CEREBRAL PALSY An introduction Posture Reflexes Management Farjad Afzal Physical therapist

BASIC TERMS Cell: cell is structural and functional of body Cell tissues organ system Neuron=nerve=brain=nervous system Neuron: structural and functional unit of nervous system Tone: ability to muscle contract Spasticity: increased tone, tight muscle(one group) Rigidity :both group Reflex: involuntary action, no conscious control Posture: A position of the body or of body parts

NERVOUS SYSTEM

what is cerebral palsy? Cerebral palsy is defined as Disorder of movement and posture Non progressive Lesion in immature brain(fetal or infant brain) Features: 1.epilepsy. 2. involuntary movement 3. abnormal sensation & cognition 4- abnormal vision , hearing & speech. 5- mental retardation. 6. abnormal movement / behavior.

LITTLE'S DISEASE 150 years ago described by Dr. Little an orthopedic surgeon known as Littles Disease Lesion results in paralysis, weakness, incoordination or abnormal movement

Possible Indicators of Cerebral Palsy After two months: 1. poor head control 2. stiffness in the legs that cross or scissors when picked- up 3. pushing away, arching pack 4. failure to smile by 3 months After six months: 1. Continued difficulty controlling head when picked up 2. Floppy or limp posture. 3. Feeding difficulties - persistent gagging or choking

possible indicators of cerebral palsy After 10 months: 1. Crawl by pushing off with one hand and leg while dragging opposite hand and leg. 2. Inability to sit unsupported After 12 months: 1. Inability to crawl. 2. Inability to stand without support. After 24 months: 1. Inability to walk. 2. Inability to push toys with wheels.

COMPLICATIONS: Spasticity Weakness Increase reflexes Clonus Seizures Articulation & Swallowing difficulty Visual compromise Deformation Hip dislocation Kyphoscoliosis Constipation Urinary tract infection

CAUSES: Prenatal (70%) Infection, anoxia, toxic, vascular, Rh disease, genetic, congenital malformation of brain Natal (5-10%) Anoxia, traumatic delivery, metabolic Post natal Trauma, infection, toxic

CAUSES.CONT. Brain injury can occur in the following periods: a. Prenatal b. Perinatal c. Postnatal PRENATAL PERIOD- where in most causes of CP occur. Intrauterine stroke Genetic malformations The most common currently understood causes are related to brain injury occurring in children born prematurely.

ETIOLOGY: POSTNATAL CEREBRAL INJURY AND CP Major causes: CNS infections Vascular causes Head injury Other Causes: Anoxia Ischemia Inflammation

CP: Epidemiology One of the most common disabling conditions affecting children. 1-2.3/1,000 live births Diagnosis is not made at any specific age Can resolve in up to 50% of children diagnosed prior to 2 years of age Or the brain insult might not occur until later in childhood.

RISK FACTORS ASSOCIATED WITH CEREBRAL PALSY GENERAL Gestational age < 32 weeks Birth weight 2/3 of patients with Quadriplegia (undernourished) 27% of patients malnourished Treatment: Gastrostomy Gastrojejunostomy tube

CHRONIC CONSTIPATION Neuromuscular control of the bowel Exaggerated by immobility and abnormal diet and fluid intake Treatment: Increase activity Increase fluid and fiber intake medications

Other problem: Gastroesophageal reflux: Urinary Symptoms: 1/3 of patients frequency, incontinence or difficulty urinating. Cognitive Impairments: 30% of patients- mental retardation Risk is directly proportional to severity of motor disability. 20-30% - have specific learning disabilities Seizure Disorders 1/3 of children with CP Hemiplegic> Quadri > Diplegic Reflects a greater extent of cortical brain injury Treatment: Antiseizure techniques

Other problem(cont.) Osteoporosis Secondary to the following factors: Feeding difficulties deficient Ca and Vit D Decreased weight bearing/ Immobilization Muscle stresses Antiseizure meds Weight percentile/ Low triceps skinfold Treatment: Ca and Vit D supplementation Bisphosphonates (Pamindronate)

FUNCTIONAL PROGNOSIS

Functional Prognosis Children typically develop motor skills craniocaudally. The age at which these skills are developed help to predict the eventual outcome.

PROGNOSIS for AMBULATION Hemiplegics/ Ataxic pxs Achievement of all motor skills by age of 8. Independent sitting before 2 years Persistence of fewer than 3 of the primitive reflexes at age 18 months. Quadriplegics Did not attain independent sitting by age 4. Persistence of primitive reflexes beyond 18 months GOOD Prognosis POOR Prognosis

Interventions

Intervention Philosophies & strategies Neurodevelopmental Therapy ( NDT) Moving through normal movement patterns to experience normal movement Major components : reflex-inhibiting posture, inhibition of abnormal reflexes, normalization of muscle tone, and adherence to normal developmental sequence of motor progression

NDT Inhibiting abnormal movement patterns. Facilitating normal movement patterns. No strong evidence that supports the effectiveness of NDT for children with CP with respect to normalizing muscle tone , increasing rate of attaining motor skills, and improving functional motor skills Butler C, Darrah J: Effects of Neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence report. Dev Med Child Neurol 2001 ; 43: 778 - 790

AlWasl Hospital - Rehabilitation Section

Sensory Integration Therapy Principle: a neurobiological process organizes sensation from ones own body and from environment and makes it possible to use the body effectively within environment Emphasis on importance of three body centered sensory systems : tactile , proprioceptive & vestibular

SI Therapy

Constrained - Induced Movement Therapy Constraining non-affected arm to encourage performance of therapeutic task with the affected arm, which children normally tend to disregard. Systematic review has found the effectiveness of CIMT for children with hemiplegic CP.

Serial casting Serial casting may serve to reduce spasticity in muscles by decreasing the strength of abnormally strong tonic foot reflexes.(Bertoli 1996). Serial casting in the CP population has been shown to improve ROM.( Brouwer 2000) Casting provides stability and prolonged stretch of a muscle which is immobilized in a lengthened position(Mosley 1997). At least 6 hrs of prolonged stretch is needed for effectiveness(Tardieu 1987).

Botox + serial casting Botox reduces spasticity and improves ambulatory status.(Flett 1999) When used in combination with serial casting it has shown to help maintain and improve muscle length and passive ROM.(Kay 2004) Without conservative interventions such as serial casting, (with & without botox injection) more expensive procedures may be necessary. (Flett 1999)

Body Weight Supported Treadmill Training Uses theories of motor learning & importance of early task specific training Theory : activate spinal & supraspinal pattern generators for gait

Strengthening Progressive resisted exercise improves muscle performance & functional outcomes in CP children Research had supported effectiveness on increasing force production in CP Dodd et.al. systematic review of strengthening for individuals with cerebral palsy . Arch Phys Med Reh,83:1157-1164, 2002

Intervention Philosophies & strategies NMES Multiple studies have demonstrated the effectiveness of NMES, Reduce spasticity. Increase ROM & strength. Increase force production. Promote initial learning of selective motor control.

Orthotic devices , splints , cast Goals : Maintenance or increase ROM Protection or stabilization of a joint Promotion of joint alignment Promotion of function

Ankle Foot Orthosis Compared with barefoot gait, AFOs enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature PF and improved progression of foot contact during stance.

Assistive Technology & Adaptive Equipment Optimizes alignment, posture & function. Inhibits spasticity patterns. Facilitates more normal movement.

Adjunct therapies Hippotherapy. Aquathearpy. suits. Theratogs.

Speech & Language Therapy Oralmotor function using strengthening / Intraoral stimulation verbal ( PROMPT) & non-verbal communication skills ( PECS ) auditory training for HI audiometry screening swallowing function

Intervention Philosophies & strategies Psychological Assessment & Management Social support

Cerebral palsy and posture

Posture is the extent to which the body is maintained in alignment with a variety of positions.

81 Feet flat on floor or footrest Knees at 90 o Head is upright Ideal Posture Table at elbow height Pelvis in neutral 90 degree RULE

Normal postural tone Normal patterns of movement Success in normal patterns of movement repetitions Normal functional Skills achievements

CP? Abnormal postural tone Abnormal patterns of movement Success in abnormal patterns of movement/ stereotyped repetition Deformity/ less functional skills acheivments

1. Head and neck 2. Shoulders and shoulder girdle 3. spine 4. Hips and pelvis Key Points of Control

Sitting

Positioning is key for normalization of tone.

Use of Adaptive Equipment for Positioning

Is it a right posture of child?

So what is correct way?

How to sit in washroom?

Corrective sitting: erect head erect neck back supported and erect foot suppotrted

Focus on backalways

Change positions frequently

How to grip a child?

standing

What to correct?

Child is shifting to side

Standing with head down and round back affecting the spine.

Locked standing back locked hip locked knee locked ankle locked

Identify what wrong here?

Reflexes and cerebral palsy

Reflex action:

Stimulus / Response S: Palm stimulated R: 4 fingers (not thumb) close Duration 5 months gestation - 4 months postpartum Concerns No palmer grasp may indicate neurological problems (spasticity) Other One of the most noticeable reflexes May lead to voluntary reaching / grasping May predict handedness in adulthood Primitive Reflexes ~ Palmar Grasp

Stimulus / Response S: touch of lips R: sucking action Duration In utero - 3 months postpartum Concerns No reflex problematic for nutrition Other Often in conjunction with searching reflex Primitive Reflexes ~ Sucking

Stimulus / Response S: Suddenly but gently lower babys head S: Hit surface beside baby R: Arms and legs extend Duration Prenatal 4-6 months postpartum Concerns May signify CNS dysfunction if lacking May signify sensory motor problem if persists May delay sitting & head control if persists May indicate injury to one side of brain if asymmetical Other Reaction time increases with age Preceeds startle refle Primitive Reflexes ~ Moro

Positive supporting

Stimulus / Response S: Prone/supine position, turn head to one side R: Limbs flex on one side, extend on other side Duration After birth 3 months Concerns Facilitates bilateral body awareness Facilitates hand-eye coordination Other Also called bow and arrow or fencers position Primitive Reflexes ~ Asymmetric Tonic Neck

Stimulus / Response S: Baby sitting up and tip forward R: Neck and arms flex, legs extend S: Baby sitting up and tip backward R: Neck and arms extend, legs flex Duration After birth 3 months Concerns Persistence may impede many motor skills and cause spinal flexion deformities Primitive Reflexes ~ Symmetric Tonic Neck

Fine motor

Major normal milestones (average age) Gross Motor Fine motor & vision Hearing & language Social 6 weeks Head level with body in ventral suspension Fixes & follows Stills to sound smiles 3 months Head at 90deg in ventral suspension Holds object placed in hand Turns to sound at ear level Laughs & squeals Hand regard 6months No head lag. Sits w support. Up on forearms when prone Reach w palmar grasp. Transfers between hands Babbles Works for toy May finger feed 9 months Crawls Sits steadily & pivots Pincer grasp, index finger approach, bangs 2 cubes 2 syllable babble. Distraction hearing test possible Waves bye-bye Pat-a-cake Indicates wants

Major normal milestones (2) Gross motor Fine motor & vision Hearing & language Social 12 months Pull to stand, cruise, stand alone. Walks alone (13m) Puts block in cup. Casting 1-2 words Imitates activities, plays ball, object permanence 18 months Walks well & runs Tower of 2-4 cubes. Scribbles 6-12 words Uses spoon, helps in house, symbolic play 24 months Kicks ball. Climbs stairs 2 ft /step Tower of 6-7 cubes. Circular scribble Joins 2-3 words 5-6 body parts Identifies 2 pictures Removes a garment 36 months Throws overarm, stairs 1 ft/step, stands briefly on 1 ft Tower of 6 cubes, 3 brick bridge, copies circle, cuts w scissors Sentences, names 4 pictures Eats w fork & spoon. Puts on clothing. Names friend

Palmar grasp: A palmer grasp appears once the grasp reflex has disappeared, at around 4 months. The whole fist is first used in this grasp- the palm covers the object and the fingers then curl around the object intentionally. The child is able to let go of the object when they want to.

Drawing and Writing Palmar grasp (power grip) < 3 years of age Fingers and thumb wrap object Movement guided by shoulder and arm Figure

Pincer grasp: A pincer grasp occurs next as the fingers become more controlled. The pincer grasp is useful for picking up small objects and uses the index finger (the first finger) and the thumb together in a pinching motion.

Tripod grasp: A tripod grasp follows where a thick crayon or piece of food is held with the fingers in a tripod style with two fingers and the thumb.

Pencil grasp: Finally, a pencil grasp develops. This enables the child to have greater control over their drawing or writing implement.

149 Development of Pencil/Crayon Grasp Least Mature Grasp Most Mature Grasp

Hand Strength The following activities promote development of strength in the small muscles of the hand and the muscles of the forearm. Adequate hand strength is essential for maintaining grasp (eg holding pencil and drawing/writing for long periods) and manipulating objects with our fingers. Activity ideas: Scissor activities Squeezing clothes pegs Painting with spray bottles Squeezing tubes Hammering Using pop beads and other interlocking toys kneading dough Using tweezers/tongs to pick up objects/materials Play musical instruments Using stapler and hole punch in craft activities Tearing and crumpling paper Squeezing sponges Screw/unscrew jars

Using water pistol Using wind up toys Putting buttons into an opening of tennis ball Playdough activities: Rotate a small ball of plasticine with finger tips; roll plasticine into a sausage shape using fingers, not palm; Hold up playdough sausage and pinch between index finger and thumb without breaking sausage; Pinch playdough into a peak using three fingers; Cutting playdough with scissors; Interweave a large rubber band between fingers and stretch fingers. Pick up beads between fingers and drop one by one.

Finger isolation The term finger isolation refers to the ability to use certain fingers in isolation from the rest of the hand/fingers. It is an important skill for children to develop as it increases and improves their ability to control their pencil when writing and drawing. Activity ideas: Draw in wet sand with finger (eg index finger) Finger painting Finger puppets Music keyboard Push button activities Using eye-dropper for painting Picking up coins & cards Sprinkling rice ,sand etc Card games Spray bottles Intrinsic colouring-in Playdough activities Using stickers as part of activity (peel off backing & place down)

29/07/2014 153 Midline Crossing Midline - A line between the eyes, separating the body into left and right sides. Midline crossing the ability to use one side or part of the body (hand, foot or eye) in the space of the other side or part. Problems with: Using cutlery, scissors, reading, handwriting and copying from the board.

29/07/2014 154 Bilateral Integration The ability to use both sides of the body together in a smooth, simultaneous, and coordinated manner. If a child has problems crossing the midline, coordinating the two sides together will be problematic.

155 Seating Position

156 7 Steps to Fine Motor Success 1. Stability of trunk, shoulder and elbow 2. Wrist extension 3. Grasp (pincer and tripod) & release 4. Arches of the hand/separation of 2 sides of the hand 5. Finger isolation 6. Thumb opposition and web space 7. In hand manipulation Stability before mobility

157 Start with Position Check how child is positioning him/herself for the activity. Do they have adequate support? When postural control is affected, arm movement and fine motor control are often impacted. May see: Rounded back, resting head on hand, resting trunk forward on desk, constant repositioning, leaning on walls, friends or teachers.

158 Positioning Strategies At the table: (sometimes easier said than done!) Feet flat on the floor, hips/knees bent at 90 Table height, about 2 inches above the level of the elbows Placing items on a slanted surface or working in vertical may encourage more upright posture.

159 Positioning Strategies On the floor: Cross legged sitting more stable than long sitting or side sitting Back supported against a wall may be best for some children Mats/carpet pieces to provide some cueing as to boundaries

160 Fine Motor Pre-requisites Good general trunk tone and strength for good position and alignment. Adequate shoulder, arm and wrist strength in order to stabilize and use the fingers. Bilateral coordination between the helping hand and the doing hand.

POSTURE AND OUR BODY

Some exercises that keep your postural muscle tone up.

Thankyou