Cerebral Palsy

CEREBRAL PALSY BY GOWRI SHANKAR POTTURI B.PT, M.PT [NEUROLOGY], MIAP

DEFINITION IT IS A NEUROMOTAR DISORDER RESULTING FROM NON-PROGRESSIVE DAMAGE TO THE DEVELOPING BRAIN.

CAUSES •

•

•

PRENATAL •

‘TORCH’INFECTIONS[Toxoplasmosis,rubella,cytomegalovirus,herpis simplex virus

•

SMOKING/ALCOHOLISM

•

DIABETIS/HYPERTENSION

•

FALL

•

CONSANGINIOUS MARRAIGES

•

RH INCOMPATIBILITY

•

DRUG ADDICTED MOTHER

PERINATAL •

FORCEPS DELIVERY

•

BREECH PRESENTATION

•

PREMATURE DELIVERY

•

ENTANGLING OF PLACENTA AROUND THE NECK

POSTNATAL •

JAUNDICE

•

FALL FROM HEIGHT

•

NEONATAL INFECTIONS Eg:meningitis

CLASSIFICATION OF CEREBRAL PALSY •

•

CLINICAL CLASSIFICATION •

SPASTIC

•

ATHETHOID

•

ATAXIC

•

FLACCID

•

MIXED

TOPOGRAPHICAL CLASSIFICATION •

QUADRIPLEGIC

•

HEMIPLEGIC

•

PARAPLEGIC

•

MONOPLEGIC

•

DIPLEGIC

CLINICAL TYPES SPASTIC CEREBRAL PALSY:
Increased tone in muscles
Also called hypertonic kids
May involve all the limbs or half of body
They have fear of fall so should never be treated on beds or couches
Increased tone results in faulty postures resulting in contractures &deformities ATHETOID CEREBRAL PALSY:
There will be irrhthymical,irregular,jerky purposeless ,involuntary writhing movements
Athetoid movements are present at rest ,increases on activity &decreases at rest
These kids may have normal IQ and can be sent to normal schools

ATAXIC CEREBRAL PALSY
These kids lack balance & equilibrium
Coordination is lost
Shows no interest in activities
Fear of fall is high FLACCID CEREBRAL PALSY:
These kids are also called as FLOPPYKIDS.
The kids are having low muscle tone[hypotonic]
Usually mentally retarded
Joint sublaxations are common due to decreased muscle tone.

CLINICAL FEATURES ABNORMAL TONE ABNORMAL REFLEXES DISTURBED HIGHER FUNCTIONS SENSORY DISTURBANCES DELAYED MILE STONES CONTRACTURES &DEFORMITIES RESPRATORY&ORO-MOTAR DYSFUNCTION DYSMORPHIC FEATURES MENTAL RETARDATION

MULTIPLE ASSOCIATED DEFICITS MENTAL RETARDATION CONVULSIONS VISUAL DEFICITS HEARING DEFECTS PERCEPTUAL PROBLEMS LEARNING DISABILITIES FEEDING PROBLEM EMOTIONAL &BEHAVIOURAL PROBLEMS SPEECH &LANGUAGE DISORDERS DYSMORPHIC FEATURES LOW SET EYES AND EARS FRONTAL BOSSING DELAYED CLOSURE OF ANTERIOR FONTANELLAE CLEFT LIP /CLEFT PALATE EXCESSIVE DROOLING OF SALIVA IRREGULAR DENTITION

EARLY INTERVENTION OF CEREBRAL PALSY “It is always a known fact that ‘EARLY INTERVETION –BETER PROGNOSIS” As the age at which diagnosis is made goes on increasing ,secondary complications of developmental delay come into picture. Therefore the CP child should receive therapeutic intervention as early as possible The earliest intervention is immediately after birth The neonate is seen by the therapist earliest in NICU where baby is admitted for medical complications

When neonate is referred to physiotherapist before starting the therapeutic intervention assessment of the infant has to be carried out.

ASSESMENT OF C.P Assessment starts with history .Detailed history of prenatal/peri natal & postnatal risk factors has to be obtained from either from mother or from medical records APGAR SCORE It is a quantitative method for assessing infants respiratory ,circulatory , & neurological status immediately after the birth Timing : 1min,5min,10-20 min after the birth SCORING OF APGAR S.NO

FACTOR

SCORE=0

SCORE=1

SCORE=2

1

HEART RATE

ABSENT

LESS THAN 100 BEATS /MIN

MORE THAN 100 BEATS /MIN

2

RESPIRATORY EFFORT

ABSENT

SLOW ,IRREGULAR CRY

GOOD CRY

3

MUSCLE TONE

LIMP

SOME FLEXION IN EXTREMITIES

ACTIVE GOOD FLEXOR TONE

4

RESPONSE TO CATHETAR

NO RESPONSE

GRIMACE

COUGH/ SNEEZE

5

COLOUR OF BABY

BLUE/PALE

BODY PINK &EXTREMITIES BLUE

COMPLETELY PINK

INTERVENTION OF APGAR SCORE APGAR score immediately after birth: SCORE

EFFECT

8-10

NORMAL

5-7

MODERATE ASPHYXIA

LESS THAN 4

SEVERE DISTRESS

As in new born ,extremities are always blue immediately after birth ,ideal score is never 10 at 1 min but 9

ILLING WORTH SCALE Along with birth asphyxia ,preterm babies also form a major group in cerebral palsy children Therefore a pre term infant should de identified from normal term infant Illingworth scale differentiate a pre term baby [risk baby] from full term baby. There are 14 factors present in the scale

S.NO

FACTOR

PRETERM

FULLTERM

1

SLEEP

DISTURBED SMALL SLEEP CYCLES

SOUND SLEEP

2

MOVEMENTS

FASTER/BIZZARE/UNCORDINATED

COORDINATED

3

CRY

CRY IS INFREQUENT/FEEBLE/

PROLONGED VIGOROUS CRY

NOT PROLONGD 4

FEEDING BEHAVIOUR

CANNOT RELIED UPON TO DEMAND FEEDS

CAN BE RELIED UPON FOR FEEDS

MAY BE UNABLE TO SUCK & SWALLOW

ROOTING/SUCKING/

REGURGITATION –CYANOTIC ATTACKS

SWALLOWING – NORMAL

5

MUSCLE TONE

LESS FLEXOR TONE

GOOD FLEXOR TONE

S.N

FACTOR

PRETERM

NORMAL

6

POSTURE OF BABY

PRONE: flat pelvis & knees at the side of abdomen

PRONE: pelvis high knees drawn up under abdomen

Acute flexion at hips SUPINE: lower limbs externally rotated & abducted Head turned to side

SUPINE: Limbs are strongly flexed .head aligned to trunk

7

HEAD ROTATION

Head can be rotated so far that chin is well beyond acromion

Chin can be rotated only as far as acromion

8

SCARF SIGN

Hand reaches beyond opposite acromion

Hand doesn't go beyond opposite acromion

WRIST FLEXION

Wrist flexion is incomplete There is a window between hand & forearm

Complete wrist flexion .no gap between palm & forearm.

s.No

FACTOR

PRE TERM

FULL TERM

10

GRASP

Less than 28 weeks it is weak

Strong palmar grasp

11

KNEE EXTENSION

When hip is flexed completely knee can be fully extended

After complete hip flexion knee extension is short of 20degrees

12

Dorsiflexion of foot

Dorsi flexion of foot is incomplete

Complete Dorsi flexion such that the dorsum of foot touches shin of tibia

13

Automatic walking

28weeks: feeble

Normal walk

9

32weeks:walks on toes 40 weeks walks with foot flat 14

HORIZONTAL SUSPENSION

Hangs limply no flexion of limbs

Flexes upper &lower limbs strongly

OTHER FACTORS REGARDING GENERAL CONDITION OF THE BABY s.no

Factor

value

1

Height of the baby

50 cms

2

Head circumference

34-35 cms

3

Chest circumference

Usually 3-4cms less than head circumference

4

Respiratory status

30-40 /min

5

Heart rate

120-140 beats /min

6

Birth weight

2.5-3.5 kg

VOJTA’S REACTIONS These are useful for diagnosis of brain damage in infants Dr.Vojta ,a German Pediatric Neurologist standardized 7 postural reflexes along with Neurological & behavioral assessment technique to diagnose the development of cerebral palsy in the neonate VOJTA’S REACTIONS THE 7 RECTIONS ARE AS FOLLOWS: 1]TRACTION 2]LANDAU 3]AXILLARY SUSPENSION 4] VOJTA’S SIDE TILT REACTION 5]COLLI’S HORIZONTAL SUSPENSION 6]PIEPER &ISBERT’S REACTION 7]COLLI’S VERTICAL SUSPENSION REACTION

VOJTA’S RECTIONS These reactions develop in which are dependent on the age of infant from 0-12 months Abnormal postural reactions indicate “disturbed central coordination” [DCC] The development of cerebral palsy depends upon the severity of DCC It is scaled as follows Mild DCC

→

3 or less than 3 abnormal reactions

Moderate DCC →

4-5 abnormal reactions

Severe DCC

6-7- abnormal reactions

→

AT BIRTH [OMONTHS] THE CHILD WILL SHOW 7 REACTIONS AS FOLLOWS S.NO

REACTION

ELICITATION & BODY PART TO BE OBSERVED

NORMAL RESPONSE

1

Traction

Infant is slowly pulled up from supine to an angle of 45 degrees

Complete head lag, but head does not fall on one side. Head remains in center lower limbs in mild flexion

Head & lower limbs are observed 2

Landau

Prone infant is held in horizontal suspension Head .spine, upper &lower limbs are observed

3

Axillary suspension

Infant is lifted in vertical suspension holding just below the axilla Lower limbs are to be observed

Head hangs in enter Spine, upper & lower limbs are in flexion

Mildly flexed

4

5

6

Vojta’s side tilt

Colli’s horizontal suspension

Pieper & Isbert’s vertical suspension

Vertically held infant suddenly tilted to lateral horizontal position

Overlying upper extremity MORO – RESPONSE

Overlying upper limb & lower limbs are to be observed

Lower limb flexed

Infant is suddenly suspended by ipsilateral upper limb &lower limb

Free upper limb

Free upper &lower limb is to be observed

Free lower limb flexion

The infant is held by its thighs & lifted suddenly head down in vertical position

Head hangs in the center

Head spine &upper limb is observed 7

Colli’s vertical suspension reaction

Infant is lifted up with one thigh ,head down Free lower limb to be observed

REFLEX MATURATION A REFLEX IS A STERO TYPED RESPONSE TO A STIMULUS REFLEX TESTING IS REQUIRED FOR -FOR EARLY INTERVENTION -LEVEL OF FUNCTION IDENTIFICATION -TREATMENT PLANNING

MORO –RESPONSE

Upper limb –MORO RESPONSE No response in spine

Flexion of lower limb

NEONATAL REFLEXES S.NO

REFLEX

AGE OF NORMAL PRESENCE

STIMULUS

RESPONSE

1

Doll’s eye reflex

Birth-10 days

Baby head is turned to one side

Eyes lag behind

2

Rooting reflex

Birth-3-4months

Light touch around lips

Turning of head, lowerlip&tongue on the side of stimulus

3

Sucking reflex &swallowing

Birth-3-4months

Place a finger on baby’s lips

Sucking movement of lips & swallows

4

Palmar grasp reflex

birth -4months

Pressure on palm of hand from ulnar side

Finger flexion with strong grip that persists & resists removal of stimulus

5

Plantar grasp

Birth-10-11 months

Strong pressure on ball foot

Flexion of toes

6

Placing of upper extremity

Birth -6 months

Brush the dorsum of one of baby’s hand against edge of the table

Flexion of upper limb with placement of hand on the table

7

Placing of lower extremity

Birth – 1 ½ months

Brush the dorsum of the foot against the under edge of the table

Flexion of the lower limb with placement of foot on the table top

8

Moro ‘s reflex

Birth – 3-4 months

Dropping the baby head

Abduction ,external rotation ,extension of

9

10

Automatic standing & walking

Birth- 1 ½ months

Gallant's reflex

Birth -36months

backwards from semi sitting position

arms &extension of fingers followed by adduction of arm to midline

Place the baby in the vertical suspension near to supporting surface &touch the feet to the ground

Extension of lower limbs as if baby is standing

In horizontal suspension stroke unilateral lumbar region with blunt object

Lateral flexion of trunk on the same side

If pelvis is rotated forwards then child will automatically put steps forward

SPINAL LEVEL REFLEXES S.NO

REFLEX

AGE OF NORMAL PRESENCE

STIMULUS

RESPONSE

1

Flexor withdrawl

Birth-2 months

Quick tactile stimulus applied to the sole of the foot

Uncontrolled flexion of hip & knee

2

Extensor thrust

Birth-2 months

One leg in extension &other fully flexion .apply pressure on the ball of the foot of flexed leg

Uncontrolled extension of same leg

g 3

Crossed extensor

Birth-2 months

One leg in flexion & other in extension. Give pressure on the ball of the foot of extended leg without allowing flexion of the same leg

The flexed leg extends

BRAIN –STEM REFLEXES S.NO

REFLEX

AGE OF NORMAL PRESENCE

STIMULUS

RESPONSE

1

ASYMMETRIC TONIC NECK REFEX[ATNR]

Birth-4 months

Passively turn the head 90 degrees

Increase in the extensor tone on face side &increase in flexor tone of limbs on occipital side

2

Symmetrical tonic neck reflex[STNR]

Birth-4-5 months

Sti1:Flex the child head bringing his chin towards chest

Res1:Flexion of upper extremities & extension of lower extremities

Sti2:extension of baby’s head

Res2: Extension of upper extremities & flexion of lower extremities

3

Tonic labyrinthine reflex

Birth-3-4 months

Patient in supine & prone position

Increase in flexor tone in prone position &extensor tone in supine

4

Positive supporting reactions

Birth- 6 months

Patient upright standing .firm contact on ball of foot to floor

Rigid extension of lower limbs resulting from cocontraction of flexors & extensors

MID BRAIN REACTIONS S.NO

REFLEX

AGE OF NORMAL PRESENCE

STIMULUS

RESPONSE

1

Neck righting reflex

Birth-months

In supine position turn the baby’s head to one side &hold it in that position

Body rotates on the same side as a whole [log rolling]

2

Labyrinthine righting

2month-life long

Baby is blind folded suspended in space by holding at pelvis .the baby is tipped sideways so that head is laterally flexed

Head brought into horizontal position

3

Body righting on head

6months-5years

Baby is blind folded & first placed in supine then in prone

The head is brought back to vertical position

S.NO

REFLEX

AGE OF NORMAL PRESENCE

STIMULUS

RESPONSE

4

Body on body righting

6months-4-5 years

Baby in supine ,passively turn the head to one side

Segmental rolling on turned side

5

Parachute reaction

6months – lifelong

Baby is held in prone suspension at pelvis ,push baby to the side with sufficient surprise & force that he/she believes his head will contact the supporting surface

Extension of all the four limbs

CORTICAL REACTIONS Equilibrium: Is tested on equilibrium board in all the functional positions or by pushing the baby from static posture. Equilibrium

Age attained

Prone

6months

Supine

8 months

Quadriped

8-10 months

Sitting

8-10 months

Kneeling

15 months

Standing

15-18 months

MANAGEMENT OF CEREBRAL PALSY AIMS : TO enable the baby to use his/her potential to maximum extent To enable the baby to have some kind of locomotion &interact with environment To enable him to have some kind of communication.

AIMS OF PHYSIOTHERAPY
DEVELOPING RAPPORT WITH PARENTS & BABY
MANAGEMENT OF ABNORMAL TONE
MAINTAINING THE LENGTH OF MUSCLE
DEVELOPING POSTURAL REACTIONS
SENSORY INTEGRATION
TRAINING THE RESPIRATORY &ORO-MOTAR FUNCTONS

PLANS OF PHYSIOTHERAPY
Developing rapport: developing rapport with the kid is very important as any goal will be difficult to achieve without the cooperation of the baby. The baby has to be motivated well enough to gain the confidence .The goals set for the baby must be challenging at the same time achievable
False appreciation must be avoided
Initially maximum support & feed back must be given
Never give false hope to parents
Explain the role of mother & teach the home exercises so that it can be carried at home as treatment of cerebral palsy is whole day management
Remember always the therapy should be play therapy .Try to include games or play items into the therapy or else the kid will not show interest in the treatment

MANAGEMENT OF ABNORMAL TONE HYPERTONICITY •

SLOW PASSIVE MOVEMENTS

•

SUSTAINED STRETCH

•

CRYOTHERAPY

•

FACILITATING THE OPPOSITE MOVEMENT

•

VIBRATIONS

HYPOTONICITY •

WEIGHT BEARING

•

JOINT COMPRESSIONS

•

RHYTHMIC STABILIZATION

•

VIBRATIONS

•

CRYOTHERAPY

•

TAPPING

MAINTAINING LENGTH OF THE MUSCLE Appropriate length of the muscle is a prerequisite to the normal control &normal postural adjustments In cerebral palsy ,because of delay or absence of normal movements ,muscles are usually in shortened state Stretching of the muscle is carried before the exercises Orthotic supports/night splints are given

DEVELOPING THE POSTURAL REACTIONS Equilibrium exercises are taught with the help of Swiss ball ,tilt board & bolster Righting reactions ,protective reactions &equilibrium reactions are taught Equilibrium reactions are necessary before the next mile stone is achieved

SENSORY INTEGRATION Perception includes whole of sensorimotor experience. Sensory integration is ability to organize the sensory inputs for use. Various functional activities incorporating different objects /sizes /colours/textures can be used in therapy Eg:beading ,putting different size objects into respective holes, getting the object under the chair,sandplay.putti-clay,colouring squares circles, obstacle walking PLANS OF PHYSIOTHERAPY

TRAINING FOR THE ORO-MOTAR CONTROL Oromotar function depends on well controlled head &neck flexion which is dependent upon the active use of supra&infra hyoid muscles that have the primary action on jaw ,tongue &hyoid movements. COMMON OROMOTAR PROBLEMS ARE Drooling Problems in sucking &swallowing Body movements associated with speech Inadequate tongue movements

THERAPY: Develop good neck control[wedge exercises] Develop good trunk control Use of nook brush to decrease the drooling