Physical therapy
Orthotics
Control of spasticity
Orthopedic surgery
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Approaches :
Remove Noxious Stimuli
Rehabilitation Therapy
Oral Medications
Neurolysis
Orthopedic Options
Neurosurgical Procedures
Selective dorsal rhizotomy
Intrathecal baclofen
Botulinum-A toxin
Modified Ashworth Scale:
0 = no increase in muscle tone
1 = slight increase in muscle tone (catch or
min resistance at end range)
1 + = slight increase in muscle resistance
throughout the range.
2 = moderate increase in muscle tone
throughout ROM, PROM is easy
3 = marked increase in muscle tone
throughout ROM, PROM is difficult
4 = marked increase in muscle tone, affected
part is rigid
Positioning
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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 seating system
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
SERIAL CASTING
Indications: focal contracture (especially elbows,
Method:
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knees, ankles ).
Limb is stretched then casted in a lengthened position ( can be
combined with blocks )
Changed every few days or weeks to gradually stretch
contracted structures.
Neurolysis
Botox Injections
Phenol Injections
Dorsal Rhizotomy
NEUROSURGERY
- 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 sensation)
- Must be followed by PT & OT
- Cutting anterior root produces atrophy
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Baclofen is a GABA agonist that binds to B receptor to
inhibit ca++ influx into presynaptic terminals to inhibit
the release of excitatory neuotransmitters.
Baclofen is lipophilic and doesn't cross the BBB.
Intrathecal Baclofen can be used for the long term
control of severe spasticity without significant central
side effects at a dose less than 100 times the oral dose.
Benefits:
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ITB reduces tone, spasms and pain resulting in
improved function
ADL's, Mobility, care giver burden, speech,sleep,
bladder control, etc.
ITB will allow reduction in mind altering spasticity
medications, which will improve cognition.
Symptoms:
 Fever
 Pruritus
 Rebound Spasticity
 Tachycardia
 Hyper/Hypotension
 Seizure
 Altered Mental Status
 Rebound Spasticity
 Myoclonus
Symptoms
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Decreased tone
Lethargy
Unresponsive
Respiratory Depression
Hypothermia
Hypotension
Bradycardia
Treatment
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Reduce rate of ITB
Hold oral Baclofen
Monitor Vital Signs
Monitor O2
Provide airway support
Stretching
Positioning
Seating
Cryotherapy
Biofeedback
Inhibitive Casting
Pool Therapy
Orthotics
Electrical Stimulation
Neuro-developmental therapy
Sensory integration therapy
Patterning
Conductive education
Pressure point stimulation
Practice specific, relevant and functional skills
• Facilitation of normal movement patterns
• Work for better active participation
• Improve/maintain range of movement
• Improve/maintain muscle strength and control
• Improve/maintain postural alignment
• Parent participation and education
Patients should be assessed individually and treated
age appropriately.
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APPROPRIATE MANAGEMENT
• Importance of early referral and intervention
• Anticipate progression/effects of condition
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POSTURAL MANAGEMENT PROGRAMME
• 24 hours
• Variation in environment, activity and
intervention
• Positively impacting on posture and function
• Enhanced communication and participation
• Transitioning through stages of life
Positioner
Wedge
Standing frame
Wheelchair (seating system)
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Immature skeletal and neuromuscular system
 Biomechanical alignment
Considerations should be given to:
 Assistive device for play, feeding,
 relaxing and independence
 Stretching positions
 Sleeping positions
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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
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.
f) Rumps, uneven ground, various floor services for gait training.
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.
Advantages
 Bone density
Decreased incidence of fractures
Decreased incidence of hip dysplasia
Increased bone growth
 Improved passive range of movement
 (maintaining neutral alignment)
 Influences tone
 Activation of anti-gravity muscles
 Improved lung function
 Improved bladder and bowel function
 Socialisation and interaction
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In physical therapy sessions, the therapist works
with the child in supine and prone positions to
improve head and trunk control.
He supports the child in the sitting position to
develop weight shifting and unilateral balance,
ability to rotate the body and the ability to
respond to sudden changes in position.
The rehabilitation team strives for long-term
functional mobility in a variety of environments
so that the child will integrate into the
community and social life in a healthy way.
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Bobath neurodevelopmental technique:
This is the most commonly used therapy approach in
CP worldwide.
It aims to normalize muscle tone, inhibit abnormal
primitive reflexes and stimulate normal movement.
It uses the idea of reflex inhibitory positions to
decrease spasticity and stimulation of key points of
control to promote the development of advanced
postural reactions.
It is believed that through positioning and
stimulation, a sense of normal movement will
develop.
An important part of treatment of the infant is
teaching the mother how to position the child at
home during feeding and other activities. The baby is
held in the anti-spastic position to prevent formation
of contractures.
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Sensory input to the CNS produces reflex motor output.
The various neuro-facilitation techniques are based on
this basic principle.
All of the techniques aim to normalize muscle tone, to
establish advanced postural reactions and to facilitate
normal movement patterns.
Vojta method of technique:
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Vojta established 18 points in the body for stimulation and
used the positions of reflex crawling and reflex rolling.
He proposed that placing the child in these positions and
stimulation of the key points in the body would enhance
CNS development.
In this way, the child is presumed to learn normal
movement patterns in place of abnormal motions.
Positioning and stimulation techniques are different from
NDT.
Vojta stated that therapy should be applied by the primary
caregiver at home at least 4 - 5 times daily and stopped
after a year if there is no improvement
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.
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 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.
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Conductive education:
This approach, developed by professor Peto
in Hungary depends on educational principles
which become the core stone during
treatment.
A conductor is responsible to treat the child
in integrated pattern in group therapy.
Each task is divided into steps and learned to
child one by one, using special rhythm of
songs and verbal commands.
Occupational therapy and play:
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Occupational therapy (OT) aims to improve hand
and upper extremity function in the child through
play and purposeful activity.
There are defined systematic treatment methods
for occupational therapy.
Ayres sensory integration therapy aims to
enhance the child’s ability to organize and
integrate sensory information.
In response to sensory feedback, CNS perception
and execution functions may improve and the
motor planning capacity of the child may
increase.
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Bracing:
Braces are devices which hold the extremities in a stable
position.
The goals of bracing are to increase function, prevent
deformity, keep the joint in the functional position,
stabilize the trunk and extremities, facilitate selective
motor control and decrease spasticity.
Lower extremity bracing:
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Orthoses are usually named according to the body parts
they cover. Various kinds of ankle foot orthoses (AFOs) are
the most common braces used in CP.
Static braces immobilize the joint, while flexible ones use
body weight to stretch the muscles of the leg and ankle.
AFOs provide appropriate contact with the ground during
stance and foot clearance during swing.
Knee immobilizing splints and hip abduction splints are
prescribed both for non-ambulatory and ambulatory
children.
Knee-ankle foot orthoses (KAFOs) work in children who
use them.
AFOs are not very useful as night splints because they do
not prevent knee flexion.
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Orthopedic surgery is widely used in the
management of children with CP to prevent or
correct certain musculoskeletal problems such as
muscle shortening and bone deformities.
The goal of orthopedic surgery in a child with
walking potential is to improve functional
ambulation.
For non-ambulatory children, the goal of
orthopedic surgery is to facilitate sitting, improve
hygiene, prevent pain and obtain plantigrade
stable feet.
Tenotomy
Myotomy
Osteotomy
Fusion
Tendon Transplant
Tendon Lengthening
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Neurosurgical Procedures
Neurectomy
Myelotomy
Rhizotomy
Selective Dorsal Rhizotomy
Chordotomy
Implantable dural electric stimulator
Intrathecal Baclofen Pump
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%
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A significant change in all the primary impairments is
expected after surgery. There is a need for gentle return to
function.
Range of motion and strength has to be regained as early
as possible after surgery.
Mobilization should be started as soon as the child is
comfortable and painless, usually on the second to fourth
day after soft tissue procedures.
Training with range of motion exercises starts and
gradually progress to strengthening as healing allows.
Keep in mind that a spastic muscle is also a weak muscle,
so strengthen the muscles after muscle lengthening.
The ultimate aim is to improve the ambulatory capacity. It
usually takes approximately 3 months to regain the
preoperative muscle strength after multi-level surgery.
Immediate postoperative physical therapy re-introduces
movement and the new alignment.
The skills that the patient acquires are established in 3 - 6
months after surgery.
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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
bolus
Use of alternative feeding routes e.g.
nasogastric tube, gastrotomy or jejunostomy
tubes with severe aspiration or caloric need.
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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
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Team: audiologist, speech therapist, OT
Items:
Cochlear implants (for profoundly deaf):
to stimulate auditory nerve & provide
awareness of sound
Hearing aid :
- Do not help purely central hearing loss.
Used for ttt of profound sensorineural
hearing loss in infancy & early childhood
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.
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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.
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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.
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
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Team : occupational therapist
Items :
- provision of self help devices
- training in activities of ADL
- provision of creative interest
- training in suitable work
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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