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

HistoryFormerly 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

EpidemiologyThe incidence of CP is about 2 per 1000 live

birthsThe incidence is higher in males than in

femalesOther 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 CPPrenatal (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 AsphyxiaMaconeum aspiration Birth trauma Disproportion Breech delivery Rapid delivery Low birth weightCoagulopathy

Post natal Brain damage secondary to cerebral

hemorrhage, trauma, infection or anoxiaMotor vehicle accidents Shaken baby syndrome Drowning Lead exposure Meningitis Encephalitis

Additional risk factors for CP include ◦Kernicterus◦methyl mercury exposure◦genetic causes

Classification of CPDepending 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 CPIt 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 CPIt is mixed muscle tone Often show involuntary motionsThe damage occurs to extrapyramidal

motor system & pyramidal tractIt occurs in 10% to 20% of all casesIn 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 CPIt is caused by damage to

cerebellumThey are least common types of

CP, occurring only in 10% of all cases

Some of these individuals have hypotonia and tremors

Hypotonic CPHypotonic 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

pathologyPeriventricular leukomalacia (PVL) is the

most common finding in CPCorticospinal 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)

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

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

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, hemiballismic, rigid

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

risk babies Biological risk 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 & 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

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 parentParental 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 screeningRoutine 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

DiagnosisThe 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

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

Bony correction E.g. femur (termed femoral anteversion or antetorsion) & tibia (tibial torsion). 2ndary complication caused by spastic muscles generating abnormal forces on bones

PrognosisCP is not a progressive but the symptoms

can become more severe over timePrognosis 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)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.

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 to compete with a disability

Prediction of ambulation

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

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

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

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

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

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

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

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

◦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

◦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

◦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

◦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

◦ 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

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

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

Motor integrity ◦Abnormalities of tone

Spasticity, hypotonicity, dystonia etc◦Muscular weakness ◦Loss of voluntary control ◦Decreased co ordination

Reflex integrity ◦Abnormal DTR ◦Abnormal Superficial reflexes ◦Abnormal primitive reflexes may be

persistent ATNR, Extensor thrust, gallant reflex etc

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)

◦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 PoundsAt birth 3.25 73-6 months Age in months +9/2 Age in months + 111-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+177-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5

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

Head circumference of the child -

◦The tape is used to measure occipitofrontal head circumference from external occipital protuberance to glabellaHead

cicumferenceCm

At birth 353 months 401 yr 452 yrs 4812 yrs 52

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

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

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

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

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 CPProvide support in their acceptance of child Goal setting & programming should be done

with family Be realistic about the prognosis & efficacy of

PT while remaining hopefulHonesty & 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 Position in a propped up sitting for feeding For greater hip stability & symmetry during

feeding position in a high chair with adaptationHead & 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 chair

Practice midline play, reach for feet, suck on fingers

Do not give too many stimuli at onceCarefully 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 imageTouch, 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 usedDelay 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 existsUse 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 MFRROM 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 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

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 CPOromotor 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

Characteristics Score 0 Score 1 Score 2 Acronym

Skin color/ Complexion

Blue or pale all over

Blue at extremitiesbody 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

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.