CEREBRAL PALSY (DIPLEGIC SPASTIC)
1. Introduction
Cerebral palsy is a disorder of movement and posture that appears during infancy
or early childhood. It is caused by non-progressive damage to brain caused
before, during or shortly after the birth. CP is not a single disease but a name
given to a wide variety of static neuromotor impairment syndromes occurring
secondary to a lesion in developing brain. Any non-progressive CNS injury
occurring during first 2 years of life is considered to be CP.
It is the name given to a number of motor problems (trouble moving the body).
CP is usually caused by damage to the brain during early childhood. It is called
"cerebral palsy" because the part of the brain that is damaged is the cerebrum. It
is a group of permanent movement disorders that appear in early childhood.
CP was first identified by an English surgeon called William little in 1860.
There are several types of cerebral palsy. The most common type is spastic
cerebral palsy. Spasticity is defined as an increase in the physiological resistance
of muscle to passive motion.
In diplegic spastic type, both upper limbs are affected and upper extremity is less
involved. Cerebral palsy is characterized by abnormal muscle tone, reflexes, or
motor development and coordination. Children with CP may also have sensory
processing issues.Adults with cerebral palsy have a higher risk of respiratory
failure.
2. EPIDEMIOLOGY
Prevalence rate of CP in India is 3 per 1000 live births. Today, 1 in every 400
children in the UK has cerebral palsy. In the last 40 years the prevalence of CP has
risen to well above 2.0 per 1000 life births.
An average of 55.5% of people with cerebral palsy experience lower urinary tract
symptoms, more commonly excessive storage issues than voiding issues. Those
with voiding issues and pelvic floor over activity can deteriorate as adults and
experience upper urinary tract dysfunction.
Population-based studies from around the world report that the prevalence
estimates of CP range from 1.5 to more than 4 per 1,000 live births or children of
a defined age range. The overall birth prevalence of CP is approximately 2 per
1,000 live births.
3. Pathophysiology
Cerebral palsy is caused by an abnormality or disruption in brain development,
most often before a child is born.
Gene mutations, infections, fetal shock, bleeding into brain, infant infections, lack
of oxygen, traumatic brain injury all these are risk factors in infant for CP.
Mother or maternal factors are any viral infection, malnutrition, etc. In CP brain
damage can occur during one of the following periods:
a. Prenatal period – conception to the onset of labour
b. Perinatal period- 28 weeks intrauterine to 7 days
c. Postnatal period- first 2 years of age
1. Literature review
● Mahendrarana, 2017. A Systematic Review on Treatment of Cerebral
Palsy, advised Progressive resistance training program, for improving joint
mobility, a range of motion exercises, Static and gentle stretches.
● Synnove.2009. Physiotherapy treatment of children with cerebral palsy:
The complexity of communication within sessions and over time, advised
weight bearing exercises muscle strengthening, functional exercises
including passive stretching.
● Julieanee P Sees, etal.2013, Journal of children’s Orthopaedics, “Overview
of foot deformity management in children with cerebral palsy”. In CP the
most common deformity is Equino varus which present in large majority
of children with CP at the beginning of standing and walking. The
Equinovarus is easily managed with daytime planter Flexion controlling
Orthotics (AFO).
● Dilip. R. patelherapeutic interventions in cerebral palsy. These include:
sensory integration, body-weight support treadmill training, conductive
education, constraint-induced therapy, hyperbaric oxygen therapy, and
the Vojta method.
NAME – XYZ
AGE – 2 Year and 3 months
SEX- M
FATHER OCCUPATION: - work in gas agency
ADDRESS - Muralipali
Chief complaints: -Unable to hold his neck properly, unable to sit and stand
properly
Prenatal history – not any complication
Perinatal history- Normal delivery at hospital after 9 months of gestation period
Birth cry was delayed by (4-5 hrs)
Birth weight- 1.5 kg
Post natal history
Admitted in NICU for 10 days
Seizure after 2 months of birth
Family history- non Consanguineous marriage, and no relevant other family
history.
Mother and Father Age was 20 and 21years at the time of child birth
Socioeconomic history - belongs to a middle class family
Environmental history – living in a small house at village
Source of water- water supply
Developmental history
Able to take turn from supine to prone and vice versa achieved at the age of 2
years
Crawling, standing and walking are yet too achieved.
Observation
Child came in his mother’s lap
Poor neck control
Can identify parents easily
LL bilaterally in adducted, externally rotated, knees flexed and foot in plantar
flexion
Social smile is present
Examination:
Higher mental function:
Vision: normal
Hearing: normal
Speech: monosyllabic words
MOTOR EXAMINATION:
TONE: hypertonic (measured by a modified ashworth scale)
Right lower limb (G2), Left lower limb (G2)
DEEP TENDON REFLEXES:-
BICEPS JERK RIGHT(++) LEFT(++)
TRICEPS JERK (++) (++)
KNEE JERK (+++) (+++)
ANKLE JERK (+++) (+++)
Babinski sign: present
VMC- fair
Clonus: Absent
Tightness/contracture/deformity- Bilateral TA, hamstring and adductors of hip
Functional abilities- able to hold his neck for 10-15 seconds 3 month ago
can point towards any object
able to sit on a chair with support and is achieved at the 2
year of age
able to hold cylindrical object
Provisional diagnosis- diplegic spastic CP
Short term goals
● Improve neck control and trunk control
● Overcome the primary disability
● Prevention of further worsening of condition
● Reduce spasticity
Long term goals
Educational goal
Self care and independency
Maximizing quality of life
Treatment protocol:
Functional stretching with NDT
Co-contraction of neck muscles
Hamstring stretching (oscillatory with 15-20 seconds hold)
Hip adductors stretching (oscillatory with 15- 20 seconds hold)
Standing is done with standing frame
Gentle rhythmic ROM exercises
Trunk extension exercise including rolling on ball
Sitting with support
Customised CP wheel chair for sitting at home is advised
Reference
● Mahendrarana et al. A Systematic Review on Etiology, Epidemiology, and
Treatment of Cerebral Palsy.2017: 76-83(7).
● Synnove et al. Physiotherapy treatment of children with cerebral palsy: The
complexity of communication within sessions and over time. 2009: 41-52.
● Julieanee P sees et al. 2013.Journal of child orthopedics "overview of foot
deformity management in children with cp".
● D.R. Patel 2005.Therapeutic interventions in cerebral palsy. Indian J
Pediatr ,979–983 (72)
