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Cerebral Palsy: PT assessment and Management

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M Gambino Cerebral Palsy
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Cerebral Palsy: PT assessment and Management

  1. 1. CEREBRAL PALSY
  2. 2. Definition  It is defined as a group of disorders resulting from permanent non progressive cerebral dysfunction developing before maturation of CNS affecting the locomotor system  It is non-contagious motor conditions that cause physical disability in human development
  3. 3.  Although brain lesions that result in CP are not progressive, clinical picture of CP may change with time  In addition to primary impairments in gross & fine motor function, there may be associated problems with cognition, seizures, vision, swallowing, s peech, bowel-bladder, & orthopedic deformities
  4. 4. Criteria of diagnosis ◦ Neuromotor control deficit that alters movement or posture ◦ Static brain lesion ◦ Acquisition of brain injury either before birth or in first years of life
  5. 5. History  Formerly known as "Cerebral Paralysis,“ ◦ First identified by English surgeon William Little in 1860. (Little’s disease) ◦ Believed that asphyxia during birth is chief cause  In 1897, Sigmund Freud, suggested that difficult birth was not the cause but only a symptom of other effects on fetal development  National Institute of Neurological Disorders & Stroke (NINDS) in 1980s suggested that only a small number of cases of CP are caused by lack of oxygen during birth
  6. 6. Epidemiology  The incidence of CP is about 2 per 1000 live births  The incidence is higher in males than in females  Other associated problems include ◦ Mental disadvantage (IQ < 50): 31% ◦ Active seizures: 21% ◦ Mental disadvantage (IQ < 50) and not walking: 20% ◦ Blindness: 11%
  7. 7.  During past 3 decades considerable advances made in obstetric & neonatal care, but there has been no change in incident of CP  The population of children with CP may be increasing due to premature infants who are surviving in greater numbers, higher incidence  in normal-weight term infants (3), and longer survival  overall.
  8. 8. Causes of CP  Prenatal (70%)  Peri-natal (5-10%)  Post natal
  9. 9. Prenatal  Maternal infections E.g. rubella, herpes simplex  Inflammation of placenta (chorion amnionitis)  Rh incompatibility  Diabetes during pregnancy  Genetic causes  Exposure to radiations  Maternal jaundice
  10. 10. Peri- natal  Prematurity- immature respiratory & cardiac function  Asphyxia  Maconeum aspiration  Birth trauma  Disproportion  Breech delivery  Rapid delivery  Low birth weight  Coagulopathy
  11. 11. Post natal  Brain damage secondary to cerebral hemorrhage, trauma, infection or anoxia  Motor vehicle accidents  Shaken baby syndrome  Drowning  Lead exposure  Meningitis  Encephalitis
  12. 12.  Additional risk factors for CP include ◦ Kernicterus ◦ methyl mercury exposure ◦ genetic causes
  13. 13. Classification of CP  Depending on the topographical distribution ◦ Monoplegic ◦ Diplegic/ Paraplegic ◦ Triplegic ◦ Hemiplegic ◦ Tetraplegic / Double hemiplegia
  14. 14.  Monoplegia is one single limb being affected.  Diplegia: LE affected, with little to no upper-body spasticity. ◦ The most common form of spastic forms ◦ Most people with spastic diplegia are fully ambulatory, but are "tight" & have scissors gait ◦ Flexed knees & hips to varying degrees, & moderate to severe adduction are present ◦ Often nearsighted & intelligence is unaffected ◦ In 1/3rd of spastic diplegics, strabismus may be present
  15. 15.  Hemiplegia ◦ The most ambulatory of all forms, although they generally have dynamic equinus on affected side  Triplegia: three limbs affected usually both LL & one UL  Quadriplegia: all four limbs more or less equally affected. ◦ Least likely to be able to walk ◦ Some children also have hemiparetic tremors (hemiballismus), & impairs normal movement
  16. 16.  Depending on tone or movement patterns (physiologic) ◦ Spastic ◦ Athetoid/ dyskinetic ◦ Ataxic ◦ Flaccid/ Hypotonic ◦ Mixed
  17. 17. Spastic CP  It is the most common type of CP, occurring in 70% to 80% of all cases.  The cerebral cortex is affected  Moreover, spastic CP accompanies any of the other types of CP in 30% of all cases  It can be monoplegia, diplegia, triplegia, hemiplegia or quadriplegia.
  18. 18. Athetoid/ dyskinetic CP  It is mixed muscle tone  Often show involuntary motions  The damage occurs to extrapyramidal motor system & pyramidal tract  It occurs in 10% to 20% of all cases  In newborn infants, high bilirubin levels in blood, if left untreated, can lead to brain damage in certain areas (kernicterus).  This may also lead to Athetoid CP
  19. 19. Ataxic CP  It is caused by damage to cerebellum  They are least common types of CP, occurring only in 10% of all cases  Some of these individuals have hypotonia and tremors
  20. 20. Hypotonic CP  Hypotonic CP have musculature that is limp, and can move only a little or not at all (Floppy child)  The location of damage is wide spread in the CNS  Although physical therapy is usually attempted to strengthen muscles it is not always fundamentally effective.
  21. 21. Mixed CP  Signs & symptoms of spastic CP is seen with any other type of CP ◦ Most commonly mixed with Athetoid
  22. 22.  Depending on functional level (Gross Motor Function Classification System) ◦ It classifies acc. to age categorized activity level
  23. 23. pathology  Periventricular leukomalacia (PVL) is the most common finding in CP  Corticospinal tract fibers to LL are medial to those of UL in periventricular white matter. ◦ Thus children with PVL typically have spastic diplegia (common type of CP)
  24. 24.  Bilirubin encephalopathy in basal ganglia is seen in athetoid CP following a diagnosis of kernicterus  Focal cortical infarcts involving both grey & white matter are found in patients with hemiparesis, & are typically related to MCA strokes  Brain malformations can be found on neuroimaging in approximately 10% of children
  25. 25. Signs & symptoms (spastic)  Hypertonia  Exaggerated reflexes & +ve barbinskis  Clonus  Poor voluntary movement  Scissoring gait  Low intelligence & loss of memory  Epilepsy  Synergistic pattern  Contracture, deformity & wasting ◦ Adduction & IR of shoulder ◦ Flexion of elbow & pronation of forearm ◦ Wrist flexion & thumb inside hand ◦ Flexion & adduction of hip ◦ Knee flexion ◦ PF of ankle
  26. 26. Extrapyramidal CP  May affect limb, face, tongue & speech  Characterized by continuous muscular worm like movement  Postural instability  Decreased movement in prone position  Fluctuation of tone from high to low  Reflexes are usually normal & muscles are able to contract  Decreased stability  Difficulty to look up  Emotional liability  Arms are more affected  Sucking & feeding problems  Delayed head & trunk control  May be either quadriplegic or rarely hemiplegic  Subtypes - dystonic, athetoid, choroid, h emiballismic, rigid
  27. 27. Ataxic / hypotonic  Inco-ordination  Intension tremor  Hypotonia  Nystagmus  Diminished reflexes  Speech, visual, hearing & perceptual problems  Joint hypermobility  Dysmetria  Incontinence  Postural instability  Gait disturbances  Imbalance & lack of trunk control  Unsteadiness 
  28. 28. risk babies  Biological risk  Established risk  Environmental & social risk
  29. 29. Biological risk  Birth weight of 1500g or less  Gestational age of 32 weeks or less  Small for gestational age (less & 10th percentile of weight)  Ventilator requirement for 36 hours or more  Intracranial hemorrhage  muscle tone abnormalities  Recurrent neonatal seizures (3 or more)  Feeding dysfunction  Symptomatic (TORCH)  Meningitis  Asphyxia with apgar score <3 in 1 min after birth or <6 in 5 min after birth
  30. 30. Established risk  Hydrocephalus  Microcephaly  Chromosomal abnormalities  Musculoskeletal abnormalities (CDH, AMC, limb deficiencies)  Multiple births more than twins  Brachial plexus injuries  Myelodysplasia  Congenital myopathies  Inborn errors of metabolism  HIV infection
  31. 31. Environmental/ social risk  Single parent  Parental age less than 17  Poor quality infant parent attachment  Maternal drug or alcohol abuse  Behavioral state abnormalities (lethargy, irritability)
  32. 32. Detection of risk babies  Principles ◦ There should be definite objective ◦ Some form of action should be possible if the test is positive ◦ The population should be defined ◦ Test should be sensitive ◦ Test should be specific ◦ Screening should start at foetal life & continue into early childhood  Some test are for all children but some are for those who are known to be at risk
  33. 33. Prenatal screening  Routine check up for mother during pregnancy is beneficial for the mother & the foetus  Health education ◦ Diet advice (avoid tobacco & alcohol) ◦ Exercise on prescription ◦ Sleep & working habits
  34. 34.  Clinical examination ◦ Breast condition ◦ Height of uterus ◦ Position of foetus ◦ BP ◦ Samples of blood & urine  For special test condition sought are ◦ Phenylketonuria ◦ Glycosuria ◦ Albuminuria ◦ Rh incompatibility ◦ Congenital syphillis ◦ Rubella, AIDS ◦ Neural tube defect
  35. 35.  Special test for screening ◦ USG from 8-12 weeks  For the assessment of the gestational period  Congenital abnormalities in various organ defect ◦ Amniocentesis from 16-18 weeks of pregnancy  To find chromosomal defect, if the test is positive terminate pregnancy ◦ Chorionic villus sampling technique in 8-11 weeks of pregnancy  For chromosomal study
  36. 36. Post natal screening  Starts in the immediate neonatal period & during the first two years ◦ To find biochemical defects ◦ Hearing & visual problems
  37. 37.  Clinical methods (at birth) ◦ Examination of weight, height, head circumference ◦ Gestational age ◦ Musculoskeletal defects ◦ Testicular descent ◦ At 6 weeks repeat test
  38. 38.  Chemical methods ◦ Blood sample from heel prick at 2-5 days of age & repeated where necessary  Respiratory conditions, cardiac pathology, haemoglobinopathies can be detected  Neuromuscular pathologies (cpk level)  Metabolic disorders  Gene abnormalities
  39. 39.  Electronic scanning ◦ USG, CT Scan, MRI  To find out AVM, hemorrhage, cyst, leucodystrophies etc
  40. 40. Diagnosis  The diagnosis of CP depends on patient's history & on the basis of significant delay in gross & fine motor function, with abnormalities in tone, posture, & movement on neurological examination.  Once diagnosed with CP, further diagnostic tests are optional.
  41. 41.  MRI is preferred over CT due to diagnostic yield & safety.  The CT or MRI also reveals treatable conditions, such as hydrocephalus, AVM, subdural hematomas etc.  Diagnosis, classification, & treatment are often based on abnormalities in tone  Apgar scores have sometimes been used as one factor to predict whether or not an individual will develop CP
  42. 42. Diagnostic tools  Movement Assessment of Infants (MAI): able to predict CP at 4 months (identifies motor delay)  Alberta Infant Motor Scale (AIMS) is able to predict CP at 6 months (Identifies motor delays & measures changes in motor performance over time)  Bayley scale is able to predict CP at 1 year (Identifies devt delay in gross & fine motor, & cognitive domains)
  43. 43. Management  Medical  Surgical  Rehabilitative
  44. 44. Drugs  Oral medications such as baclofen, diazepam, and trihexyphenidyl as well as therapeutic botulinum toxin (Botox)  Children with dystonic CP have dopa- responsive dystonia, with improved motor function using levodopa  Children with basal ganglia/thalamic injury from perinatal asphyxia may develop improved expressive speech & hand use with trihexyphenidyl
  45. 45. Surgery  Dorsal rhizotomy reduces spasticity  Joint & Tendon release most often performed on hips, knees, & ankles.  The insertion of a baclofen pump usually during young adolescence. ◦ usually placed in left abdomen - a pump that is connected to spinal cord, ◦ sends bits of Baclofen to relax muscle  Bony correction E.g. femur (termed femoral anteversion or antetorsion) & tibia (tibial torsion). 2ndary complication caused by spastic muscles generating abnormal forces on bones
  46. 46. Prognosis  CP is not a progressive but the symptoms can become more severe over time  Prognosis depends on intensity of therapy during early childhood  Tend to develop arthritis at a younger age than normal because of pressure placed on joints by excessively toned & stiff muscles
  47. 47.  Intellectual level among people with CP varies from genius to intellectually impaired ◦ (it is important to not underestimate a person with CP and to give them every opportunity to learn)  The ability to live independently with CP varies widely depending on severity of each case. ◦ Some individuals with CP are dependent for all ADL. ◦ Some can lead semi-independent lives, needing support only for certain activities. ◦ Still others can live in complete independence.
  48. 48.  Persons with CP can expect to have a normal life expectancy  Survival is associated with the ability to ambulate, roll, & self-feed  As the condition does not directly affect reproductive function, some have children & parent successfully  There is no evidence of increased chance of a person with CP having a child with CP
  49. 49. Notable persons  Abbey Curran, American beauty queen with CP who represented Iowa at Miss USA 2008 and was the first contestant to compete with a disability
  50. 50. Prediction of ambulation
  51. 51. Pt assessment  Subjective Examination: ◦ Obtained from parents especially mother or from relatives and through case-sheet. ◦ General details includes  Name  Age & Sex  Address  When did the mother first noticed the dysfunctions ◦ Siblings having same type of symptoms
  52. 52. PT assessment  History ◦ Review of complications of pregnancy & delivery, birth weight, gestation, any neonatal & perinatal difficulties, feeding problems, and other health- related problems ◦ Developmental milestones
  53. 53.  Prenatal History ◦ Age of mother ◦ Consanguity marriage ◦ Any drugs taken during pregnancy ◦ Any trauma & stress ◦ Any addiction – smoking or alcoholism ◦ History of TORCH infection ◦ History of previous abortions, still born or death after birth ◦ Multiple pregnancies ◦ Status & cast of the mother
  54. 54.  Perinatal History ◦ Place of delivery ◦ History preterm or post-term delivery ◦ History of asphyxia at birth ◦ History of prolonged labour pain ◦ Type of delivery (Forceps, vacuum delivery) ◦ Presentation of child (Breech) ◦ Condition of mother at the time of delivery
  55. 55.  Postnatal History ◦ Delayed birth cry ◦ Weight of the child at birth ◦ History of trauma to brain during the first 2 years of life ◦ History of neonatal meningitis, jaundice, hypoglycemia, Hydrocephalus or Microcephaly ◦ Nutritional habits of the child (malnutrition), Feeding difficulties ◦ Any medical, surgical or physiotherapy treatment taken before ◦ What treatment was used? ◦ Was the treatment effective or not? ◦ What was the ability level of child at that time? ◦ What obstructs the child from progress? ◦ Apgar Score from the case-sheet
  56. 56. On Observation:  Behaviour of the child ◦ Whether child is alert, irritable or fearful in the session or during particular activities ◦ Child becomes fatigued easily or not during activity ◦ What motivates his action – particular situation, person or special plaything  Communication of the child ◦ With the parents ◦ Whether child initiates or responds with gestures, sounds, hand or finger pointing, eye pointing or uses words and speech
  57. 57.  Other observations ◦ Involuntary movements ◦ Deformities & contracture ◦ Scar may be present ◦ Trophic changes may also be seen due to poor positioning ◦ Postural faults ◦ Gait abnormalities ◦ Use of external appliances
  58. 58.  Attention span ◦ What catches child’s attention ◦ For how much time child’s attention is maintained on particular thing ◦ How does parent assist him to maintain attention ◦ What distracts the child ◦ Does child follows suggestions to move or promptings to act
  59. 59. ◦ Position of the child  Which position does the child prefer to be in?  Can child get into that position on his own or with help?  With assistance, child makes any effort to go in that position  Symmetry of the child (actively or passively maintained)  If involuntary movements present, then in which positions these movements are decreased or increased
  60. 60. ◦ Postural control & alignment  How much parental support is given  Postural stabilization and counterpoising in all postures  Proper & equal weight bearing  If the child’s center of gravity appears to be unusually high, resulting in floating legs and poor ability to raise head against gravity  Fear of fall in child due to poor balance
  61. 61. ◦ Use of limbs & hands  Limb patterns in changing or going into position as well as using them in position ◦ Attitudes of limbs during playing & in all positions  Whether one or both hands are used, type of grasp and release  Accuracy of reach and hand actions  Any involuntary movements, tremors or spasms, which interfere with actions, are present
  62. 62. ◦ Sensory aspects  Observe child’s use of vision, hearing, of touch, smell and temperature in relevant tasks  Does child enjoys particular sensations  Whether child enjoys being moved or having position changed ◦ Form of Locomotion  How child is carried  Any use of wheelchair or walking aids  Which daily activities motivates child to roll, creep, crawl, bottom shuffle or walk
  63. 63. ◦ Deformities  Any part of body, which remains in particular position in all postures & in the movements  The positional preferences typically seen in spastic cerebral palsies are for mid positions of body –  In the UL  Shoulder protraction or retraction, adduction and internal rotation, Elbow flexion, Forearm pronation, Wrist & Fingers flexion  In the LL  Hip semi-flexion, internal rotation and adduction, Knee semi-flexion, Ankle plantar flexion, Foot pronation or supination, Toes flexion  Athetoid or dystonic posturing usually incorporates extremes of movement such as total flexion or extension  Windswept Deformity of hip – One hip flexed, abducted and externally rotated; other hip flexed, adducted and internally rotated and in danger of posterior dislocation
  64. 64.  Higher cognitive function ◦ Drowsy & lethargic ◦ Decrease in intellectual function ◦ Mental retardation (mild to profound) ◦ Attention deficit & easily distractible ◦ Poor memory ◦ Poor comprehension of speech & language
  65. 65.  Cranial nerve integrity ◦ Strabismus or squint (Occulo motor nerve) ◦ Visual defects (optic nerve) ◦ Auditory defects (auditory nerve) ◦ Feeding & swallowing problems (lower cranial nerves) etc.
  66. 66.  Special senses ◦ Visual & auditory defects ◦ Tactile & vestibular hyposensitivity or hypersensitivity
  67. 67. On examination  Sensory Assessment ◦ It is difficult to assess sensation in babies and young children with severe multiple impairments. ◦ If any hearing or visual or psychological abnormalities are present then assessment done by specialist is required
  68. 68.  Motor integrity ◦ Abnormalities of tone  Spasticity, hypotonicity, dystonia etc ◦ Muscular weakness ◦ Loss of voluntary control ◦ Decreased co ordination
  69. 69.  Reflex integrity ◦ Abnormal DTR ◦ Abnormal Superficial reflexes ◦ Abnormal primitive reflexes may be persistent  ATNR, Extensor thrust, gallant reflex etc
  70. 70.  ROM & flexibility ◦ Decreased in the ROM of the involved limbs ◦ Tightness & contracture in hip adductors, hamstrings, calf are very common
  71. 71.  Anthropometric measurement ◦ Height or length decreased (growth retardation) ◦ Weight – decreased (thin & lean) or obese ◦ Head circumference – decreased (growth retardation or microcephaly), increased (hydrocephalus)
  72. 72. ◦ Growth Parameters  Height - Until 24 to 36 months of age, length in recumbency is measured using an infantometer. After the age of 2 years standing height is recorded by a stadiometer Weight kg Pounds At birth 3.25 7 3-6 months Age in months +9/2 Age in months + 11 1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17 7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
  73. 73. Weight kg Pounds At birth 3.25 7 3-6 months Age in months +9/2 Age in months + 11 1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17 7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5  Weight
  74. 74.  Head circumference of the child - ◦ The tape is used to measure occipitofrontal head circumference from external occipital protuberance to glabella Head cicumference Cm At birth 35 3 months 40 1 yr 45 2 yrs 48 12 yrs 52
  75. 75. Developmental milestones  Age Developmental Milestones  4 to 6 weeks Social smile  3 months Head holding  6 months Sits with support  7 months Sits without support  5 to 6 months Reaches out for bright object & gets it  6 to 7 months Transfers object from one hand to other  6 to 7 months Starts imitating cough  8 to 10 months Crawls
  76. 76.  10 to 11 months Creeps  9 months Standing holding furniture  12 months Walks holding furniture  10 to 11 months Stands without support  13 months Walks without much of a support  12 months Says one word with meaning  13 months Says three words with meaning  15 to 18 months Joints 2 or 3 words into sentence
  77. 77.  13 months Feeds self with spoon  15 to 18 months Climbs stair  15 to 18 months Takes shoes and socks off  24 months Puts shoes and socks on  24 months Takes some clothes off  3 to 4 years Dresses self fully  2 years Dry by day  3 years Dry by night  3 years Knows full name and sex  3 years Rides tricycle
  78. 78.  Joint Range of Motion (active & passive) ◦ Active head and trunk flexion, extension, rotation observed during head raise in prone, supine, sitting, standing developmental channels ◦ Active shoulder elevation, abduction, rotation, flexion and extension movements are observed during functional examination of creeping, reaching and other arm movements ◦ Active elbow flexion and extension observed during child’s reach to parts of body or toys ◦ Active wrist and hand movements will be observed during function development ◦ Active hip flexion and extension will be observed during all functions ◦ Active knee flexion and extension seen with active hip flexion extension ◦ Foot movements are also check during functional development
  79. 79.  Posture ◦ Poor posture in all types of CP ◦ Kypho-Scoliosis, knock knee & flexion deformity & inverted flat foot are commonly seen
  80. 80.  Balance & gait ◦ Compromised static & dynamic balance ◦ Balance severely affected in athetoid & ataxic CP ◦ Independent walking is rarely achieved by spastic quadriplegic & athetoid CP,  few diplegic CP can walk with aids,  hemiplegic CP can achieve independent walking
  81. 81.  Bowel & bladder involvement ◦ If the child is able to communicate & understand, training can be helpful ◦ In profound MR and those unable to communicate have dependent functions
  82. 82.  Functional capacity ◦ Varies from complete dependence to complete independent
  83. 83. PT MANAGEMENT
  84. 84. INFANCY (FIRST STAGE – BIRTH TO 3 YEARS)
  85. 85. PT aims  Family education  Handling & care  Promote infant & parent interaction  Encourage development of functional skills & play  Promote sensory motor development  Establish head & neck control  Attain & maintain upright position
  86. 86. Family education  Educate families about CP  Provide support in their acceptance of child  Goal setting & programming should be done with family  Be realistic about the prognosis & efficacy of PT while remaining hopeful  Honesty & commitment towards child  Listening to parental concerns & recognizing personal values & strength
  87. 87. Handling & care  Promote parents ease, skill & confidence in handling child  Positioning, feeding & carrying techniques should be taught  Promote symmetry, limit abnormal posturing & facilitate functional motor activity  Use variety of movement & posture to promote sensory function  Include position to allow lengthening of spastic or hypoextensive muscles  Use positions to improve functional voluntary movement of limbs
  88. 88. Mother & child relationship  Activities should be done on mother's lap, close to body & face so that her touch & stroking & talking to baby not only help motor development but also body image, movement enjoyment by baby & demonstrate love & security  Weaning of child to a PT should be carefully done after mother-child bonding & confidence is established
  89. 89.  Introducing more than one therapist or developmental worker may be disconcerting to child & even parents  Not to overload with exercises, but rather use corrective movements & postures within ADL of child
  90. 90. Feeding & respiration  Position in a propped up sitting for feeding  For greater hip stability & symmetry during feeding position in a high chair with adaptation  Head & neck position should be in neutral rotation & slight flexion to facilitate swallowing  Deep respiration can be facilitated before feeding by applying pressure in the thorax or the abdominal area
  91. 91. Facilitate sensory-motor development (body image)  Reaching, rolling, sitting, crawling & transitional movements like standing & pre walking are facilitated ◦ Promotes spatial perception, body awareness & mobility, facilitate play, social interaction & exploration of environment  Use of equipments that facilitates function when impairment is preventing development E.g. sitting on adapted chair
  92. 92.  Practice midline play, reach for feet, suck on fingers  Do not give too many stimuli at once  Carefully introduce different surfaces for child to roll on, creep, crawl, & walk on with bare feet  Always give child time to experience tactile & auditory stimuli & let him reach & find out about himself whenever possible
  93. 93. Improve proprioceptive & vestibular function  They are compensatory stimuli for visual impairment & also develop body image  Touch, pressure & resistance can be correctly given to stimulate movement giving clues as to direction & degree of muscle action.  Do not use Rx with handling or other proprioceptive stimuli from behind as leaning back will facilitate extensor thrusts
  94. 94. Visual development  Can be easily integrated with methods for head control, hand function & all balance & locomotor activities  Relate appropriate level of visual ability with child's motor programme.  Also one may have to accept unusual head position & other patterns which make it possible for the child to use residual vision  Use favorite toys or colors to facilitate visual function
  95. 95. Language development  Talk & clearly label body parts used  Delay is normal for a child who cannot yet understand meaning of sounds, words & conversation  Use simple & easy words with appropriate examples & models  Communication is also fostered through motor actions, touch & body language relevant to sign system of a child
  96. 96. Facilitating motor development  Postural stability of the head when ◦ lying prone (0-3 months) ◦ on forearms (3 months) ◦ on hands and on hands and knees (6 months), ◦ during crawling, half-kneeling hand support (9-11 months) ◦ in the bear-walk (12 months) in normal developmental levels.
  97. 97.  Acceptance of prone position. ◦ Accustom child to prone  on soft surfaces, sponge rubber, inflatable mattress, in warm water, over large soft ball, over your lap  rock and sway a baby held in prone suspension.
  98. 98.  Postural stability of the shoulder girdle ◦ weight on forearms (3 months), ◦ on hands (6 months), ◦ on hands & knees & arms held stretched forward along the ground to hold a toy at 5-6 months also include postural stability.  Pivot prone with arms held extended in air activates stabilizers (8-10 months).  Maintenance of half-kneeling lean or upright kneeling (lean on hands) or grasp a support - 9-12 months stimulates shoulder girdle stability
  99. 99.  Postural stability of pelvis ◦ On knees with hips at right angles (4 months) ◦ on elbows & knees & on hands and knees (4-6 months), ◦ on half-kneeling and upright kneeling with support (9-12 months) in normal motor levels.
  100. 100. Maintaining an upright position  Use of adapted chairs & standing frame  Use of orthosis can be delayed until some voluntary movement is gained  Sitting on swiss ball, vestibular board etc can be given to improve challenges
  101. 101. PRESCHOOL PERIOD
  102. 102.  Main aim is to reduce the primary impairments & prevent the secondary impairments
  103. 103. Increase force generation (strengthening)  Creating demands in both concentric & eccentric work ◦ Transitional movements against gravity, ball gymnastics etc.  If a child has some voluntary control in muscle group, capacity for strengthening exists  Use of electrical stimulation or by strengthening within synergistic movement patterns
  104. 104.  Ambulatory children with CP have capacity to strengthen muscles, although poor isolated control or inadequate length  To participate in a strength-training program, child must be able to comprehend & to consistently produce a maximal or near-maximal effort
  105. 105. Reduce spasticity  Positioning in anti synergistic pattern  Stretching of tight structures  MFR  ROM exercise  Rhythmic rotations  Splinting & serial casting  Dorsal rhizotomy  Botox injection
  106. 106. Increase mobility & flexibility  ROM exercise  Maintain length of muscle by regular stretching & splinting ◦ Prolonged stretching of 6 hours a day with the threshold at which the muscle began to resist a stretch  Strengthening exercise of prime movers of a joint
  107. 107. Prevent deformity  Serial Casting techniques  Orthosis & night splints  Lycra splinting & taping techniques ◦ Skin reactions should be carefully assessed  Allignment of the body in a variety of positions in which they can optimally function, travel & sleep
  108. 108. Improve physical activity  Exercise should be intensive, challenging & meaningful & involve integration of skills into function  Movement should be goal oriented & interesting to maintain motivation ◦ Kicking a soccer ball  Feedback is important & feedforward is also considered  CIMT also improves function in hemiplegic CP  Oromotor rehabilitation should also be provided
  109. 109. Improve ambulatory capacity  Weight bearing, promoting dissociation, & improving balance  Walkers & crutches may be used ◦ Posterior walkers encourages more upright posture during gait  Treadmill training or body weight support treadmill training  Adapted tricycle, wheelchair or motorized wheelchair may improve mobility in more disabled children
  110. 110. Improve play  Play is the primary productive activity of children it should be motivating & pleasurable  Motivates social skills, perception conceptual, intellectual & language skills  Appropriate toys & play methods should be suggested  Parents should encourage to let children enjoy their typical play activities s/a rolling downhill or getting dirty
  111. 111. SCHOOL AGE & ADOLESCENCE
  112. 112. Improve activity, mobility & endurance  Gait training can be continued throughout school age with other conjunction s/a spasticity mgt  Architectural modification may be required s/a ramps or rails  Orthosis increases energy expenditure  Regular exercise, proper diet & nutrition & participation in recreational activities is encouraged
  113. 113. School & community participation  Positioning, lifting & transfer techniques should be taught to the school personnel  Opportunities should be given to participate in community & recreational activities  Adapted games & athletic competition & team participation improves self esteem  Introduce to Community fitness program
  114. 114.  Barriers s/a transportation, finances, time preferences & involvement, interest should also be considered carefully  Injury prevention will limit impairment & disability
  115. 115. TRANSITION TO ADULTHOOD
  116. 116. Improve functional skills  Maintain & improve cardiovascular fitness  Weight control, maintain integrity of joints & muscles, help prevent osteoporosis  Fitness clubs, swimming, wheelchair aerobics & adapted sports are options  Disability certificate should be provided to reimburse handicap facilities & compensations  Introduce to help lines & community care centers
  117. 117. Transition planning  Vocational training & occupational training should be provided  Living arrangement, personal mgt including birth control, social skill & household management should be made available  Continuation of professional health service should be done
  118. 118. Characteristics Score 0 Score 1 Score 2 Acronym Skin color/ Complexion Blue or pale all over Blue at extremities body pink (acrocyanosis) No cyanosis- body & extremities pink Appearance Pulse rate Absent <100 ≥100 Pulse Reflexirritability No response to stimulation grimace/feeble cry when stimulated cry or pull away when stimulated Grimace Muscle tone None some flexion flexed arms & legs that resist extension Activity Breathing Absent weak, irregular, gasping strong, lusty cry Respiration Apgar score
  119. 119. Scoring  Test is done at 1 & 5 min after birth, & repeated later if score is/ & remain low ◦ 3 & below- critically low, ◦ 4 to 6 - fairly low ◦ 7 to 10- generally normal.  A low score on 1 minute -requires medical attention  If score remains below 3 at times s/a 10, 15, or 30 min, there is a risk that child will suffer longer-term neurological damage.  Purpose of Apgar test is to determine quickly whether a newborn needs immediate medical care or not & not designed to make long-term predictions  A score of 10 is uncommon due to prevalence of transient cyanosis, & is not substantially different from a score of 9. ◦ Transient cyanosis is common, particularly in babies born at high altitude.

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