05/08/2017

Cerebral Palsy: Thanking everyone for inviting me to

the difficulties and the possibilities. come and to share and to learn 

Feeding disorders and spinal malformation

discussed and the possibilities of touch as
therapeutic tool introduced.

International conference of Autism, Cerebral

palsy and Neurodevelopmental disorders.
Mumbai India 1-3rd May 2015

Tape in sports, fashion & animals

Plan
• Discuss spinal malformations related to CP
• Discuss oral motor issues related to CP
• BUT ESPECIALLY talk about the skin and
physiological skin movement possibilities.
• Present relevant information touch.
• How can we use this information to our
advantage.

This tape has many names:
Elastic Therapeutic Taping, Elastic
Rehabilitative Taping,
Emotional Taping, Fascia taping, Kinaesthetic
taping, Kineotaping,
KinesioTaping,
Kinesiology Taping,
K-active taping,
K-taping, KT-taping,
Medical Taping Concept, MyoFascial Taping,
Neuro-Muscular Taping & Neuro Structural Taping
Children with cerebral palsy cannot
use the range of physical movement
available to most of us.
• Difficulties may occur in the development of
walking, speech and hand function.
• The developing bones will be affected by the
different forces. Every joint can be affected.
• Spinal deformations are common and they can
result in sitting posture problems, gait
problems and organ problems.

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Children with cerebral palsy cannot

Cerebral Palsy: the difficulties
use the range of physical movement
available to most of us. Spasticity
Seizures
Bony malformation (joints and spine)
• Movements such as biting, chewing and Posture and gait problems
swallowing are frequently affected. If a child Feeding difficulties
cannot move their mouth muscles to eat and Organ dysfunction
drink efficiently they are likely to have problems Dental decay
Scoliosis
eating enough food to grow and to stay healthy. Sleeping problems
• Result can be: problems with frequent chest Speech (dysarthria) and learning difficulties
infections because particles of food or drink Stress (communication, frustration)
Mobility problems
entering their lungs when they swallow. These
Energy expenditure
difficulties continue throughout life.

Definition SOSORT Classification

Today, scoliosis can be defined as a "three-dimensional
torsional deformity of the spine and trunk“. I. Non-structural scoliosis
It causes a lateral curvature in the frontal plane, an postural scoliosis
axial rotation in the horizontal one, and a disturbance compensatory scoliosis (example short LL)
of the sagittal plane normal curvatures, kyphosis and
lordosis, usually, but not always, reducing them in
direction of a flat back. II. Transient structural scoliosis
Sciatic scoliosis
SOSORT Society on Scoliosis Orthopaedic and Hysterical scoliosis
Rehabilitation Treatment. Inflammatory scoliosis

Classification General Classification &

classification in age
III. Structural scoliosis
1. Idiopathic (70-80%) • Mild
2. Neuromuscular scoliosis: Poliomeylitis, Cerebral Palsy,
• Moderate
Syringomyelia, Muscular Dystrophy, Amyotonia Congenita,
Friedreich´s Ataxia • Severe
3. Congenital
4. Neurofibromatosis • Infantile scoliosis IS (0-2.11yrs)
5. Mesenchymale disorders: Marfan Syndrome,
• Juvenile scoliosis JS (3-9.11 yrs)
Rheumatoid Arthritis, Osteogenisis Imperfecta, dwarfism
6. Trauma: fractures, irradiation & surgery • Idiopathic Adolescent scoliosis IAS (12- 11.11yrs)
• Adult scoliosis (18- onward)

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Thoracic & lumbar curves
Common characteristics scoliosis
• Progressive: muscular weakness,
breathing restrictions
• Joint contractures
• Nutritional disorders
• Cardiac dysfunction and mental
retardation can occur
• Multidisciplinary evaluation and
treatment is a must
Spinal Surgery
• Improves the cardio-pulmonary function
• Improves sitting balance
• Improves appearance
• •!
Improves quality of life
BUT: it is a major intervention with high
risks.
05/08/2017
Severe scoliosis: patients with
neuromuscular disorders
Severe scoliosis
• Causes discomfort (pain)
• Compromises respiratory system and internal
organs
• Spinal surgery is considered the primary
treatment option for correcting severe
scoliosis in neuromuscular disorders
Controversial
• Some issues around surgical intervention
controversial
• What is the best point for surgery?
• Is surgery always needed?
• Many uncertainties…….
• Uniformity in terminology & definitions
needed, clear guideline desirable.
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Guideline definition
Neuromuscular disorder is defined as
• a defective function of the peripheral nerve
system, the neuromuscular junction or muscles
causing weakness in the patient.
• Most frequent occurring progressive disorders
are:
DMD -Duchenne Muscular Dystrophy &
SMA - Spinal Muscular Atrophy
Disorders of the CNS such as Cerebral Palsy &
Spina Bifida were not included in this guideline
Dysarthria
The extent of dysarthria’s damage to speech production
varies from person to person.
Symptoms can be:
slurred speech, swallowing problems, soft or barely
audible speech, slow talking, rapid and mumbling speech,
abnormal rhythm or tonality of speech, hoarseness, and
drooling.
There are many instances of dysarthria affecting eating
and nutrition in persons with the disorders, especially
when coupled with cerebral palsy.
Other oral motor related symptoms
• Apnea during feeding : falls asleep during feeding.
• Aspiration: food penetrates the larynx and enters the
airway below the vocal folds.
• Difficulty in or an unwillingness to feed.
• Eosophageal spasms
• Globus sensation: the feeling of having an obstruction
in the throat.
• Odynophagia : signs of pain while swallowing.
• Oral apraxia: inability to make movements of the
mouth, such as opening or closing.
• Physical reactions while feeding, such as frowning.
05/08/2017
Dysarthria and Dysphagia
• Dysarthria: speech disorder caused by motor
control problems.
• Dysphasia (aphasia) is an impairment of
language.
• They often co-exist.
dysphagia
• A child with cerebral palsy will likely face a
number of health concerns during his or her
lifetime. One of the most common – and the
most difficult to management – is dysphagia.
• Commonly referred to as oral-motor dysfunction,
dysphagia is more common among children with
moderate to severe cases of cerebral palsy. It’s a
dangerous condition that, if left mismanaged, can
cause numerous life-threatening consequences.
Classification system EDACS
• Eating and Drinking Ability Classification
System (EDACS) offers an alternative to the
subjective terms (mild-moderate-severe) using
five distinct descriptions of different levels of
ability.
• Children from 3yrs to adulthood
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Malocclusions In Cerebral Palsy Affected

EDACS www.edacs.org
• Level I: Eats and drinks safely and efficiently
• Level II: Eats and drinks safely but with some
limitations to efficiency.
• Level III: Eats and drinks with some limitations to
safety; there maybe limitations to efficiency.
• Level IV: Eats and drinks with significant
• limitations to safety.
• Level V: Unable to eat or drink safely – tube
feeding may be considered to provide nutrition.
Children
Liang and Negar and Dr Audrey Bellerive N=21
Conclusion: the orthodontic abnormalities are limited in
the anterior segment: tipping of the anterior incisors, with
decreased inter-incisal angles.
Posterior segments are not affected.
Further studies could characterize and correlate between
the behaviour of these patient’s muscles and the
malocclusion that they suffer from, in order to establish a
better standard of care and improve their quality of life.

CP children & dentist. Protraction

shoulder linked to oral breathing
Mode characterization respiratory oral and
amendments postural in children of a paediatric
dentistry clinic. Characterization of respiratory
and oral mode changes in children of postural
the paediatric dentistry clinic.
Janieny Silva Vieira , Liliane Pereira, Adriano Rockland, Ricardo Santos,
Inês Lopes DOI: 10.13140 / 2.1.4784.9762 Poster Conference: I Ibero-
American Symposium of Orofacial Motricity, At Porto, Portugal,
Volume: ATAS SIAMO'15 - ISBN 978-989-99356-0-0
Oral health status CP in India
Case controlled study N= 50 7-17yrs
CP group higher caries, poor oral hygiene and
class II malocclusion because of compromised
general health issues and also less dental
awareness.
Nidhi Sinha et al J. Indian Soc Periodontology
2015 Jan-Febr. 19(1)78-82

Taping to ‘externally rotate shoulders’ before

going to the dentist?

Anatomy skin
The Skin: The Outer Brain
• Skin: development & changes with age.
• Dermatomes.
• Forces on skin, how they act in the body,
biotensegrity and physiological movement
direction of skin.
• Research on Touch
• Could we use this knowledge at home and in
Sources: Wikipedia & Imágenes obtenidas de Cardinali, Daniel P. Neurociencia
the clinic? aplicada. Sus fundamentos. Buenos Aires: Médica Panamericana, 2007. 528 p.

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Skin - CNS
Properties Skin
Protection - water resistance
Sensation
Heat regulation
Control of evaporation
Aesthetics and communication
Storage
Excretion
Absorption
Returns to original state after stretch
Video: The skin excursion

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Skin anatomy & physiology modifies Neonatal skin

during whole life
Structural characteristics skin children differs from
adults, especially in the first years of life.
Skin thickness gradually ↑ from birth to
adulthood.
Only sensory organ that functions from birth
Dermatology 2000;201:218-222 Thickness and Echogenicity of the Skin in
Children as Assessed by 20-MHz Ultrasound Stefania Seidenari, Giulia Giusti,
Laura Bertoni, Cristina Magnoni, Giovanni Pellacani
Developmentally the skin is the surface of our
brain. The skin ‘closes the loop’ preventing
exposure nerve endings and providing interface
between CNS and environment.
Challenge neonate transition moist - dry
Air breathing, enteral nutrition, elimination of
waste and maintenance body temperature and
water balance transition from aqueous womb to
terrestrial environment at birth.

Vernix and stratum corneum

Stratum corneum
Vernix = natural cleaner, anti-infective, anti-oxidant,
moisturizer and wound healer. Synthesized last Vernix is believed to interact with developing
trimester pregnancy. Vernix covering developing
stratum corneum allows for cornification. Role in
epidermis and facilitate the in utero formation
adaptation of neonate to extra uterine or dry of stratum corneum.*
environment… * Hoath SB Physiological development of the
Shouldn’t we be rubbing it IN instead of off? skin, in Polin RA, Fow WW, Abman SH eds Fetal
Similar to stratum corneum, holds large volume of and Neonatal physiology Pa Elsevier 2004
water. It detaches into amnion fluid (turbidity in
fluid) marker lung maturity.* Narendran V et al
(2000)

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Defense mechanism skin
Stratum corneum is anatomical barrier: with
acidic environment, commensal microflora,
antimicrobial peptides and phagocytes.
Colonization after birth = skin infection defence.
Epidermis internalizes bacteria and contains
infection. Langerhans cells function as sentinels
for immune system
1st few weeks after birth
Skin neutral Ph becomes more acidy in first
postnatal weeks. Ph fall helps antimicrobial defense
by inhibiting growth pathogenic bacteria.
This development is delayed in extremely preterm
infants. Even in term infants, this acid mantle is
slow to develop in occluded skin (diapers).
Leaving vernix on newborn = earlier skin
acidification.
Skin of newborn = well developed immune system
Immune system
Total immune system matures continuously
until 2 years of age
TSH fluctuations have an effect on the skin.
Children have more thyroid per kilogram of
body weight than adults.
Children with M. Down more likely to have
hypothyroidism. (check skin condition)
http://www.nature.com/ni/multimedia/skin/i
ndex.html?WT.mc_id=TOC_NatureImmunol
_1403_SkinImmunology
05/08/2017
Preterm infant & immature skin
Has to undergo acceleration of barrier
maturation when exposed extra-uterine.
Rapid formation stratum corneum = excessive
desquamation and scaliness (characteristic for
VLBW infant skin)
This dry scaly skin is poor barrier = susceptible
for infection and penetration of exogenous
agents increased.
Transepidermal water loss to 28 days postnatal
Intrauterine growth retarded (IUGR)
infants*
Postnatal physiological adaptation & maturation
IUGR of infants is slower than normal and
therefore they remain in a physiologically
immature state for longer.
The higher heart rates and greater cortisol excretion
in such infants may be precursors to hypertension
and cardiovascular disease seen in adults.
* Jackson JA et al Early physiological development of infants with intrauterine
growth retardation Arch Dis Child Fetal Neonatal
Ed 2004;89:F46-F50 doi:10.1136/fn.89.1.F46
Skin in the elderly population
Epidermis thins with age (number of cell layers remain
unchanged. Wrinkles, blemishes, skintags, warts and
sagging skin.
Changes in the connective tissue reduce the skin's
strength and elasticity.
Melanocyte numbers decrease, the remaining
melanocytes increase in size. Aging skin appears
thinner, more pale, and clear (translucent). Large
pigmented spots may appear in sun-exposed areas.
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Skin in the elderly population
The blood vessels of the dermis become more
fragile. Leads to bruising, bleeding under the
skin (often called senile purpura), cherry
angiomas, and similar conditions.
Source: http://www.nlm.nih.gov/medlineplus/ency/article/004014.htm
Sebaceous glands produce less oil.
Men (< 80) minimal decrease. Women
gradually produce less after menopause. This
results in skin dryness and itchiness.
Result: increased risk skin injury
Ability to sense touch, pressure, vibration,
heat/cold may be reduced.
Bruises, purpura and hematomas may occur
from a minor injury (rubbing or pulling skin).
This can happen anywhere on the body.
Skin changes, loss of subcutaneous fat,
inactivity, nutritional deficiencies and other
illnesses can contribute to pressure ulcers and
infections.
Tsutumo Ben Fukui
Science of Movement of skin, the art of thinking
about function and treatment
Study skin physiologic
movement direction.
Skin moves in a specific
Direction.
05/08/2017
Skin in the elderly population
The subcutaneous fat layer thins. Increased risk
of skin injury and reduces ability to maintain
body temperature. Risk of hypothermia.
Some medications are absorbed by the fat layer
and loss of this layer may change the way that
these medications work.
The sweat glands produce less sweat. This makes
it harder to keep cool, increased risk for
becoming overheated or developing heat stroke.
Result: increased risk skin injury
Aging skin repairs itself more slowly than the
younger skin.
Wound healing may be up to 4 times slower.
More than 90% of all older people have a skin
disorder and this can be caused by many
conditions: arteriosclerosis, Diabetes, heart
disease, liver disease, nutritional deficiencies,
obesity, & medication.
Touch: the Research
• Cutaneous afferents provide information about knee
joint movement in humans.
• Unmyelinated tactile afferent signals touch and
project to insular cortex
• Cortical processing of lateral skin stretch stimulation
in humans.
• Evidence that little touches do mean so much.
• Cutaneous afferent regulation of motor function.
• Discriminative and affective touch; sensing and
feeling.
• Pain relief by touch: A quantitative approach.
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Cutaneous afferents provide
information about knee joint
touch and project to insular cortex. 2002
movement in humans. 2001
Benoni B Edin. J.of Physiology 2001, 531.1.
pp289-297
Receptors of the hairy skin of humans can
provide high-fidelity information about knee
joint movement.
Cortical processing of lateral skin
stretch stimulation in humans. 2008
Backlund Wasling H et al . Exp. Brain Res (2008)
190:117-124
Conclusion: the second somatosensory cortex
(S2) and especially the opercular parietal (OP1)
area seem to be important for processing of
lateral skin stretch stimulation. A lesion in this
area might cause a disturbance in tactile
direction discrimination.
Cutaneous afferent regulation of
motor function. 2014
Panek I et al in Acta Neurobiol.Exp 2014, 74:158-
171
Low threshold mechanoreceptors are critical for
normal motor function and for inducing
plasticity in motor microcircuits following injury
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Unmyelinated tactile afferent signals
Olausson H et al. Nature Neuroscience 5, 900-904 2002
There is a dual tactile innervation of the human hairy skin: a
fast-conducting myelinated afferent fibres & a slow-
conducting unmyelinated afferents that respond to light
touch.
Study of patient lacking large unmyelinated afferents found
that stimulation of C tactile (CT) afferents produced a faint
sensation of pleasant touch.
These findings identify CT as a system for limbic touch that
may underlie emotional, hormonal and affinitive responses
to caress-like skin-to-skin contact between individuals.
Evidence that little touches do mean
so much. 2010
Experiments M. Hertensein, at eh DePauw
University Indiana.
New York Times 22-02-2010
‘We used to think that touch only served to
intensify human emotions.
It turns out to be a ‘much more differentiated
signalling system than we imagined’.
Discriminative and affective touch;
sensing and feeling. 2014
F. McGlone et al.
Neuron 82, may 21-2014, 201 pg 737-750
There is mounting evidence that of the sub-
modalities of the human somatosensory system
-touch- has another dimension, providing not
only its well—recognized discriminative input
to the brain, but also an affective input.
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Pain relief by touch: A quantitative
approach. 2014
Mancini F et al Pain, Mar 2014:155(3) 635-642
Experiments testing whether, how and where
within a dermatome touch modulates the
perception of laser-evoked pain.
Results: both experiments demonstrated that
touch can inhibit pain.
Results show that touch induces analgesia in a
spatially dependent fashion.
We all have this power
Touch and Orofacial function
Light touch and skin stretch: to facilitate movement.
You are activating the underlying muscles.
Light touch to relax muscles.
Touch to relieve pain.
* Improve dental care
05/08/2017
How to use this information?
Realize how much skin matters.
It is the direct connection to our brain.
Try…..
Asking the skin what is best?
Use the lightest touch and stretch.
Touch, wait, let the brain do the rest and see,
the results.
Touch & Scoliosis Management
Touch (stretch) and see what you can change in
breathing pattern.
Light touch and skin stretch to facilitate a
movement direction. You are activating the
underlying muscles.
Touch to relieve pain.
Do more during growth spurts?
* Make sure sleeping position is changed more
often.
It is not difficult  & you do no harm.
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