Cerebral Palsy

Spastic Quadriplegia Type

2019 KPBIA

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Etiology

 Microcephalus, Hydrocephalus

 Epilepsy, Seizure, Convulsion

 I.V.H(Grade 3 or 4 and wide damage of brain)

 Total Asphyxia

 Meningitis, Inflammation

 Severe Brain Damage, T.B.I

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Spastic Quadriplegia
1. Severe Case
 Microcephalus, Hydrocephalus

Main Problems
1) Visual Blindness, Visual Agnosia
2) Hearing (deaf) Problems
3) Seizure
4) Feeding Problems : G.E.R (Gastro – Esophageal Reflux), Hypersensitivity
around Oral Areas & Inside Mouth
5) Keep on Crying : Cyanosis, Convulsion
6) Constipation
7) Breathing : Irregular Breathing, Reverse Breathing, Rib Cage Deformities
8) Sleeping Disorder : Loss of Homeostasis
9) Mental Retardation
KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
2. Hypertonus
 Co-contraction
 Moves in Total Patterns
 Lack of Voluntary Movement
 Contracture and Deformities
 Hip Subluxation and Dislocation

3. Associated Reaction
4. Poor Adaptation : Startling Reaction
5. Poor Survival Life : Consider to Homeostasis

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Special Consideration

 Altered Vestibular System

 Poor or None Head Control

 Total & Asymmetric Pattern with Hypertonus related to

Location of the Head and Eyes

 Limited Sensory Channel (esp. Vision)

 Poor Survival Function

 Contracture & Deformity

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Two Patterns of S.Q

 Flexor or Extensor Pattern

― Extensor Pattern : Severe and Moderate Type

― Flexor Pattern : Mainly Moderate Type (can move with poor head control)

 Altered Vestibular System (Head & Eye)

 Hypertonic Pattern of the Neck in relation to Location of the

Eye and Head

 Altered and Higher Muscle Tone of the Neck : Altered and

Inappropriate Signal Activates the Body within Altered Axis

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Extensor pattern

 With Extremely Asymmetry

― In case of More Extended Child Presents Rotation of the Body

to one side within Altered Axis.

― Because Higher Extensor Muscle Tone of the Neck leads to

Rotation of the Eye and Head to one side to get More
Extension, thus it drives Extended and Rotated Body to
maintain an Axis.

KOREA BOBATH PEDIATRIC INSTRUCTOR ASSOCIATION

 Flexor pattern

 More Symmetry than Extensor Pattern

― But likewise, the case of this pattern have Different Tone Distribution of
Both Side (Weighted & Unweighted side).

― Flexor Component means that it is possible to Move.

― In case of difficulties to move the Head Upright Against Gravity which

drives Eyes and Head fall into Flexion with Gravity Direction.

― Therefore, the Body and Other Limb Parts move in Flexor Pattern with
Hypertonus.

KOREA BOBATH PEDIATRIC INSTRUCTOR ASSOCIATION

Features of Severe Spastic Quadriplegia
None Head Control
- Out of Neck Axis
Poor Eye Ball Movement
Total Extensor Patterns
- Eye Ball Deviation with
with Hypertonus
Altered Vestibular System

Less Movement Poor Survival Functions

- immobility of the whole Poor Regulating
Arousal Level - Breathing (reverse pattern)
body(esp. Spine, Rib Cage, - Feeding, Nutrition, GER
Neck, Shoulder, Pelvis) (Common Lower Alertness)
- Constipation
- Contracture & Deformities - Seizure
- Fisted Hands

Limited Sensory Channels

- Lesion : blindness, deaf etc.
- tactile : poor hand to mouth (misunderstanding
somatosensory system)
- Alerted vestibular system
⇒ Limited Perceptual Process Development
Poor Adaptation & Continuously Frightening,
- Hypersensitivity
- Poor Regulation of Homeostasis

KOREA BOBATH PEDIATRIC INSTRUCTOR ASSOCIATION

 Severe S.Q – Breathing Pattern
 Irregular Breathing Pattern

 Reverse Breathing Pattern

 Deformity of Rib Cage

― Upward and Asymmetric Rib Cage, Hollow and Flat Chest

 Noise by Sputum, Pneumonia, Apnea

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
Moderate type of S.Q

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

Features of Moderate Spastic Quadriplegia
Expression of Two Total Pattern
- Hypertonus Altered vestibular system
- Associated Reaction - out of axis in eye & neck
- Less Sequential Movement

Asymmetry Posture
- more changeable Tone Phonation & Speech Problems
than Severe SQ

Immobility of the Body Pulling Arms

- Partially stiff Trunk & - Moving Scapulars
Back, Shoulder, Pelvis Poor Head together
Control - Poor Eye-Hand
Contracture & Deformity
(Out of Axis) Coordination
- Incomplete Arm Support
- Subluxation & Dislocation

Limited sensory channels

- Altered vestibular system with visual problem (can’t watch)
- somatosensory systems

⇒ limited perceptual & cognitive process development

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

General Feature of Severe and Moderate S.Q

POSTURAL TONE

 Severe Spasticity : Severe type

 Moderate Spasticity : Moderate type

- Involved Hypertonus on the whole body, but More Higher on U/E than L/E

- In case of Moderate type, these children are able to move but, with
Hypertonic Pattern.

 Different Distribution

- More Higher Postural Tone on More Extended and Rotated Side

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

Problems Assessment of S.Q based PACa
 Severe or moderate-spasticity
 Different distribution
FACE & NECK
 Low tone on facial muscle
- Open mouth (drooling)
- Feeding problems (sucking, swallowing)
- Poor deep & nasal breathing
 Poor oculomotor muscle
- Altered axis of the eyes (A.V.S)
- Poor downward vision
- Poor two eyes vision
- Deviated and upward eye ball to one side
- Limited and inappropriate visual sensory input
 Inappropriate and altered neck musculature
- Shortened and changed muscle direction related to A.V.S
- Disappearance of capital and neck flexion muscle
- Difference bulk of neck muscles between Lt. side and Rt. Side
 Hypertonus on the neck

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

Problems Assessment of S.Q based PACa

PROXIMAL PART
 Hypertonus on the proximal part because of strong fixation
- Shoulder and hip joint.
 Low tone on core muscle group
- Muscles of axis keeper
- Esp. prematurity
DISTAL PART
 Hypertonus on the distal part because of strong fixation
- Fisted hand
- Flexed and int. rotated arm
- Frozen ankle
- Hypersensitivity

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

Problems Assessment of S.Q based PACa
 Altered vestibular system of the head, neck and eyes
 Axis of the whole body are altered following location of the head, neck and eyes.
HEAD & NECK
 None or poor head control
 Out of axis (esp. eyes)
 Fixed C1-C2 segment
- None or poor capital flexion
movement
- None or poor straightening up
movement of cervical bone
- None or poor package of capital
flexion movement ; downward
vision, mouth closure, nasal
breathing
 Hyperextended and rotated head and
neck to one side (asymmetry)
 Disappearance of C7 process
 Difference between LT. and RT. neck
muscle(SCM, UT)
TRUNK
 Altered posture following location of
the head & neck(A.V.S)
 Hyperextended and rotated spine to
one side
- More twisted in moderated type
 Immobility of spine (too stiff)
 Poor connective spine movement from
cervical to lumbar
 Higher and asymmetrical rib cage
- Breathing problem
 Asymmetrical & twisted spine
- Scoliosis
KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
Problems Assessment of S.Q based PACa
SHOULDER and U/E
 Upward shoulder girdle and narrow
neck and shoulder space
- sternum, clavicle
 Pulling arm with fisted hand
- In case of moderate type, one arm is
pulled and one arm is pushed when
moving
 Poor construction of shoulder joint
(G.H joint)
- None or less voluntary movement
of arm and hand
- Poor hand and elbow support
 None or poor dissociated scapular
and arm movement because of poor
connective spine movement (Esp.
thoracic spine)
 Limited sensory input of hands
PELVIC and L/E
 Out of the middle
- Wind-swept and ant. Tilted pelvis
 Poor construction of pelvis and hip
JT.
- Inadequate angle of hip JT.
- Femur head and acetabulum
 Less and weak legs movement (kicking
– subluxation)
- In case of moderate type, one leg
is possible to kick more than
severe type.
- Poor dissociated L/E movement
 None or poor pelvis 3-dimensional
movement because of connective spine
movement (ESP. lumbar spine)
 L/E mal-alignment and frozen ankle
KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
Problems Assessment of S.Q based PACa

LOWER LEVEL OF ALERTNESS

 Low Arousal level
 Poor cognition level
POOR WATCHING WITH TWO EYES VISION
 Altered vestibular system (V.O.R)
 Poor head control
POOR VOLUNTARY MOVEMENT OF HAND AND FOOT
 Poor body scheme from head to feet
 Moves by itself with intention
 As a B.O.S such as elbow support

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

Problems Assessment of S.Q based PACa

POOR ADAPTATION TO ENVIROMENT

 Too much scare from extrostimulation (esp. auditory)
POOR SENSORY INTEGRATION AND PROCESS
 Vision, auditory, vestibular and somatosenseation
 Increasing dependency of auditory than other sensory
 Poor body scheme
 Hypersensitivity
MULTIPLE CONTRACTURES ON THE JOINTS
 Hip JT. Subluxation and dislocation
 Shoulder JT., Ankle JT., Wrist JT., Etc.
 More risk in moderate type than severe type

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

Problems Assessment of S.Q based PACa

SEIZURE & EPILEPSY

POOR SELF-REGULATION
 Irregular and reverse sleep cycle
 Homeostasis problem
FEEDING PROBLMES
 Poor oral motor control
 G.E.R, Poor cough reflex, A high risk of aspiration
BREATHING PROBLEMS
 Higher and asymmetry rig-cage
 Reverse and irregular pattern
 Sputum, Apnea

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

General feature of Severe and Moderate S.Q

POSTURAL PATTERN
 Lower level of alertness
- Poor cognition & mentality

 Extremely asymmetric postures with hyperextension

- Movement with hypertonic pattern
- Altered vestibular system of the head with the eyes and neck
- Poor or no head control
- Fixed and shortened C1-C2 segment, hyperextended neck (contractures)
- Disappearance of S.C.M, two columns of trapezius
- Poor or no segmental spinal rotation movement
- Poor or no scapular movement ; no dissociated movement of the arms

Jung Sun Hong. (2014). Cerebral palsy treatment ideas from normal development 3rd edition.
KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
General feature of Severe and Moderate S.Q

POSTURAL PATTERN
 Extremely asymmetric postures with hyperextension
- Too stiff spine (immobility, scoliosis)
- No shoulder and arm joint construction ; always extended arm with flexed and
pronated hand
- Asymmetry rib cage and poor proximal stability
- No pelvis 3-dimensional movement
- Extension and internal rotated legs, less movements

 Poor voluntary movements

- Poor or no hand and foot voluntary movement
- Lack of movements from cortical level

Jung Sun Hong. (2014). Cerebral palsy treatment ideas from normal development 3rd edition.
KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
General feature of Severe and Moderate S.Q
POSTURAL PATTERN
 Poor body scheme

 Reverse, irregular breathing pattern / apnea

- Poor cough reflex / sputum on the lungs

ASSOCIATED PROBLEM

 Problems of the vision, auditory, vestibular system

 Seizure, epilepsy

 Poor sleeping cycle, poor homeostasis

 Associated reaction

Jung Sun Hong. (2014). Cerebral palsy treatment ideas from normal development 3rd edition.
KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
General feature of Severe and Moderate S.Q

CONTRACTURE & DEFORMITY

 Multiple contractures on the joints

 Higher rib-cage with fixed shoulders

 Hip subluxation or dislocation

 Frozen ankles and malalignment of the ankles

Jung Sun Hong. (2014). Cerebral palsy treatment ideas from normal development 3rd edition.
KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION
Consideration for Treatment of Severe S.Q

 Arousal level

 Breathing

 Feeding, Nutrition & Constipation

 Sleeping rhythm & Seizure

 Sensory channel

 Adaptation

 Altered Vestibular System

 Subcortical level of movement

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

Consideration for Treatment of Modereate S.Q

 Altered Vestibular System

 Package of Capital Flexion

 The axis of eyes & neck

 Connective movement with Capital Flexion

 Cortical level of movement as eye, hand & foot

 Contracture & deformities

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Principles of Treatment of S.Q

 Alertness, Breathing, Eating(Nutrition), Defecation,

Sleeping rhythm
- Severe type
 Make sequential movement
- Moderate type
 Low alertness
- To activate alertness include adjustment and
stimulation of V.O.R or face muscles
- Lowering eyes and face muscles

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Principles of Treatment of S.Q based on PACa
POSTURAL TONE
 Regulation of hyper-tonus by activating movement of distal part and neutralization of
altered vestibular system
 Building up the face & neck M. tone for arousal level
 Activating the muscle tone of proximal part
AXIS
 Neutralize of altered vestibular system and bring eyes and head to the middle
 Finding the c1-c2 segment and making capital flexion movement
 Special consideration of package of capital flexion
 Making the correct axis of whole body part from head to feet
 Activating automatic movement within the correct axis
CORTICAL LEVEL MOVEMENT
 Watching
 Hand movement such as grasping or holding something

ASSOCIATED PROBLEMS
 All things of associated problems will be considered, similar to PAC

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Treatment of S.Q
Facial muscles Forearm support

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Treatment of S.Q
PREPARATION IN SITTING
- MOBILIZATION OF THE SPINE AND PELVIS
- PULLING PELVIS AT RIGHT ANGLE

⇒ HEAD CONTROL WITH ARM SUPPORT

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION

 Treatment of S.Q
CHANGING DIRECTION OF THE ARMS AND LEGS
- PRONE IS A GOOD POSITION OF PREPARATION
- WEIGHT TRANSFER TOWARDS THE LATERAL SIDE
(elongate muscles of arm and leg)

KOREA PEDIATRIC BOBATH INSTRUCTOR ASSOCIATION