REHABILITATION OF
CEREBRAL PALSY &
:
MOTOR DELAY
REHABILITATION OF C.P
CEREBRAL PALSY
Static encephalopathy(=non progressive) caused
by an insult to the immature brain
REHABILITATION:
The process of making the child w/ disability
maximally able again through the application of
rehab principles & techniques.
REHABILITATION OF C.P
Principles of proper rehabilitation :
1. Proper evaluation ( individual treatment )
- to plan a therapy program.to assess
progress.
- to add observation to the diagnostic picture.
2. Early treatment( increasing functional deficits
w/ age as secondary effects of spasticity
&other primary problems
3. Team work ( global dysfunction )
EVALUATION OF CP CHILD
(A) Clinical evaluation
1. Functional : Postural control
Mobility
Primitive reflexes
Motor exam
2. Swallowing & dysphagia
3. Communication: Speech/ language
Auditory
4. Chest
5. Urinary bladder
7. Self -care activities (ADL)
Visual
Mentality
6. Bowel
8. psychosocial
EVALUATION OF CHILD
WITH CP.
(B) Imaging
1. Serial X-rays:
Hips (dislocation spastic adductors)
Th-L-Spine (scoliosis, hyperlordosis in spastic CP
kyphoscoliosis in floppy CP)
2. MRI or CT brain (progressive motor deficits ?
tumors, hydrocephalus
ASSESSMENT OF MILESTONES &
POSTURAL CONTROL
• Understanding normal development allows to adaptive
equipment to assist child in gaining increase the
interaction with the environment.
• Sitting balance at age 2 yrs. is an indicator of future
walking.
• Observe how much parental support given to child.
child own ability in postural stabilization.
collapse on one side of his body, twist to one
side, tilt & turn to one side.
EVALUATION OF PRIMITIVE
REFLEXES
• Can be used as indicator of ambulation
• Abnormal response for two of the following seven reflexes
by age 12 month has a poor prognosis for walking this are
Should be absent
Should be present
ATNR
parachute reaction
STNR
foot placement
Moro response
Neck righting reflex
Extensory thrust
• Presence of Moro or ATNR, seizures, ability to sit at 12
month indicate ambulation by age of 6 yrs.
MOTOR EXAMINATION
GAIT
• Hemiplegia
• Diplegia
• Cerebellar
Toe walk
Bilateral equinovaras,
Knee flexed & in valgus
Scissoring
Ataxic
MOTOR EXAMINATION
DEFORMITIES
• Hemiplegia : adducted arm, flexed elbow, wrist & fingers
equinus foot.
• Diplegia:
adducted hip, flexed knee in valgus, bilateral
EV
knee height discrepancy indicates hip
dislocation.
• Quadriplegia: combination
scoliosis & hyperlordosis in spastic CP
kyphoscoliosis in hypotonic CP
MOTOR EXAMINATION
R.O.M.
• Degree by goniometry:
• Limited (= fixed deformity = ms. Contracture)
• Not limited (+ deformity = threatening deformity
= muscles imbalance)
ABNORMAL MOVEMENT
• Dystonia, ( cervical = spasmodic torticollis )
• Chorea & Athetosis
• Tremors
MOTOR EXAMINATION
MUSCLE TONE
• Spasticity ( = clasp knife ):
- generalized or focal
- grade 0 (non) - 4 (severe) [Ashworth scale]
• Rigidity ( = lead pipe )
• Hypotonia ( cerebellar )
• Combination : the predominant symptoms will
contribute to diagnostic type referred for
treatment
MOTOR EXAMINATION
MUSCLE STRENGTH
Grade 0 = No contraction detected
1 = Flicker of contraction w/ no movement.
2 = Joint movement possible only with
gravity eliminated.
3 = Muscle contraction possible against
gravity without resistance.
4= Muscle contraction against gravity &
less than normal amount of resistance.
5 = Normal power against gravity and
resistance.
MOTOR EXAMINATION
MUSCLE STRENGTH
Values of muscles grading:
- To determine ambulation with or without brace
( grade 3 antigravity muscles can ambulate without
brace
- Topographic classification for treatment plan
( strengthening exercise for weak muscles )
- Ex. must be low grade and non-fatiguing in ms.<3/5
-N.B (I) grade drops form muscle power following
tendon lengthening.
SWALLOWING STUDY
Values: - To facilitate appropriate position for safe, effective feeding
- To increase ability to self feed.
Methods:
1. Video fluoroscopic swallowing study
- Requires speech - pathologist & radiologist
- Patient is given liquid & various consistency of solid food
impregnated w/ baruim & folowed by X-ray until be sure safe
effective swallowing
2.Fiberoptic evaluation of swallowing ( FEES )
Transnasal endoscopy of hypopharynx to observe foodway &
airway before & after( but not during ) the moment of swallowing.
3. EMG, manometry, scintigraphy & U.S: less commonly use.
Assessment of speech
Speech problems :
• Dysarthria (oral motor control problems ) :
Spastic
Hypokinetic (ataxic )
Hyperkinetic (dystonia,chorea)
• Aphasia
• Language delay (brain pathology, MR,
hearing impairment )
VISUAL ASSESSMENT
• Problems: Strabismus ( imbalance in eye ms. )
Hemianopsia(in dense hemiplegi w/
MCA occlusion)
• Effects:
delay
Blindness ( anoxic cortical vision loss )
1. More motor delay
2. Language
3. Abnormal movements ( blindism )
4. More delayed postural mechanism
especially hypotonic CP
AUDIOLOGICAL EVALUATION
• Must be early so that important speech development
period not lost.
In infant (1-2 d. of birth):
Brain stem auditory evoked response (BAER):
Electrodes placed on the child & presenting a stimulus
picked up from a computerized system.
A specific wave form response is recorded from the brain
stem if stimulus is heard.
Otoacoustic emission testing (OAE):
Echo from hair cell of normally functioning cochlea picked
by a microphone placed in the middle ear & connected to
micro computer.(middle ear pathology is ruled out)
AUDIOLOGICAL
EVALUATION
• 6 months children:
Behavioral testing in sound treated room
• 2-3 years children :
Play audiometry done by presenting auditory
stimulus through loud speaker and associate
the sound with light or toy
CHEST EVALUATION
Vital Capacity is measured by spirometry
Ventilatory impairment may be caused by:
1. Rib cage abnormalities 2ry. to scoliosis &
hyperlordosis (spastic) or kyphoscoliosis (floppy)
2. Respiratory muscle dysfunction (spasticity or
hypotonic)
ASSESSMENT OF BLADDER
DYSFUNCTION
• Problems:
-incontinence,urgency,hesitancy (brain damage,motor
disability, impaired cognition )
-small capacity hypereflexic bladder
-detrusor sphincter dyssynergia
• Assessment :
-Renal function with serial determination of post-voidal
volume
-Cytometric evaluation with associated EMG
monitoring of pelvic floor muscle
ASSESSMENT OF BOWEL
DYSFUNCTION
• Problems :
-Fecal incontinence or defecation stress
( brain damage, motor disability,
impaired cognition,incoordination of
anal sphincter or pelvic floor muscle )
-Constipation : exaggerated by
immobility & inadequate fluid intake
• Assessment : anorectal manometry
SCOPE OF CP REHAB.
1. Neurodevelopmental training.
2. Motor facilitation approach.
3. Treatment of spasticity.
4. Rehab. of swallowing problems.
5. Rehab. of speech problems.
6. Rehab. of auditory problems.
7. Rehab. of visual problems.
8. Rehab. of chest problems.
9. Rehab. of urinary bladder & bowel problems.
10.Rehab. Of ADL &
11.Psychosocial rehab.
NEURODEVELOPMENTAL TRAINING
EQUIPMENT TRAINING
Criteria for selection:
1. to carry out tasks otherwise impossible with his ability.
2. appropriate support to participate in social & educational
activities .
3. good alignment & correction of abnormal postures
4. adjust for child” growth, removal of support with increasing
ability.
5. modification for different children in schools & clinics
6. provide additional motor experience in different posture
7. Comfort and protect joints & skin.
NEURODEVELOPMENTAL
TRAINING
Equipments varieties:
1. Wedges: Abductor W : prevent adduction
deformities
2. Trumble form wedges & trumbles.
3. Large inflatable ball set
4.Crawlers:
-platforms on wheels or wedges on wheels
-A canavas sling under child” abdomen & supports
on casters, straps to hold thighs in flexion.
5. Sitters
NEURODEVELOPMENTAL
TRAINING
6. Apparatus for supporting standing
a) Prone or supine standers to encourage weight bearing &
standing
b) Standing frames adjusting correct alignment:
-checked for height so that child does not grasp them w/
abnormal shoulder
hunching , excessive elbow flexion & radial deviation of
wrist.
-supplied w/ strapping to correct flexed hip & knees
-feet held at right angles by a board &/or foot place.
c) Parallel bars
d) Mirrors
e) Stairs with bannisters: very in height.
NEURODEVELOPMENTAL
TRAINING
7.Walking aids
Walkers
Crutches
Braces & Calipers:
Knee gaiters (polyethylene knee moulds) to
keep knee straight abduction parts to keep
legs apart.
Elbow gaiters which keep elbow straight for
correct arm push & grasp of walkers.
MOTOR FACILITATION APPROACH
1. Bobath Method: inhibition of abnormal tone & posture of
released postural reflex while facilitating specific automatic
motor response (by special technique of handling) resulting in
performance of skilled voluntary movements.
2. Rood Method: Use of peripheral input of cutaneous sensory
stimuli (brushing, tapping, icing, heating, pressure, ms. stretch,
muscle contraction, joint approximation. or retraction)
Various nerves & sensory receptors are described & classified
into types ,location, effect, response, indication.
MOTOR FACILITATION APPROACH
3. Propioceptive Neuromuscular facilitation (Kabat & Knott)
Use of such mechanisms as maximum resistance , quick stretch &
spiral diagonal (mass) movements, sensory afferent stimuli (touch,
pressure, traction,compression & visual) to facilitate normal mov .
[special techniques: irradiation. stim. of reflexes,reversal(successive
induction), relaxation.].
4. Brunstrom Method ( hemiplegia): Produces motion by provoking
primitive movement pattern or synergitic pattern as follows :
-Reflex response used initially & later voluntary control
-Control of head & trunk by stim. of TNR, tonic labrinythine R
-Associated reaction : hyperextension of the thumb produces
relaxation of finger flexors.
MOTOR FACILITATION APPROACH
5. Motor relearning program of Carr & Shepherd:
functional training, practice, repitition, in the performance
of tasks & carry over those motor skills into functional
activities.
6. Forced use paradigm (= constraint - induced
movements therapy CIMT):
Non hemiplegic limb is restrained in a sling during 90% of
waking hrs. to force the patient to use the hemiplegic limb.
The minimum amount of motion in the paretic limb before
being enrolled into CIMT protocol is 20 of wrist extension
and 10 of extension of 2 fingers at MCP or IPJ.
TREATMENT OF SPASTICITY
Positioning
• Avoid prolong sitting (less hip & hamstring flexion )
• Prone lying at night (less hip flexion )
• Abduction wedge at night & in wheelchair (less hip
adduction)
• AFO splint
• Standing frame
• Molded thoracolumbar orthosis for early scoliosis or
kyphosis
• Total contact support incorporated into a contoured
TREATMENT OF SPASTICITY
Drugs
Indication : generalised spacticity to aid in mobility
Types :
1. Dantrolene Sodium (Dantrium):
Inhibits Ca release in excitation-contraction coupling
Used in cerebral form of spacticity Dose: 25- 200mg
2. Baclofen (Lioresal ) [ presynaptic inhibition ]
Used in spinal form of spasticity Dose :5-40mg
3. Diazepam (Valium) [postsynaptic inhibition]
Used in spinal form of spasticity Dose :2-30mg
TREATMENT OF SPASTICITY
PHYSIOTHERAPY
PHYSICAL AGENTS
Aim: a. Analgesia b. Ms. Relaxation c. Collagen extensibility
Modalities: 1) Ice 20mins.
2) Heat: Superficial : Dry: I.R. Moist: hot packs
Deep :
S.W.
U.S
ELECTRIC CURRENTS Aim: Ms. strengthening (galvanic & faradic) .
Analgesia ( TENS, IF)
EXERCISES For spasticity : Passive ROM
Stretch (short ms.)
Strengthening (weak ms., antagonist),
resistive > 3/5
For hypotonia : Strengthening ( weak ms) Balance
For athetosis : Training to control simple joint motion
TREATMENT OF SPASTICITY
Nerve/ Motor Point Block
Indications Localized spasticity poorly responsive to
drugs or PT,
interfering w/ mobility, bracing, hygiene &
causing pain
Contraindication:
- Absolute: Allergy Infection Pregnancy
- Relative: Coagulopathy
Problems:
-Loss of motor function of injected ms.
-Return of spasticity ( axon sprouting )
TREATMENT OF SPASTICITY
Nerve/ Motor Point Block
Agents :
1- Botulinum toxin(Botox) [inhibits A.C at NMJ]
Used in motor point block of UL & LL
Antibodies are formed against it
2- Phenol [ produce coagulation of axon protein]
Used in nerve motor point block
Produces sensory dysesthesia.
3 - Alcohol [produce coagulation of axon protein]
Used in motor point > nerve block
Produces hyperaemia & transiant burning
TREATMENT OF SPASTICITY
INTRATHECAL BACLOFEN PUMP
Indications: ambulatory or non ambulatory child > 28lbs.w/
spastic diplegia.
Method:
- Baclofen is delivered via pump implanted S.C.in
abdominal wall & surgically placed in subarachnoid
space (CSF) close to its site action ( receptors just 1mm
under the surface of spinal cord )
- Start with intrathecal test dose via lumbar puncture to
assess baclofen effect over 6-8hs (1grade drops of
spasticity)
. Advantage: avoid high dose of oral baclofen.
Risk: Infections e.g. meningitis, hypotonia & resp.problem
TREATMENT OF
SPASTICIRY
SERIAL CASTING
Indications: focal contracture (especially
elbows,
knees, ankles ).
Method:
• Limb is stretched then casted in a
lengthened
position ( can be combined with
blocks )
TREATMENT OF SPASTICITY
BRACES ( = CALIPERS = ORTHOSIS )
Aim:
Types:
.
To correct deformity
To control athetosis
To obtain upright position
AFO: For ankle instability w adequate Q > 3/5
Types: solid ( in ankle clonus )
Klenzak ankle joint w/spring(A,P)
w/ stop (A,P)
Accessories: varus strap valgus strap
KAFO: For correction of knee deform. & instab.
HKAFO: For ambulation w/ hip instability
Shoe modification
TREATMENT OF SPASTICITY
ORTHOPAEDIC SURGERY
1. Spastic equinovarus foot: combination of:
a. Achillis tendon lengthening ( equinus def. )
b. Split anterior tibial transfer: Splitting TA tendon
medial half left attached to its origin
lateral half tunneled into 3rd cuneiform & cuboid
2. Tight hip adductor: Adductor tenotomy or
derotational osteotomy
( + surgical reduction )
3. Scoliosis: surgical correction in ambulatory child
w/ curvature > 45 & vital capacity < 35%
TREATMENT OF SPASTICITY
NEUROSURGERY
Dorsal Rhizotomy
- Ideal patient: young child (3-8 yrs.) w/ spastic
diplegia
ambulatory w/ spastic gait.
- Method:
- Surgical cutting of posterior
(sensory) root to
decrease sensory input to spinal
cord reducing
muscle tone (but decreases
REHAB OF SWALLOWING
PROBLEMS
• Team: speech language specialist, OT, Dietary
specialist.
• Items:
• Changes in posture & head position during
feeding.
• Oral motor exercise for the tongue & lips to
increase strength,
ROM, velocity, percision.
• Use of thickened fluid & soft food in small boluse
• Use of alternative feeding routes e.g. nasogastric
tube, gastrotomy or jejunostomy tubes with severe
REHAB OF SPEECH PROBLEMS
• Team : speech -language pathologist & nurse
• Items : 1- oral option : electrolarynx
2 - non oral options :
- simple hand writing
- gestures
- augmentative communication
device (simple alphabet & picture board
to sophosticated computer systems
3- treatment of hearing & visual problems
REHAB OF AUDITORY PROBLEMS
• Team: audiologist, speech therapist, OT
• Items:
Cochlear implants (for profoundly deaf):
to stimulate auditory nerve & provid awareness
of sound
Hearing aid :
- Do not help purely central hearing loss.
Used for ttt of profound sensorineural hearing
loss in infancy & early childhood
REHAB OF AUDITORY
PROBLEMS
• Assistive listening device:
Voice amplifiers used with or in place of hearing
aids.
Speaker microphone is connected to
the listener’s head set or hearing aid through a
wire, FM radio waves or IR light.
The
signal is amplified and background noise is not
picked.
• Compensatory strategies:
Hand signs, lip reading, gestures, written
communication,
speaking clearly at slow speed,
visual fire alarms,
enrichment of visual & tactile sensory environment,
REHAB OF VISUAL PROBLEMS
• Training of postural reaction (large balls, rolls)
• Use of compensatory stimuli (auditory, tactile,
vestibular, propioceptive) for:.
-Training of motor function of child’s life e.g
dressing, feeding, bathing, roll over, creeping,
crawling (listen to sound, reach to sound, move to
sound).
-Training of body image movements enjoyment
(hand to hand, hand to mouth, hand to body)
• Mother - child relationship ( kisses, touches,
stroking, talking to the baby) is important.
•
REHAB OF VISUAL
PROBLEMS
Use of vibrating toys, bells & playthings placed
for his tummy legs & similar ideas.
• Language development:
Important to talk & clearly label the body parts &
to encourage the child’s language.
• Visual enhancement (illumination, magnification,
altered contrast, glare reduction, expanders of
visual field)
• Visual substitution: Recorded talking books,
Computer w/ vebral output,
Braille book.
REHAB. OF CHEST PROBLEMS
• Elimination of air way secretion by
manually assisted cough OR
mechanical insufflator or exsufflator.
• Respiratory ms. aid by manual force
(breathing ex) OR
mechanical ventillatory
assistance(hypoxia)
• Mouth intermittent positive pressure
ventillation (IPPV) in late stages.
REHAB. OF U.B. PROBLEMS
Timed bladder emptying schedule
Regulation of fluid intake.
Use of diapers.
Adequate cleaning of perineum
Family education about transfer & dressing skill .
REHAB. OF BOWEL PROBLEMS
A timed toileting schedule for incontinence
Use of dietary fibers, adequate fluid intake, stool
softeners, supp., & enema for constipation
.
REHAB OF ADL
• Team : occupational therapist
• Items :
- provision of self help devices
- training in activities of ADL
- provision of creative interest
- training in suitable work
PSYCHOSOCIAL REHAB
• Team : psychiatrist + social specialist
• Items : - provision of recreational activities
e.g.- special olympics, athletic competition
- horse back riding programs
(recreational & therapeutic )
- computers ( for schools & recreation