her hand closed, stroke the outer edge of the
hand from little finger to wrist. This often causes the
baby to lift and open her hand, and to grip your finger.
 When the child opens her hands well, but has trouble
holding on, place an object in her hand, and bend her
fingers around it. Be sure the thumb is opposite the
fingers.
 Gradually let go of her hand and pull the object up
against her fingers or twist it from side to side.

26. 26
4. Activities for body control, balance, and sitting:
After the child can hold an object placed in her hand,
encourage her to reach and grasp an object that just
touches her fingertips. First touch the top of her hand-
then place it below her fingertips.
At first a child can only grasp large objects with her whole
hand. As she grows she will be able to pick up and hold
smaller things with thumb and fingers. Help her do this
by playing with objects of different sizes.
To help strengthen grip, play 'tug-of-war' with the child -
making it a fun game.
As the child gains more and more control, introduce toys
and games that help develop hand-eye coordination.
Make games of putting things in and out of boxes and
jars.
After a child gains good head control, he
normally starts sitting through these stages.
If the child simply falls over when you sit him up, help
him develop a protective reaction with his arms. Put him
on a log, hold his hips, and slowly roll him sideways.
Encourage him to 'catch' himself with a hand.
Do the same thing with the child on your belly.

27. 27
After the child learns to 'catch' herself when lying, sit her
up, hold her above the hips, and gently push her from
side to side, and forward and backward so that she learns
to catch and support herself with her arms.
 To help your child gain balance sitting, first
sit her on your knees facing you.
 Later, you can sit her facing out so that she
can see what is going on around her.
 You can do the same thing with the child sitting on a log.
 As he gets better balance, move your hands down to his hips and
then thighs, so that he depends less on your support
 Give him something to hold so that he learns to use his body and
not his arms to keep his balance.
 With an older child who has difficulty with balance, you
can do the same thing on a 'tilt board' or ‘large ball’.
 At first let her catch herself with her arms.
 Later, see how long she can do it holding her hands
together. Make it a game.
 Tilt it to one side and the other and also forward and
back.
Some children will need seating aids to sit well. To help
improve balance, the aid should be as low as possible and still
let the child sit straight. Often, firmly supporting the hips is
enough. Here are 2 examples:
For the child who needs higher back support, simple
'corner seats' can be made of cardboard, wood, or poles
in the ground.
 For the child slides out of the chair, use a lap strap
which pulls down and back
 If his hips are too straight use a seat wedge under his
thighs
 If his legs straighten so that his feet are not flat, use
a foot box

28. 28
5. Activities for creeping and crawling:
If the child can lift her head well when lying on her stomach, encourage her to begin creeping in
these ways:
Help the child learn to keep her balance while using her
hands and twisting her body, sitting on the ground,
 Put a toy or food the child likes just out of reach
 If the child cannot bring her leg forward to creep,
help her by lifting the hip
Put the child over a bucket or log. To help him bear weight
with his elbows straight, firmly push down on his shoulders and
release. Repeat several times.
 If the baby has trouble beginning to crawl, hold him up
with a towel like this. As he gains strength, gradually
support him less.
 You can hang the child from a roof beam or branch, or a
doorway, like this.
When the child has learned to crawl fairly well, have him play
crawling games
To help an older child with balance problems to prepare for
walking, encourage him to crawl sideways and backward.
Later, have him practice holding one arm and the opposite leg
off the ground at the same time.

29. 29
6. Activities for standing, walking, and balance
7. Activities for communication and speech
 Hold the baby so that she uses the early stepping reflex to
strengthen her legs. You can even bounce the baby gently.
 When the child begins to stand, support her hips with your
hands. Spread her feet apart to form a wide base. First do
this from in front, later from behind. Move her gently from
side to side, so that she learns to shift her weight from one
leg to the other.
Have the child hold a hose or rope. Because it is flexible, he
needs to balance more.
 To encourage a child to pull up to standing, put a toy he
likes on the edge of a table.
 To encourage him to take steps, put something he likes at
the other end of the table.
For the older child with poor balance, a homemade balance
board will turn developing better balance into a game. Move
slowly at firstespecially with a child with cerebral palsy.
 Simple homemade parallel bars can help a child with weak
legs or a balance problem get started walking.
 Homemade walker can provide both support and
independence for the child who is learning to walk or who
has balance problems.
Make noises with bells, rattles, clickers, and drums, first
directly in front of the baby, then to one side, so that she turns
her head. If she does not turn her head, bring the toy back so
she can see it, and move it away again.
Or, gently turn her head so that she sees what makes the
sound.

30. 30
8. Early play activities and toys
have conversations with him in his language. But when he
begins to say words, repeat and pronounce them clearly and
correctly-do not use 'baby talk'.
A child understands words before he can speak them. Play
question games to help him listen and learn; he can answer
your questions by pointing, nodding, or shaking his head.
To strengthen the tongue and lips, put honey or a sweet, sticky
food on the upper and lower lips. Have the child lick it off.
 You can also put sticky food on the inside of the front teeth
and roof of the mouth. Licking this food helps prepare the
tongue for saying the letters T, D, N, G, H, J, and L.
 Put food into the side of the mouth. Also, have the child try
to take food (sticky & nonsticky) off a spoon with his lips.
Play games in which you have the child:
Begin to give the child solid foods and foods she needs to chew,
as early as she can. This helps develop the jaw and mouth.
 Look for ways to keep changing the activity a little so that it is always
new and interesting
 Continue with the same activity for a short time only
 Play needs some aspect of adventure, surprise, and freedom. It is
important that a child learn to play with other children as well as
alone

31. 31
Play activities should 'fit' a child's level of development and
help him move one step farther. For example:
 If the child is at the level of a very young baby, play
games that help him use his eyes and hold up his
head.
 If the child is at the level where she sits, but finds it
hard to keep her balance or open her knees, look for
play that helps her with these
Play is more important than toys. Toys -or 'playthings'- offer stimulation for a
child. Many simple things in the home can be used as toys, or can be turned
into them. Here are a few examples of interesting toys:
Toys for touching:
Toys to taste or smell :
Foods, flowers, fruits, animals, spices, perfumes
Toys for seeing:
mirrors, colors, colored paper or tinfoil, daily family activity,
puppets, old magazines with pictures, crystal glass pieces
(rainbow maker), flashlight (touch)
Toys for balance:
Swings, hammocks, seesaws, rocking horses

32. 32
Will my child walk ?
Most children with cerebral palsy do learn to walk, although often much later than normal. In
general, the less severely affected the child is and the earlier she is able to sit without help, the
more likely she is to walk. The best indicator of how the child will do is how the child is doing:
 Sitting: If independent sitting occurs by age 2, prognosis for ambulation is good.
Toys for hearing
rattles, flutes, drum, bells, bracelets on baby's wrist and
ankles, whistles, pet birds, animal sounds, seashells or other
echo toys, talking, laughing, singing
Toys to develop a child's hand-eye
coordination:
 Start simple-dropping objects into a jar, then taking
them out again
 As the child develops, make things more complex
(Rings can be of different sizes, colors or shapes so that
the child can also learn to match these)
Matching games:
 The child can match objects of similar shape, size, and
color
 Small pegs glued onto cut-out pieces help develop fine
hand control
Puzzles:
Jigsaw and block puzzles and building blocks also help a child
learn how shapes and colors fit together

33. 33
 Crawl: Ability to crawl on hands and knees by 1.5–2.5 years is a good prognostic sign.
 Primitive reflexes: persistence of 3 or more primitive reflexes at 18–24 months is a poor
prognostic sign
 Hemiplegic CP: 100% patients are ambulatory (usually by 2 years)
 Diplegic CP: Most patients are ambulatory
 Quadriplegic CP:
 1/4 are independent in ambulation
 1/2 require assisted ambulation
 1/4 are completely disabled
 Dyskinetic: 1/2 of children attain walking, most of them after 3 years of age
Dystonia: Sustained involuntary muscle contraction causing abnormal postures or movement.
Chorea: Chorea refers to jerky, brief, purposeless involuntary movements, appearing fidgety
and affecting different areas. They suggest disease in the caudate nucleus (as in Huntington’s
disease and are a common complication of levodopa treatment for Parkinson’s disease.
Athetosis: Slower, writhing movement of the limbs are often combined with chorea and have
similar causes.
Autism spectrum disorders
Definition:
Autism spectrum disorder (ASD) is a developmental disorder that affects social interaction,
communication, interests and behaviour.
ASD is characterized by:
A. According to DSM-4 (Diagnostic and Statistical Manual of Mental Disorders):
 Impairments in social interaction
 Impairments in communication
 Presence of restricted, repetitive behaviors (RRBs)
B. According to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders):
 Difficulty with communication and interaction with other people
 Restricted interests and repetitive behaviors
 Symptoms that hurt the person’s ability to function properly in school, work, and
other areas of life

34. 34
Pervasive developmental disorders: It includes-
1. Autism
2. Asperger’s Disorder
3. Pervasive developmental disorder—not otherwise specified (PDD-NOS)
4. Rhett’s Disorder
5. Childhood Disintegrative Disorder
Autism spectrum disorder (ASD): It includes-
1. Autism
2. Asperger’s Disorder
3. Pervasive developmental disorder—not otherwise specified (PDD-NOS)
Autism:
It is a developmental disability significantly affecting verbal and nonverbal communication,
social interaction and behavior, generally evident before age three that adversely affects child’s
educational performance.
Asperger’s Disorder: Similar to autism but the language skills remain relatively intact
PDD-NOS:
Presence of features of 1 of DSM-IV diagnostic criteria for autistic disorder, but insufficient
for a specific diagnosis.
Risk factors of ASD:
 Having a sibling with ASD
 Having older parents
 Having certain genetic conditions—people with conditions such as Down syndrome,
fragile X syndrome, and Rhett’s syndrome are more likely than others to have ASD
 Very low birth weight
Clinical features of ASD:
A. Impaired social interaction:
 Abnormal eye contact
 Failure to orient to name

35. 35
 Failure to use gestures to point or show
 Lack of interactive play
 Failure to smile, lack of sharing
 Lack of interest in other children
B. Impaired communication:
 Early abnormal language concerns include-
 Absent babbling or gestures by 12 months
 Absent single words by 16 months
 Absent 2-word purposeful phrases by 24 months
 Inability to initiate or sustain a conversation
 Odd prosody or intonation
 Echolalia (imitative repetition of words)
 Pronoun reversal
 Nonsense rhyming
C. Impaired behavior
 Spends hours in solitary play
 Getting upset by slight changes in a routine
 Lack of sensitivity to some sensory stimuli like-
 Mouthing of objects
 Rubbing of surfaces
 Diminished responses to pain
 Diminished responses to sudden loud noises
Investigations:
 Hearing and visual evaluation: To rule-out hearing and visual impairment
 Genetic testing :To search for genetic syndromes
 Other: EEG, brain imaging, metabolic testing (To search for co-morbid conditions like
seizures)
Differential diagnosis:
 Rhett’s Disorder
 Childhood Disintegrative Disorder
 Mental retardation not associated with PDD
 Early onset psychosis (e.g., schizophrenia)

36. 36
 Obsessive-compulsive disorder
 Childhood-onset dementia
Treatment:
A. Rehab team:
 A Physiatrist
 A Psychiatrist
 A behavioral therapist
 A speech-language pathologist
 An occupational therapist
 A physical therapist
 Social worker
B. Behavioral Therapy: It is the most successful approach
 Applied Behavior Analysis (ABA):
 This is the most-researched intervention
 It is a highly structured, scientific approach that teaches play, communication,
self-care, academic and social living skills and reduces problematic behaviors.
 Therapist observes a child’s abilities and defines what would benefit him
 For example, if a child is not interested in greeting others or in learning toilet
training, an ABA therapist might focus on those skills anyway.
 Verbal Behavior Therapy (VBT):
 It teaches non-vocal children how to communicate purposefully.
 Children learn how we use words functionally – to get a desired response.
 The therapist uses stimuli that will attract a child’s interest — a cookie in the
kitchen or a swing on the playground.
 Cognitive Behavioral Therapy (CBT):
 It is usually recommended for children with milder symptoms
 Developmental and Individual differences Relationship (DIR) therapy (also called
Floortime):
 It engages children through activities each child enjoys.
 Relationship Development Intervention (RDI):
 It is a family-centered approach to establish more meaningful relationships.
 Social skills groups:
 It helps children to engage with peers

37. 37
 Children with autism are usually more comfortable talking and interacting with
adults than with peers, social skills groups bring out difficulties that come up
when being with peers.
 Increasing desired behavior:
 Rewarding
 Positive reinforcement: Example- a child is not cooperating to therapy can be
offered sweet or the therapy can be converted into a game
 Aversion therapy:
 Reducing maladaptive behavior by associating it with an unpleasant experience,
such as pain or noxious smell
C. Speech and language therapy:
 A speech-language pathologist (SLP) assesses the patient’s communication strengths
and challenges. From this evaluation, the SLP creates individual goals for therapy.
 Examples of the skills that speech therapy may work on include:
 Strengthening the muscles in the mouth, jaw and neck
 Making speech sounds more clear
 Modulating tone of voice
 Matching emotions with the correct facial expression
 Understanding body language
 Responding to questions
 Matching a picture with its meaning
 Alternative Augmentative Communication (AAC):
 Some people with autism find that using pictures or technology to communicate
is more effective than speaking. This is known as Alternative Augmentative
Communication (AAC).
 Examples of AAC methods include:
 Sign language
 Picture exchange communication system (PECS)
 iPads
 Speech output devices (such as Dynavox)
D. Occupational therapy:
 An occupational therapist works to develop skills for handwriting, fine motor skills and
daily living skills.
 The most essential role is to assess and target the child’s sensory processing disorders.
 Sensory integration therapy is based on the assumption that the child is either “over
stimulated” or “under stimulated” by the environment. Therefore, the aim of sensory
integration therapy is to improve the ability of the brain to process sensory information

38. 38
 Sensory integration therapy is designed specifically to wake up all the senses like visual,
auditory, tactile and proprioception. Examples are:
 Occupational therapists will often recommend starting the day with a sensory
circuit: a sensory–motor activity program which helps children achieve a “ready
to learn” state. Each session includes:
 Playing with heavy toys, bouncing on a gym ball, skipping, pushing or
pulling heavy weights etc. These all will improve the proprioception.
 Dancing on a rocking horse, swing on a rope, spinning and rolling on the
ground, balancing on a wobble board, log rolling, catching a ball, hitting a
ball with bat etc. All these will improve the balance and coordination
 Decorating the bedroom or the classroom with colorful toys, bright pictures,
bright colored lights for “under stimulated” babies and avoiding these for ”over
stimulated” babies. These all will give visual inputs.
 Musical toys or instruments can be used for auditory input in “under stimulated”
babies whereas ”over stimulated” babies can be kept away
 Strong perfumes mixed in materials used for day to day activity will give the
olfactory input
 Some children may like pressure all over the body. They can be given tight
clothing or regular hugs, involved in a game of hide and seek under blankets.
Others may not like tight clothing or too much hugging.
 Children can be taken on an excursion or a visit to a park or play ground for
audio-visual inputs.
 Skill training:
 Can be promoted by giving toys and building blocks and asking the child to make
a particular object
 Using both sides of the body for activities like crawling, juggling etc.
E. Physical therapy:
 After an assessment, the physical therapist will design and implement a program to
improve the patient’s areas of need
 Following are the areas where the physical therapist will work on
 Gross Motor Skills – using large muscles for sitting, standing, walking, running,
etc.
 Balance/Coordination Skills
 Building up muscle strength
 Functional Mobility
F. Medication:
 SSRIs for anxiety & depression: fluoxetine, escitalopram, paroxetine, sertraline

39. 39
 Antipsychotics for agitation, aggression, beligerance, & stereotypies: risperidone,
olanzapine
Mental retardation
Definition:
It means a condition of arrested or incomplete development of mind of a person which is
specially characterized by sub-normal intelligence.
Characteristics:
 Intelligence should be sub-average
 This should have occurred in the developmental period that is up to 18 years of age
 Behavior should be significantly inappropriate
Classification: according to American Association of Mental Retardation (AAMR)-
Degree of retardation IQ range
Profound 0-24
Severely retarded 25-39
Moderately retarded 40-54
Mildly retarded 55-69
Borderline 70-84
Prevention of cerebral palsy and mental retardation:
 Public education
 Maternal and child health services
 Genetic counseling
 Consanguinity
 Malnutrition