Dr.P.

UDHAYA KUMAR
MD.PM&R 1st year PG
DEPARTMENT OF PM&R

MODERATOR
DR.S.CHIDAMBARANATHAN
DEPARTMENT OF PAEDIATRICS
 To prevent contractures,deformities and abnormal
posture.
 Promote normal development.
 Enable child to attain greatest possible level of
independence.
 Family support.
This can all be achieved by,
Multidisciplinary team approach
 Physical therapy.
 Bracing.
 Management of spasticity.
 Surgical options.
 Pediatric Psychiatrist
Pediatrician neurologist

Nurse
Physiatrist
Physiotherapist

Orthopeadician
Occupational
therapist

Child
Family
Orthotist

Teacher
Speech therapist

Social worker Psychologist Special educator

 AGE MISSED MILESTONES REQUIRING INTERVENTION

2 months : Lack of visual fixation.

No social smile.
4-6 months : Fails to track person or object.
No steady head control.
No response/turn to sound or voice.
6 months : Decrease/absence of vocalizations.
9-12 months : Fails to sit independently.
18 months : Fails to walk independently.
Does not seek shared attention to object/event
with caregiver.
24 months : No single word.
36 months : No three word sentences.
Cannot follow simple commands.
>3 years : Speech unintelligible.
Dependence on gestures to follow commands.
 Physical therapy consists of hands-on approach by
physical,occupational and speech therapists to
improve gross motor,fine motor and oromotor
functions.
 Stretching:stretching is a component of therapy
program and it reduces the risk of contracture
development as a result of muscle imbalances and
hypertonicity.
 There are various forms of neuromotor therapy
approaches to cerebral palsy in which the main
goal of all therapies is to promote and facilitate
development in all domains of function.
 NEUROMOTOR APPROACHES IN CP

 Neurodevelopmental treatment(Bobaths).
 Neuro Development Therapy(NDT).
 Sensorimotor approach(Rood).
 Sensory Integration approach(Ayres).
 Vojta approach.
 Patterning Therapy(Doman-Delcato).
 Constraint- Induced Movement
Therapy(CIMT).
 Bobaths Neuro Development Therapy is the most widely used
and efficient therapy that emphasises hands on facilitation of
movement and positioning to normalise tone and reduce the
influence of abnormal postures including primitive reflexes.
 Kinesthetic,proprioceptive and tactile stimulation used to
produce motor response.
 Treatment activities include positioning and handling to
normalise sensory input and also by facilitation of active
movements by children.
 Family members participation required for handling and
positioning for ADL.
BOBATHs NEURODEVELOPMENTAL
THERAPY
 NDT is child centered,hands on,problem solving
approach.
 It involves managing problems related to the
development of the child,including impairment in
perception and cognition.
 Key elements in NDT are facilitation,management
of compensatory motor behaviour and an overall
management strategy.
 It involves task-specific postures and movements
and emphasises functional activities and
participation in daily life situations.
NEURODEVELOPMENT THERAPY
 This approach was first developed by Mrs.MARGARET ROOD
(Occupational Therapist)in 1950.
 The goal of this therapy is to activate postural
responses(stability) and to activate movement (mobility) once
stability is achieved.
 Tactile,proprioceptive and kinesthetic sensations are used to
activate motor response.
 Treatment activity emphasizes sensory stimulation to activate
motor response(taping,brushing,icing).
 No family involvement required during treatment.
ROODs SENSORIMOTOR APPROACH
 The main aim of this therapy is to improve efficiency of
neural processing and to better organise adaptive response.
 Vestibular,tactile and kinesthetic responses used to activate
motor response.
 Therapist guides the therapy but child controls sensory input
to get adaptive purposeful response.
 Children with learning diabilities and autism benefits from
this therapy.
 Family participation is not needed during treatment but
supportive role is encouraged.
AYRES SENSORY INTEGRATION APPROACH
 This approach helps to prevent cerebral palsy in infants at
risk and also improves motor behavior in infants with cerebral
palsy.
 Proprioceptive,kinesthetic and tactile stimulation used to
produce motor response.
 Treatment activities emphasizes trigger reflex locomotive
zones to encourage movement patterns(e.g.,reflex crawl).
 It is used in young infants at risk for cerebral palsy and
infants with cerebral palsy.
 Family people administers treatment at home daily.
VOJTA APPROACH
 The main purpose of this therapy is to achieve independent
mobility,to improve motor coordination,to prevent or improve
communication disorders and to enhance intelligence.
 All sensory systems are used to facilitate motor response
 Treatment activities emphasizes sensory and reflex
stimulation,passive movement patterns,encouragement of
independent movements.
 Children with neonatal or acquired brain damage gets benefit
from this therapy approach.
 Family and friends administer treatment several times daily.
PATTERNING THERAPY
 CIMT or forced use program uses restrictive slings
and casts in the functional upper limb of children
with hemiplegia produced early recovery of upper
limb function.
 In children with hemiplegic CP,the unaffected limb
is restrained with a removable cast typically for 3
weeks and the child undergoes intensive structured
therapy in addition to daily activities and play.
 The review suggests that home based CIMT had
shown better improvement than clinic or camp
based settings.
 Will my child walk is usually the question asked most frequently
by parents of a newly diagnosed child with CP.
 In discussion one must clarify not only distances
involved(household vs. community) but also the quality of gait
and need for both orthoses and/or upper limb assistive devices.
 Clinical type of CP is an important prognostic factor for
ambulation.
Good prognosis
 Hemiplegic children
 Independent sitting occuring by 2 years
 Ability to crawl on hands and knees by 1.5 to 2 years
 Transition from supine to prone by 18 months.
Poor prognosis
 Atonic CP
 Persistence of 3 or more primitive reflexes at 18-24 months
 Bracing goals include reduction of
abnormal tone,avoidance of
deformity,and facilitation of normal
movement patterns.
 Light weight plastics are widely used
and include aquaplast and
polypropylene.
 The primary use of upper limb orthoses is to
prevent fixed deformity.
 The cortical thumb loop orthoses,a simple
fabric loop provides pressure into thenar
eminence,promotes abduction and
extension of the thumb and facilitates
thumb-opposed grasp.
 Wrist and/or elbow extension splints can be
used during the day to extend reach,or at
night to prevent flexion deformities.
 CORTICAL THUMB ORTHOSES

WRIST SPLINT

UPPER LIMB ORTHOSES

ELBOW EXTENSION SPLINT

 Supramalleolar and inframalleolar othoses are
used primarily to control foot and talocalcaneal
ligament.

 Articulated AFO allows setting of a plantarflexion

stop while allowing free dorsiflexion and
promotes active use of tibialis anterior necessary
in stair climbing,crouching and half kneeling.

 Posterior Leaf Spring Orthoses(PLSAFOs) are solid

ankle orthoses,thinned posteriorly to stimulate
push-off at the end of stance phase,following
passive dorsiflexion in early to mid stance.
 Knee Ankle Foot Orthoses(KAFOs) add
direct control over knee flexion and
extension as well as varus and valgus
alignment.

 Hip Knee Ankle Foot Orthoses(HKAFOs) add

control over hip position.

 Neither of above 2 braces significantly

improves gait capability, but reduces
deformity and facilitate standing
SMO

IMO PLSAFO

LOWER LIMB ORTHOSES

AFO
KAFO HKAFO
 An exoskeletal orthoses is different from a conventional
orthoses as it uses an external power source to supplement
and produce movement.
 Powered orthoses may be used to enable walking who cannot
walk,or can be used as rehabilitaion aid in people who have
only some ability to walk.
 Walking with a powered exoskeleton requires specialised
training and practice.
 The mainstay of treatment is through the application of
modalities,primarily therapeutic exercise,ROM exercises,heat
and cold application,casting,medications and splinting.
Medications
 By limiting the effects of spasticity,deformity can be
prevented ,nursing care improved,bracing better
tolerated,and function enhanced.
 Most commonly used medications are,
 Baclofen:1-2 mg/kg/day.
 Diazepam:0.5mg/kg/day.
 Clonidine:0.05-0.1 mg bid.
 Tizanidine:1-2mg/day.
 common side effects:sedative and GI effects.
LOWER LIMBS:
 Obturator nerve block:reduces adductor
tone,diminish scissored gait,and promote
passive abduction by means of protecting
hip integrity.
 Sciatic branch block:to the medial
hamstring muscles lessen crouch gait and
internal rotation posture.
 Tibial nerve block: diminish plantarflexion
tone and allow better tolerance of AFO.
 Femoral nerve block :diminish spastic genu
recurvatum.
UPPER LIMBS:

 Musculocutaneous nerve block: promotes

elbow extension and facilitate reach.
 Motor point injections into the
forearm,wrist and finger flexors are
preferred.
 These nerve blocks are given with
Botulinum toxin A.
 Botulinum neurotoxin type A is used recently in the
treatment of spasticity in children.
 Botox A acts by irreversible blockage of presynaptic
release of acetylcholine at neuromuscular junction
 given as an IM injection the onset of clinical action
is delayed by 24 to 72 hours and its clinical effect
peaks at 2 to 6 weeks and last about 3 to 6 months
with reinnervation by axonal sprouting.
 Large muscles require several injection
sites.common clinical practice allows injection of 12
to 14 U/kg divided among all injected muscles.
 Advantages over nerve block include no need
for anaesthesia,no sensory side effects, and no
apparent tolerance to repeated injections.
 Botox A significantly improved positioning in
children with severe quadriplegia with
paraspinal spasticity,enhanced gait function in
hemiplegic and diplegic children with severe
gastrocnemius spasticity.
 Botox injected into thenar muscles reduced the
cortical posture of thumb and resulted in
significant hand opening.
 The cost of 1 vial of BOTOX A is $400.
 Intrathecal baclofen infusion offers the advantage of
bypassing the poor ability of baclofen to cross the
blood brain barrier leading to CSF concentration 30
times higher than when given by mouth.
 Incidence of side effects are reduced .
 The intrethecal catheter is inserted by lumbar
puncture and positioned at T10 spinal level.The
dose is delivered by a programmable pump
implanted in a subcutaneous abdominal pouch and
dosage varies from 30 to 800mg/day.
 Changes in dose as well as mode of
delivery(continous,bolus or variable rate) can be
made by transcutaneous telemetry.
 While tone reduction is most significant in the
lower limbs,effects on the upper limb and
trunk are also seen by upward migration of
infused baclofen.
 Complications:CSF seroma,leaks,catheter
kinking or dislodgement,infection and pump
failure but has low incidence.
 Battery life is upto 7 years but replacement
requires surgical procedure.
 The cost of the pump and its placement is
about $25,000 with refills every 2 to 3 months
costing about $750.
 Physiotherapy should be continued while the
child is on intrathecal baclofen.
The CP child is at risk of respiratory complications due to retained
secretions,infections ,V/Q mismatch.These can be prevented by,

POSTURAL DRAINAGE POSITIONS

 Supine 30 degree head up,
 Prone horizontal,
 Right and left horizontal side lying,
 Upright sitting for apical segment of upper lobe.

PERCUSSION AND CHEST WALL VIBRATIONS are used in CP

as it is passive and effective at mobilising secretions.
 Should be combined with postural drainage positions to remove
secretions faster than positioning alone.
 Hyperbaric oxygen Therapy-awaken dormant brain
tissue surrounding the original injury.
 Threshold electical stimulation-increased blood flow
from electrical current will lead to stronger muscles.
 Functional neuromuscular stimulation-increased muscle
contraction will improve strength and function.
 Conductive education-problems with motor skills are
problems of learning ,new abilities are created out of
learning.
 Hippotherapy-riding a horse can improve muscle
tone,head and trunk control,mobility in the pelvis,and
equilibrium.
 Positive factors for independent living include regular
schooling,completion of secondary school,independent
mobility and ability to travel beyond the house,good hand
skills,having spasiticity as a motor dysfunction.
 Mental retardation,seizures and wheel chair dependency are
factors that reduces the likelyhood of independent living.
 Positive prognostic factors for employment include mild
physical invovement,good family support and vocational
training.
 Immobility and severe or profound mental retardation
reduces life expectancy.About 90% of children with CP survive
to adulthood.
Predictors of successful and unsuccessful employment include,
Competitive/able to work:
 IQ>80%.
 Ambulation with or without assistive device.
 Speech hard to understand to normal.
 Hand use normal to requiring assistance.
Sheltered employment:
 IQ 50-79%.
 Ambulation with or without assistive device.
 Speech hard to understand to normal.
 Hand use normal to requiring assistance.
Unemployable/unable to work:
 IQ<50%.
 Non ambulatory and non oral.
 Requires assistance using hand.
 One of the most common complaints with aging is neck pain
occuring in 50% of spastic patients and 75% in the dyskinetic
group.
 Scoliosis has a much higher incidence in non ambulatory
individuals.
 Data suggests that individuals with CP are capable of near
normal reproduction.
 Regular antenatal care.
 Safe delivery.

 Breast feeding.

 Good neonatal care.

Regular follow up of risk infants like

 Low birth weight babies,

 Premature babies,

 Low APGAR score.

THANK YOU
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