Rehabilitation Approach of
Children with Cerebral Palsy
Presented by
Amal AlShamlan
Head of Rehabilitation Section
AlWasl Hospital
Dubai Health Authority
AlWasl Hospital - Rehabilitation Section
outline
 Definitions
 Model of care
 Classification
 Outcome measures
 Intervention strategies & philosophies
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Section
What is Cerebral Palsy?
It is a group of conditions results in permanent disorders of movement &
posture due to damage in 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 / behaviour.
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What is Rehabilitation ?
Rehabilitation is combined and coordinated use of
medical , therapeutic , social , educational and
vocational measures for training or retraining the
individual to highest possible level of function
• Holistic Approach
• QOL
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Aims
 Improve functional status
 Prevent secondary impairments & functional
limitations
 Efficiently use resources when there is reasonable
prognosis for improvement
 Facilitate integration into the community
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Model of care
 Functional & social vs disease-based
 Growth & development
 Child-focused & family centered.
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International Classification of Functioning,
disability and Health (ICF)
condition
Body Function &
structure
Activities
Environmental Factors
World Health Organization , 2001
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Participation
Personal Factors
International Classification of Functioning,
disability and Health (ICF)
C.P.
Impairments
Muscle weakness
Muscle hypoextensibility
Poor balance
Poor endurance
Activity Limitation
Walking on slopes
Walking in crowds
Climbing on equipment
Environmental Factors
Teachers’ concern
Distance to play ground
Children crowded in equipment
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Participation
Walking to class room
Play during recess
P.E class
Personal Factors
Child’s attitude toward:
being transported
Adult assistance
Multidisciplinary Team
Social worker
Physiotherapists
psychologist
client
Occupational
Therapists
Physician
Speech
/language
therapists
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Orthotists
Care Pathway
referral
screening
Initiate therapy
Discharge / long
term follow up
Interdisciplinary
clinic
Cross referral therapy
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Interdisciplinary Approach
 Working for common goals
 Pooling of expertise
 Opportunity for personal growth & development
 Forum for problem solving
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Classification of CP
 Etiology
 Body involvement
 Movement disorder
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impairment
GMFCS for children with CP
GMFCS
Description
Level I
Walks without restrictions; limitation in more advanced gross
motor skills
Level II
Walks without assistive devices; limitations are walking outdoors
and in the community
Level III
Walks with assistive mobility devices; limitations are walking
outdoors and in the community
Level IV
Self-mobility with limitations; children are transported or use
powered mobility outdoors or in the community
Level V
Self-mobility is severely limited even with the use of assistive
technology
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Outcome measures
 Validate progress
 Provides accountability to child/family/third-party
payers for intervention used
 Aides in plan of care
 Provides normative data to obtain developmental
levels e.g. age equivalent , standard score
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Tests Measuring Developmental Age , Activity , or
participation Abilities
Test
Developmental
Function/Activity
AIMS
X
X
GMFM
PDMS II
X
X
X
TIMP
X
Quest
X
LAPI
Participation
X
PEDI
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X
X
Assesses normative
performance of
gross/fine motor
function for
children from birth
to 72 months of age
Used to evaluate
quality of UE
functions in 4
domains:
dissociated
movement,
grasping,
protective
extension &
weight bearing
Assess gross motor
function including
maturation of skills
and postural
alignment of of
infants from birth to
18 mths of age
Assessment of motor
tone & oromotor
function for preterm
babies
More than 33 wks
corrected age – 1 mths
post term
Assess postural
control & alignment
needed for age
appropriate
functional activities
in early infancy
34 wks gestational
age to 4 mths post
full term delivery
date
Specifically designed
for CP , developed to
measure change over
time . Consists of
activities in 5
dimensions: lying &
rolling, sitting,
creeping & kneeling,
standing & walking,
running & jumping.
communication rating scale
skill
%
Pointing
0 – 10
Gestures
11- 20
Gestures with speech
sounds
21- 30
Speech sounds
31- 40
Single words
41 – 50
Phrases
51 – 60
Short sentences
61 – 70
Complete sentences
71 – 80
Complex sentences
81 – 90
paragraphes
91 - 100
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Spasticity
 Spasticity is one of the most common UMN lesion
problem seen in children with CP resulting in postural
control & movement disorder thereby limitting,
delaying or arresting the sensory motor
development.(also other areas like communication,
cognition, social , perception etc).
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What is spasticity?
 Spasticity is a motor disorder characterized by a velocity
dependent increase in stretch reflexes(muscle tone) with
exaggerated tendon jerks resulting from hyper
excitability of the stretch reflex as one component of the
UMN syndrome (Lance, 1980).
 Spasticity is a movement disorder affecting both the
neural & non-neural characteristics of postural tone and
can be described by the positive & negative UMN
symptoms” (D. Burke, 1988).
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Neural components of UMN symptoms
Positive symptoms
Negative symptoms
 Spasticity.
 Weakness.
 Spasms (flexor &
 Loss of dexterity.
extensor).
 Exaggerated tendon
reflexes.
 Clonus.
 Babinski response.
 Fatigability.
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Non-neural component of UMN symptoms
 Altered muscle length (elasticity): muscle fibres
shorten (hypoextensible).
 Altered muscle structure (viscosity): filaments
become sticky affecting muscle glide(stiffness).
 Abnormal co- contraction (reciprocal innervation) :
due to bio- mechanical effects of abnormal position.
(too much stability & not enough mobility).
Changes in visco-elastic properties leads to stiffness,
tightness & contracture.
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Normal
postural
tone
Normal
functional
Skills
achievements
Normal
patterns of
movement
repetitions
Success in
normal
patterns of
movement
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CP?
Abnormal
postural
tone
Deformity/ less
functional skills
acheivments
repetition
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Abnormal patterns of
movement
Success in
abnormal
patterns of
movement/
stereotyped
Intervention Philosophies &
strategies
Evidence based?
 There is no evidence that any one treatment
method is superior to another.
 Therapists select from the variety of
treatments available those that best meet
the child’s and family’s need.
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Analyzing
 Analysing the postural tone & patterns of movement.
 What the child can do? How? /can’t do ? why?
 Choosing appropriate intervention/frequency depends
on:




Age (infant, toddlers, preschool, adolescent etc)
Distribution of postural tone (diplegic, hemiplegic,
quadriplegic etc)
Quality of postural tone (mild, moderate or severe).
Associated problems.(vision, hearing, cognitive, seizure, SPD
etc)
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Early intervention
 Studies focused on child and family reported
favorable outcomes.
 The analysis also suggested that parent participation
might have a greater impact on child’s outcomes for
children younger than 3 yrs.
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Neonatal Developmental screening




Neonatal physiotherapy is an advanced practice
subspecialty area of paediatric physiotherapy and
involves a highly complex set of skills in
observation, examination and intervention
procedures for the extremely fragile NICU
population.
Main objective to identify developmental delay in 1st
year of life
Early intervention can change abnormal movement
pattern in mild to moderate cerebral palsy
Those whom deemed to be delay remain delay if no
intervention started.
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
1.
2.
3.
4.
5.
All high risk preterm infants with
meeting criteria:
Gestation 32 weeks and below
Birth weight < 1.5 kg
IVH GR.3&4, PVL
Chronic lung disease or O2
dependency
Ventilated for RSD
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Neonatal Developmental screening
 NICU : LAPI
 Outpatient : TIMP , AIMS , PDMS
 2008
 2009
37 - 11 detected
57 - 17 detected
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Relative comparison of sensitivity and specificity of unit
assessment and BUSS in this audit
BUSS SENSITIVITY
54.5
AUDIT SENSITIVITY
65.40%
final outcome N
45.5
34.60%
final outcome A
outcome N
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outcome A
Relative comparison of sensitivity and specificity of unit
assessment and BUSS in this audit
AUDIT SPICIFICITY
BUSS SPICIFICITY
90.3%
PERCENTAGE
76%
23%
9.7%
0.0%
final outcome N
N
D
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A
final outcome A
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
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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
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Intervention Philosophies &
strategies
Sensory Integration Therapy
Principle: a neurobiological process organizes sensation from one’s
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
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SI Therapy
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Intervention Philosophies &
strategies
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.
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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).
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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)
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Intervention Philosophies &
strategies
Body Weight Supported Treadmill Training
Uses theories of motor learning &
importance of early task –specific
training
Theory : activate spinal & supraspinal
pattern generators for gait
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Intervention Philosophies &
strategies
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
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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.
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Intervention Philosophies &
strategies
Orthotic devices , splints , cast
Goals :
 Maintenance or increase ROM
 Protection or stabilization of a joint
 Promotion of joint alignment
 Promotion of function
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Ankle Foot Orthosis
 Compared with barefoot gait, AFO’s enhanced gait
function in diplegic subjects. Benefits resulted from
elimination of premature PF and improved progression
of foot contact during stance.
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Intervention Philosophies &
strategies
Assistive Technology & Adaptive Equipment
 Optimizes alignment, posture & function.
 Inhibits spasticity patterns.
 Facilitates more normal movement.
Adjunct therapies
 Hippotherapy.
 Aquathearpy.
 suits.
 Theratogs.
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Intervention Philosophies &
strategies
Speech & Language Therapy
Oralmotor function using strengthening / Intraoral
stimulation
 verbal ( PROMPT) & non-verbal communication skills
( AAC & PECS , macatone)
auditory training for HI
audiometry screening
 swallowing function
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Intervention Philosophies &
strategies
Psychological Assessment & Management
Social support
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% of patients who did not attend PT Mx
31%
Attended PT
m anagem ent
69%
Not attended PT
m anagem ent
Out of 32 patients received botox 69% attended PT
& 31% did not attend
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% of patients included in PT Mx
9%
Attended PT Mx
Dropped out
91%
Out of 22 patients, 91% fully attended PT Mx.
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% of patients who improved in ROM post botox
3-6 weeks & 3-6 months.
80%
70%
60%
post 3-6 weeks
%
50%
40%
30%
20%
68%
56%
10 %
0%
post 3-6 w eeks
post 3-6 months
post 3-6 weeks & months
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post 3-6 months
Benefits of communication
 Case selection.
 Goal setting.
 Educating parents/caregiver in active
participation
 Compliance
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Thank you
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Cerebral Palsy - REHAB Dubai 2010