Cerebral palsy

By Andaleeb zehra
Definition
 [Link] little who first defined
cerebral palsy, described the condition
as “ a persistent disorder of movement
and posture appearing early in life and
due to a developmental non-
progressive disorder of the brain.”
 [Link] Bobath elaborates that “ the
lesion affects the immature brain and
interferes with the maturation of the
central nervous system, which has
specific consequences in terms of the
type of cerebral palsy which develops,
its diagnosis, assessment and
treatment.
Prevalence rate
A reasonable estimate of the
prevalence of cerebral palsy is 2 per
1000 live births (Paneth et al,1981).
 Cerebral palsy is the most common

motor disorder in children occurring

in 2-2.5 per 1,000 live births (Stanley
et al,2000)
Causes of cerebral palsy
 Pre natal causes
 Peri natal causes
 Post natal causes
Pre-natal causes
 Trauma during pregnancy
 Infection like jaundice or any other infection

to the mother during gestation.

 Any drug disorder
 Pre eclampsia, eclampsia
 Any genetic cause
 Any condition due to vascular change
 Asphyxia
 Defective development of the foetus
Peri–natal causes
 The birth asphyxia – knotted umbilical cord
around the foetus or umbilical cord
strangulated around the foetal head.
 Forceps delivery
 Breech delivery – especially occurring

through a partially dilated cervix, and

without forceps applied to protect the head.
 Premature baby
 Birth anoxia
Post-natal causes
 Delayed birth cry leads to hypoxia
 Severe infection like rubella and

cytomegalovirus, neonatal encephalitis

and meningitis.
 Hypoglycemia
 Severe jaundice
 There could be occlusion of MCA or

internal carotid artery

Classification of topography
 Quadriplegia – involvement of all four
limbs
 Diplegia – involvement of 4 limbs with

legs more affected than arms.

 Paraplegia – both lower limbs are

affected
 Hemiplegia – one side of the body is

affected
 Monoplegia – one limb is affected.
Perlstein 1949, 1952
 Degree of Severity
◦ 1. Mild CP
◦ 2. Moderate CP
◦ 3. Severe CP
Types of cerebral palsy
 Spastic
 Athetoid
 Ataxic
 Flaccid
 Mixed
Spastic cerebral palsy
 It is caused by the damage to the upper
motor neuron in the cerebral cortex or along
the pathways which terminate in the spinal
cord.
 There is hypertonous or clasp knife variety.
 If these spastic muscles are stretched at a

speed they respond in an exaggerated

fashion, they contract blocking a movement.
 This hyperactive stretch reflex occur at the

beginning, middle or near the end ROM.

 There are increased tendon jerks, occasional
clonus and other signs of UMN lesions.
 Abnormal postures :

these are usually associated with the

antigravity muscles. The abnormal postures
appear as unfixed deformities which may
become fixed deformity or contractures.
 Voluntary movements: spasticity doesn’t

mean paralysis. Voluntary motion is present

but may be laboured, there maybe weakness
on initiation of movement or movement at
different part of its range.
 If spasticity is decreased or removed by
treatment or drugs, the spastic muscles
maybe found to be more weak or more
strong.
 Once the spasticity decreased the

antagonist muscle may also be stronger

once they no longer have to overcome the
resistance of tight spastic muscles
 However in time these antagonist may have

to become weak with disuse atrophy.

 Voluntary movements are present but they

are clumsy and uncoordinated.

 Intelligence – it varies but may be more
impaired than in children with athetoid
cerebral palsy.
 Perceptual problems – specially of spatial

relationships are more common in spastic

type of cerebral palsy.
 Sensory loss occasionally occurs with the

child with [Link] maybe visual

field loss and lack of sensation in hand.
 Growth of the hemiplegic limb can be less

than on the unaffected side.

 Rib cage abnormality and poor respiration

may exist.
 Epilepsies are more common in this case as
compared to other types of cerebral palsies.
Athetoid
 Athetosis: these are bizarre purposeless
movements which may be uncontrollable. The
involuntary movement maybe slow or fast.
They maybe jerky, tremor, swiping or rotary
patterns or they maybe unpatterned. They are
present at rest in some children.
the involuntary movement is increased by
excitement, any form of insecurity and effort
to make a voluntary movement.
Factors which decrease athetosis are:
 Fatigue
 Drowsiness
 Fever
 Lying prone
 Child’s attention deeply held
 Athetosis maybe present in all parts of the
body including face and tongue. The
athetosis may sometimes only appear in
hands and feet or in the proximal joints or in
both proximal or distal joints.
 Postural control:

The involuntary movement of dystonic spasm

may throw a child off balance. However, the
well known instability in athetoids is often
indirectly connected with postural
mechanism.
Voluntary movement
 these are possible but there may be an initial
delay before the movement is begun.
 The involuntary movement may partially or

totally disrupt the willed movement making it

uncoordinated
 There is lack of fine motor movements.
Hypertonia or hypotonia
 Either may exist or there maybe fluctuations of
tone.
 Athetoids are sometimes called as tension or non
tension types.
 There maybe dystonia or twisting of head , trunk or
limbs.
 Sudden spasm of flexion or extension could occur.
 The hypertonia is rigidity but occasionally spasticity
may be present specially in athetoids quadriplegics.
 The fluctuating tone sometimes occur with
fluctuation of mood or emotions.
Paralysis of gaze muscles
 May occur so that athetoids may find it
difficult to look upwards and sometimes also
to close their eyes voluntarily.
Athetoid dance
 Some athetoids are unable to maintain weight on
their feet and continually withdraw their feet
upwards or upwards and outwards in an athetoid
dance.
 They may take weight on one feet while pouring

or scrapping the ground in withdrawal motion

with the other leg.
 This has been attributed to a conflict between

reflexes specially grasp and withdrawal reflexes.

 The conflict of reflexes may also be seen in the

hand.
 Intelligence is frequently good and may be
very high. Occasionally intellectual
impairments may also be present.
 Hearing loss is specific high frequency type.
 ‘drive’ and outgoing personalities are often

observed among the athetoids.

 Emotional liability is more frequent than in

other cerebral palsies.

 Articulatory speech difficulties and

breathing problems may be present.

Ataxic
 Disturbance of balance:
 There is poor fixation of head, trunk,
shoulder and pelvic girdle.
 Some ataxic overcompensate for this
instability by having excessive balance saving
reactions in arms
 Instability is also found in athetoids and
spastics.
Voluntary movements
 Present but clumsy or uncoordinated.
 The child over reaches or under reaches for

an object and is said to have dysmetria.

 Now this inaccurate limb movement in

relation to its objective may also be

accompanied by intention tremors.
 The fine movement of the hand maybe

poor.
 Hypertonia:Hypertonia is usual. Ataxia may
be present in hypertonic cases as well.
Nystagmus may exist.
 Intelligence impairments appear especially in

presence of visual and perceptual problems.

 Clumsy, intelligent children are sometimes

diagnosed as ataxic cerebral palsy.

 A pure ataxic is rarely diagnosed.
Physiotherapeutic management
 The treatment should be aimed at the
neurological mechanism of posture, balance,
movement supplemented by procedures for
muscles and joints when necessary. This needs
to be integrated into motor learning models.
 There should not be rigid adherence to
particular diagnostic classification in treatment
programmes.
 Aetiology may not influence the treatment in
cerebral palsy
 Emphasis should be given to train various
postural mechanism which are absent or
abnormal in all types of cerebral palsy or may
be absent in any developmental motor delay.
 Treatment should provide features if motor

disorders such as hypotonicity, hypertonicity,

involuntary movement, weakness, abnormal
pattern of voluntary movement, abnormal
reflex in context of total motor function as
well as the specific treatment for individual
cases.
 Therapist should deal with abnormal reflexes
only in those cases where they directly
disrupt function.
 The therapist must deal with the complex

situation of pathological symptoms which in

the context of a developing child in the
cerebral palsy and other motor disorders.
 The developmental schedule or sequence of

normal child should only be used as a

guideline and adaptations should be
according to each child.
 The treatment should commence as early as

possible in order to get good results.

 The treatment plan should be reviewed
periodically to take account of changes in the
clinical picture as a child grows older.
 Physiotherapist needs to include learning

principles in their work which also include

emotional issues.
techniques
 The handling techniques aims to
promoting :-
 Child assests and ability and if possible to

stimulate normal pattern of movement.

 To reduce or prevent deformity
 To discourage position, movement and

behaviour that makes handling difficult

 To develop independence in daily activities
 To promote child ability and stimulate normal

pattern of movement.
 To play and develop recreational activity
 To decrease spasticity
 Improve muscle power and range of motion of joints
 Improve static and dynamic balance
 Improve gait and walking pattern
 Improve functional deformity
 To develop some form of mobility which may include

wheelchair, walker and electronic mobile wheelchair.

 Treatment should be aimed at neurological

mechanism of posture, balance and movement.

 Treatment should be aimed for motor disorders such

as hypertonicity,hypotonicity, involuntary movement,

weakness, abnormal pattern of voluntary movement.
Techniques included are:
 Lifting and carrying
 Positioning
 Position for function
 Movement between position
 Mobilization activity
 Passive stretching
 Hydrotherapy
 PNF techniques
 Muscle power and strengthening
 Occupational and speech therapy
 Walking aids
Lifting and carrying techniques
 The child should be lifted keeping a straight
back with a wide base of support, knees
bended, holding the child as whole as
possible.
 For flex children constant extend positioning

should be favoured for extending or thrusting

positioned child.
 The adult’s hand may be under or in front of

the child’s knee in either method of carrying

or lifting.
positioning
 Lying supine:
 Many cerebral palsy patient are completely

unable to function and in this position they

are most asymmetrical.
 If this position has to be used, a pillow

should be placed under head and shoulders.

Side lying
 It’s a position in which child could be very
asymmetrical. Both the hands are in his range
of vision and are more likely to be used
together.
 Care must be taken that the child doesn’t fall

partially into prone or supine lying.

sitting
 Long sitting with knees slightly flexed or straight
is the position in which normal baby learns to
establish his bottom and legs as his base of
support.
 Sitting is a posture in which the hamstrings and
the hip adductors can be stretched.
 The child is unable to sit flat on the floor without
this pelvis rotating posteriorly.
 In such a case he can be placed so that his
bottom is slightly raised. Such as on a very low
stool or on a pile of books.
standing
 The cerebral palsy child who in not able to
stand on his own by the age of 12-18 months
should be able to stand with the help of
therapist or the attendants.
 Hips should be extended, slightly externally

rotated and abducted.

 The knees should be straight.
 The feet should be plantigrade.
Positioning for function
 Improve exhalation and breath control for
speech can often be obtained in prone lying
or standing.
Balance exercises
 Head and neck control in prone lying
 Trunk control in sitting
 Standing balance by weight shifting
 Adaptive device and orthotic may be used as

HKAFO, KAFO, AFO, cervial collar, walking

aids etc.
Muscle strengthening
 By hydrotherapy
 Whirlpool bath
 Suspension therapy
 Active free exercise (with some resistance)
 Physio ball can also be used.
Passive stretching
 Hip adductors, quadriceps, hamstrings,
tendoachilles, calf muscles, biceps, triceps,
abductors and adductors of shoulders
 Neck extensors
15 modules
 Specific combination of these modules is used
for specific type of cerebral palsy
 Module 1 : massage for hypotonic muscle but
this is contraindicated in spastic and athetoid.
 Module 2 : passive motion through joint range
for mobilising the joints
 Module 3 : Active assisted movements
 Module 4 : Active motion
 Module 5 :resisted motion is followed
according to child’s ability
 Module 6 : conditioned motion is
recommended for babies, young children and
children with certain degrees of MR.
 Module 7 : confused motion which involves

resistance to a muscle group in order to

contract an inactive muscle. Mass movements
such as extensive thrust or the flexion
withdrawal reflex are usually used.
 Module 8: combined motion is the training

motion of more than one joint such as

shoulder and elbow flexion using the
modules 2,3,4 and 5.
 Module 9 :relaxation techniques are those of
conscious letting go of the body and its
parts. these methods are usually used with
the athetoid type of cerebral palsy.
 Module 10: movement from relaxation is

conscious control of movements, once

relaxation has been achieved. It is mainly
used in children to control involuntary
movements.
 Module 11 :rest periods of rest are suggested

for all types of cerebral palsies.

 Module 12: reciprocation : it is the training
movement of one leg after another in a
bicycling pattern
 Module 13 : balance : the balance is aimed to
be achieved in all positions possible. For eg
training of sitting balance, training to stand
with the help of braces.
 Module 14 : reach grasp and release is used for
training of hand function
 Module 15 : skills of daily living such as
feeding, dressing washing and toileting are
mastered. Many aids can also be achieved for
achieving independence in ADL’s.