CEREBRAL PALSY

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
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, speech,
bowel-bladder, & orthopedic
deformities
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
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
 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%
 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.
Causes of CP
Prenatal (70%)
Peri-natal (5-10%)
Post natal
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
Peri- natal
 Prematurity- immature respiratory & cardiac
function
 Asphyxia
 Maconeum aspiration
 Birth trauma
 Disproportion
 Breech delivery
 Rapid delivery
 Low birth weight
 Coagulopathy
Post natal
Braindamage secondary to cerebral
hemorrhage, trauma, infection or anoxia
Motor vehicle accidents
Shaken baby syndrome
Drowning
Lead exposure
Meningitis
Encephalitis
Additional risk factors for CP
include
◦ Kernicterus
◦ methyl mercury exposure
◦ genetic causes
Classification of CP
Depending on the topographical
distribution
◦ Monoplegic
◦ Diplegic/ Paraplegic
◦ Triplegic
◦ Hemiplegic
◦ Tetraplegic / Double hemiplegia
 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
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
Depending on tone or movement
patterns (physiologic)
◦ Spastic
◦ Athetoid/ dyskinetic
◦ Ataxic
◦ Flaccid/ Hypotonic
◦ Mixed
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.
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
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
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.
Mixed CP
Signs & symptoms of spastic CP is
seen with any other type of CP
◦ Most commonly mixed with Athetoid
Depending on functional level (Gross
Motor Function Classification System)
◦ It classifies acc to age categorized
activity level
 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)
 Bilirubinencephalopathy 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
 Signs & symptoms (spastic)
 Hypertonia  Synergisticpattern
 Exaggerated  Contracture, deformity &
reflexes &
+ve barbinskis wasting
 Clonus ◦ Adduction & IR of shoulder
◦ Flexion of elbow &
 Poor voluntary movement pronation of forearm
 Scissoring gait ◦ Wrist flexion & thumb
 Low intelligence & loss inside hand
◦ Flexion & adduction of hip
of memory ◦ Knee flexion
 Epilepsy ◦ PF of ankle
 Extrapyramidal CP
 May affect limb, face, tongue  Decreased stability
& speech  Difficulty to look up
 Characterized by continuous  Emotional liability
muscular worm like movement  Arms are more affected
 Postural instability
 Sucking & feeding problems
 Decreased movement in
prone position
 Delayed head & trunk
control
 Fluctuation of tone from high
to low
 May be either quadriplegic
 Reflexes are usually normal & or rarely hemiplegic
muscles are able to contract  Subtypes - dystonic,
athetoid, choroid,
hemiballismic, rigid
 Ataxic / hypotonic
 Inco-ordination  Joint hypermobility
 Intension  Dysmetria
tremor
 Incontinence
 Hypotonia
 Postural instability
 Nystagmus
 Gait disturbances
 Diminished reflexes  Imbalance & lack of
 Speech, visual,
trunk control
hearing & perceptual  Unsteadiness
problems 
risk babies
Biologicalrisk
Established risk
Environmental & social risk
 Biological risk
 Birth weight of 1500g or less
 Gestational age of 32 weeks or less
 Small for gestational age (less & 10 th 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
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
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)
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
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
 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
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
Post natal screening
Starts in the immediate neonatal
period & during the first two years
◦ To find biochemical defects
◦ Hearing & visual problems
Clinical methods (at birth)
◦ Examination of weight, height, head
circumference
◦ Gestational age
◦ Musculoskeletal defects
◦ Testicular descent
◦ At 6 weeks repeat test
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
Electronic scanning
◦ USG, CT Scan, MRI
 To find out AVM, hemorrhage, cyst,
leucodystrophies etc
 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.
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
Children often change their clinical
signs & symptoms & their respective
disabilities
The disorder is not progressive, but
the presentation of involvement of
body segments may manifest
differently as child grows & his or
her structure changes against gravity
 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)
Management
Medical
Surgical
Rehabilitative
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
 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
 Bonycorrection E.g. femur (termed femoral anteversion or
antetorsion) & tibia (tibial torsion). 2ndary complication
caused by spastic muscles generating abnormal forces on
bones
 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
 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)
 Theability 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.
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
 Notable persons
Abbey Curran, American beauty queen
with CP who represented Iowa at
Miss USA 2008 and was the first
contestant with a disability to compete
Stephen Hopkins, signer of USA
Declaration of Independence, reputed to
have stated, "My hand trembles but my
heart does not."
Prediction of ambulation
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
Observation
◦ 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
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
Cranial nerve integrity
◦ Strabismus or squint (Occulo motor
nerve)
◦ Visual defects (optic nerve)
◦ Auditory defects (auditory nerve)
◦ Feeding & swallowing problems (lower
cranial nerves) etc.
Special senses
◦ Visual & auditory defects
◦ Tactile & vestibular hyposensitivity or
hypersensitivity
Sensory integrity
◦ Superficial sensation are usually intact
◦ Proprioceptive sensation may be
affected due to improper weight
bearing & muscle control
◦ Cortical sensations may be affected or
inaccurate
Reflex integrity
◦ DTR are exaggerated
◦ Superficial reflexes are absent
◦ Abnormal primitive reflexes may be
persistent
 ATNR, Extensor thrust, gallant reflex etc
Motor integrity
◦ Abnormalities of tone
 Spasticity, hypotonicity, dystonia etc
◦ Muscular weakness
◦ Loss of voluntary control
◦ Decreased co ordination
ROM & flexibility
◦ Decreased in the ROM of the involved
limbs
◦ Tightness & contracture in hip
adductors, hamstrings, calf are very
common
Anthropometric measurement
◦ Height or length decreased (growth
retardation)
◦ Weight – decreased (thin & lean) or obese
◦ Head circumference – decreased (growth
retardation or microcephaly), increased
(hydrocephalus)
Posture
◦ Poor posture in all types of CP
◦ Kypho-Scoliosis, knock knee & flexion
deformity & inverted flat foot are
commonly seen
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
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
Functional capacity
◦ Varies from complete dependence to
complete independent
PT MANAGEMENT
INFANCY
(FIRST STAGE – BIRTH
TO 3 YEARS)
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
 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
 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
 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
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
 Feeding & respiration
Positionin 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
 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
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
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
 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
 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
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.
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.
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
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.
 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
PRESCHOOL PERIOD
Main aim is to reduce the primary
impairments & prevent the
secondary impairments
 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
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
Reduce spasticity
Positioning in anti synergistic pattern
Stretching of tight structures
MFR
ROM exercise
Rhythmic rotations
Splinting & serial casting
Dorsal rhizotomy
Botox injection
 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
Prevent deformity
SerialCasting 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
 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
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
 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
SCHOOL AGE &
ADOLESCENCE
 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
 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
Barriers s/a transportation, finances,
time preferences & involvement,
interest should also be considered
carefully
Injury prevention will limit impairment
& disability
TRANSITION TO
ADULTHOOD
 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
 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
 Apgar score
Characteristics Score 0 Score 1 Score 2 Acronym

Blue at extremities No cyanosis-

Skin color/ Blue or pale all
body pink body & extremities Appearance
Complexion over
(acrocyanosis) pink

Pulse rate Absent <100 ≥100 Pulse

No response to grimace/feeble cry cry or pull away

Reflexirritability Grimace
stimulation when stimulated when stimulated

flexed arms & legs

Muscle tone None some flexion Activity
that resist extension

weak, irregular,
Breathing Absent strong, lusty cry Respiration
gasping
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.