PEDIATRIC REHABILITATION:

CEREBRAL PALSY
 CEREBRAL PALSY
-New England Journal of Medicine

• Cerebral palsy is a symptom complex, rather

than a specific disease
• The most recent consensus definition states
that cerebral palsy is an:
– umbrella term covering a group of non-
progressive, but often changing, motor
impairment syndromes secondary to lesions
or anomalies of the brain arising in the early
stages of its development
– Cerebral: pertaining to the cerebrum
(largest part of the brain)
– Palsy: Temporary or permanent loss of
sensation or loss of ability to move or control
movement
 Epidemiology

• Leading cause of childhood d/a

• Incidence: 2-3 per 1000 live
births
• General risk factors
– Gestational age < 32 weeks
– Birth weight < 2500 grams
 Etiology

• Brain injury resulting in CP

may occur:
– Prenatal period
• 70-80% of the CP
– Perinatal period
– Postnatal period
Volpe’s Subtype of Hypoxic-
Ischemic Neuropathology

– Parasagittal cerebral injury

– Periventricular leukomalacia
– Focal and multifocal ischemic
brain necrosis
– Status marmoratus
– Selective neuronal necrosis
 Prenatal Factors

• May lead to premature birth

or intrauterine growth
retardation of both of term
or preterm infants
• Prematurity- MC antecedent
of CP
Human Growth Development:
Milestone in Child Development

-Molnar
 Age Gross Motor Fine Motor Personal/ Cognitive Cognitive Emotional
Adaptive Social

NEWBORN Flexor tone Hands Habituation Sensorimot Cry Basic trust vs.
predominates fisted & some or 0-24 mo. State- basic mistrust
In prone, Grasp control of Reflex dependent (first year)
turns head to reflex state stage quieting & Normal
side State ability head turning symbolic
Automatic to fix & follow to rattle or phase- does
reflex walking bright object voice not differentiate
between self &
Rounded mother
spine when
held sitting

4 MONTHS Head Hands Recognizes Turns voice Circular Lap baby-

midline mostly open bottle & bell reaction- the developing a
Head held Midline consistently interesting sense of basic
when pulled hand play Laugh & result of an trust
to sit squeals action
Crude motivates its
In prone, palmar grasp Responsive repetition
lifts head to vocalization
90° & lift Blows
chest slightly bubbles
Turns to
supine
 Age Gross Motor Fine Motor Personal/ Cognitive Cognitive Emotional
Adaptive Social

7 MONTHS Maintain Intermediat Differentiat Uses single @ 5 mo.

sitting, may e grasp es between words & Began to
lean on arms Transfer familiar double differentiate
Rolls on cube from person & consonants- between
prone hand to hand stranger vowel mother & self
Holds combination Has a sense
Bears all Bangs
weight; object bottle of belonging to
bounces Looks for central person
when head dropped
held erect object
Cervical “Talks” to
lordosis mirror image

10 MONTHS Creeps on Pincer Plays peek Shouts for Can Practicing

all four grasp, mature a boo attention retrieve an phase or
Pivots on thumb to Finger Imitates object hidden separation-
sitting index grasp feeds speech from view individualizatio
Bangs two sounds n, practices
Stands Chews on initiating
momentarily cubes held in rotatory Waves bye-
hands separations
Cruises movement bye
Slight bow Uses
leg “mama” &
“dada”
Inc. lumbar
lordosis Inhibits
behavior to
“no”
 Age Gross Fine Motor Personal/ Speech Cognitive Emotional
Motor Adaptive Social and
Language

14 MONTHS Walks Piles 2 Uses Uses Differentia Rapproche

alone, arms cubes spoon with single tes ment phase
in high Scribbles overpronati words available of
guards or spontaneou on and Understa behavior separation-
midguard sly spilling ndsimple patterns for individualizati
Wide Removes commands new ends, on; practices
Holds ie.,pulls rug initiating
BOS crayon full a garment
on which is separations
Excessive length in a toy
hip & knee palm
Fx Casts
foot contact objects
in the entire
saole
Slight
valgus of
knees &
feet
Pelvic tilt
& rotation
 Age Gross Fine Motor Personal/ Speech Cognitive Emotiona
Motor Adaptive Social and
Language
18 Arms at Emerging Imitates Points to Capable
MONTHS low guard hand housework named of insights,
Mature dominance Carries,h body part i.e., solving
supporting Crude ugs doll Identifies a problem
base and release one picture by mental
Drinks combinatio
heel strike Holds from cup Say “no” ns,not
Seats self crayon butt neatly jargons physical
in chair end in palm groping
Walks Dumps
backward raisin from
bottle
spontaneou
sly
 Age Gross Fine Motor Personal/ Speech Cognitive Emotional
Motor Adaptive Social and
Language
2 YEARS Begins Hand Pulls on Two- Preopera
running dominance garment word tional
Walks up is usual Uses phrases period (2-7
and down builds spoon well are yrs.old)
stairs eight-cube common Able to
Opens
alone tower door Uses evoke an
Jumps Aligns turning verbs object or
on both cubes knob Refers to event not
feet in horizontall self by present
Feeds
place y doll with name Object
Imitates bottle or Uses permanen
vertical spoon “me” ce
line Toilet “mine” Establishe
Places training Follows d
pencil usually simple Compreh
shaft bet. begun directions ends
Thumb symbols
and fingers
Draws
with arm
and wrist
action
 Age Gross Fine Motor Personal/ Speech Cognitive Emotional
Motor Adaptive Social and
Language
3 YEARS Runs well Imitates Most 3 word Preoperat Stages of
Pedals three cube children sentences ional period initiative vs.
tricycle bridge toilet are usual contiinues guilt (3-5)
Copies trained day Uses Child is Deals with
Broad and night
jumps circle future tense capable of: issue of
Uses Pours Asks deffered genital
Walks up from pitcher imitation sexuality
stairs overhand what, who,
throw with Unbottons where symbpolic
alternating play
feet anteroposte :washes Follows
rior arm and dries preposition Drawing
and trunk hands and al of graphic
motion face commands images,
Catches Parallel mental
Gives full images &
with play name
extended verbal
Can take Mat evocation
arms turns
hugging stutter in of events
against Can be eagerness
body reasoned Identifies
with self as boy
or girl
Recogniz
es three
colors
 Age Gross Fine Personal/ Speech Cognitive Emotional
Motor Motor Social and
Adaptive Language
4 YEARS Walks Handles Coopera Gives
down a pencil tive play- connected
stairs by finger sharing & account of
alternting & wrist interacting recent
feet action, Imaginat experienc
Hops on like adults ive make es
one foot Copies a believe Question
Plantar cross Dresses s why,
arches Draws a & dresses when how
developin froglike with Use past
g person supervisio tense
Sits ups with head n adjective,
from & distuingui adverbs
supine s extremitie shing front Knowsw
rotating s & back of opposite
Throws clothing & analogies
underhan buttoning
Repeats
d Does four digits
Cuts simple
with errands
scissors outside of
home
 Erikson’s Psychosocial Child
Development
Trust vs. Mistrust
Is the first psychosocial challenge the infant faces in
its social environment.

Autonomy vs. Shame and Doubt

In this stage, the central psychosocial challenge faced
during the second and third years of life concerns
autonomy.

Initiative vs. Guilt

This stage, corresponding to the preschool years of 3
to 6, is a time of climbing gyms and play dates, a time
at which the child is challenged to initiate actions and
carry them out.

Industry vs. Inferiority

At this stage, which corresponds to the elementary
school period of 6 to 12 years, the child faces the
central challenge of developing industriousness and
self-confidence
Classification of Cerebral Palsy
 Neurologic Classification

• Spastic or Pyramidal CP
• Dyskinetic or Extrapyramidal
CP
• Mixed Types
 Spastic CP

• Most common
• Manifest signs of UMNL:
– Hypereflexia
– Clonus
– Babinski response
– Abnornal after 2y/o
– Persistent primitive reflexes
– Overflow reflexes
 Topographic Distribution
of Spastic CP
• Monoplegia
• Diplegia
• Triplegia
• Quadriplegia
• Hemiplegia
 Spastic Monoplegia

• Isolated UE or LE involvement
• Rarely seen
• Mild clinical presentation
 Spastic Diplegia
• Little’s Dse.
• Hx of prematurity
• Hx of intraventricular
hemorrhages
• MRI may show periventricular
leukpmalacia or posthemorrhagic
porencephaly
• Hx of early hypoonia followed by
spasticity
• Gross motor devt’ delays
• Mild coordination problems in UE
 Spastic Diplegia

• Diplegic gait pattern

• Contrctures assoc. w/ spasticity
• Eye findings
– Strabismus
– Visual deficit
• Seizure
• Cognitive impairmeent
• Vasomotor signs in affected
extremities
 Spastic Triplegia

• Three extremities involved

• Bilateral LE & one UE
• Spasticity in involved limbs
• Mild coordination on noninvolved
limbs
• Scissoring & toe walking
• Similar features to spastic
quadriplegia
 Spastic Quadriplegia

• All extremities involved

• UE>LE
• Hx of difficulty of delivery w/
evidence of perinatal asphyxia
• MRI in preterm showed PVL
• Opisthotinic posturing
• Oromotor dysfunction
• Pseudobulbar involvement
• Feeding difficulties & may require
NGT
 Dyskinetic CP

• Extrapyramidal movements
• Secondary to:
– AbN regulation of tone
• Defecit in postural control
• Coordination deficits
• Generally hypotonic at birth
 Dyskinetic CP

• UE > LE frequently
• During sleep, muscle tone is normal
• DTR’s are normal or slightly
increased
• Usually thin or ectomorph
• Low incidence of contracture
• Scoliosis may develop
 Dyskinetic CP

• Pseudobulbar involvement may be

present: (4D’s)
– Drooling
– Dysphagia
– Dysarthria
– Oromotor Dyskinesias
 Dyskinetic CP

• Normal intelligence range

• High incidence of sensorineural
loss
• Hearing loss associated with:
– Hyperbilibirunemia  dental
enamel dysplasia
– Neonatal jaundice
 Dyskinetic CP

• Types:
– Athethosis
– Chorea
– Choreoathethoid
– Dystonia
– Ataxic
 Athetosis

• Slow writhing involuntary

movements of the distal
extremities
• Active agonist & antagonist muscle
• Intensity may ￪ with emotions &
purposeful activities
 Chorea

• Abrupt, irregular jerky mov’t

• Occurs in head neck & extremities
 Choreroatethoid

• Combination of atethosis &

choreiform mov’t
• Large amplitude involuntary mov’t
• Athetosis is dominant
 Dystonia

• Slow, rhythmic mov’t with tone

changes
• Found in trunk & extremities
• AbN posture
 Ataxic

• Unsteadiness with uncoordinated

mov’t
• Associated with:
– Nystagmus
– Dysmetria
– Wide based gait
 Mixed Types CP

• Description include both spastic &

dyskinetic classification
 Functional Systems
• Classification based on functionality &
severity of CP:

• Mild
– No limitation in ordinary activities
• Moderate
– difficulties on ADL & may require
assistive device
• Severe
– Moderate-severe limitation on ADL
 Gross Motor Function
Classification System
• Level I
– Walks s restriction
– Limitations in more advanced gross motor skills
• Level II
– Walks s assistive device
– Limitations walking outdoors & community
• Level III
– Walks with assistive mobility device
– Limitations walking outdoors & community
• Level IV
– Self mobility with limitation
– Transported or use power mobility outdoor &
community
• Level V
– Self mobility is severely limited with even with the
use of assistive technology
 Clinical Examination
• Musculoskeletal Examination
• Static Evaluation
– Geared toward isolation each
joint & assessing passive ROM
along with tone & spasticity
• Dynamic
– Observing mov’t function & gait
Dynamic Evaluation: Gait Ax–
Typical Gait Abnormality
• Spastic Diplegia • Hemiplegia
– Scissoring gait – Weak hip Fx &
pattern Ankle DFx
– Hips Fx & Add – Overactive TP
– Knees Fx & – Hip hiking &
valgus hip
– Ankle in circumduction
equinus – Supinated foot
 Static Evaluation
• Hip Assessment
– Test for Hip Contracture
• Thomas Test
• Ely Test
• Staheli Test
– Test for Adductor Contracture
– Test for both Internal &
External Rotators
– Leg length Evaluation
 Static Evaluation

• Knee Assessment
– Test for Hamstring
Contractures
– Evaluation of the Position of the
Patella
– Test for Posterior Capsular
Tightness
 Static Evaluation

• Foot & Ankle Assessment

– Test for Gastrocsoleus
Contracture
• Silfverskiold Test
– Evaluation of the TP & Peroneal
mmuscle
– Test for Tibial Torsion
– Back Assessment
– UE Assessment
 Neurologic Examination

• Tone Assessment
• Postural & Reflex Assessment
– Moro
– ATNR
– Neck Righting
– Vertical suspension
– Grasp reflex
– TLR
– Protective Reflex
– STNR
 Clinical Course
• Characterized by changing
function & dysfunction over
the years of growth &
development
 Hemiplegic CP

• Exhibits definite hand preference

usually before 1 y/o compared with
normal handedness of 2 y/o
• UE: shoulder add, elbow fx, FA
pronated, wrist fx, hand fisted & thumb
in the palm
• Impaired sensation
• Independent ADL’s but need with some
aids
• Ambulatory
• Unequal stride length
• Fx hips & knee
 Spastic Diplegia

• Spasticity in LE
• Little or no functional l9imitation
in UE
• Late attainment of gross motor
skills- standing & walking
• Maintenance of sitting by age of 2
 predictive sign of ambulation
• Children who did not sit by the age
of 4  cannot ambulate
 Spastic Diplegia
• Scissoring pattern of LE
– Simultaneous hip Add
– Knee hyperEx
– Ankle PFx
• Gait requires walkers & orthoses
• With increasing age, crouched
posture may develop
 Spastic Quadriplegia

• Delayed developmental milestones

• Excessive extensor spasticity
• Hip dislocation & scoliosis
• Spastic muscle imbalance
• Sublaxation, acquired acetabular
dysplasia & hip dislocation occur on
nonambulatory child
• Mild involvement with minimal or no fxn’l
limitation on ADL’s
• Sitting at 2 y/o & suppression of
infantile reflexes by 18 mo.  good
prognosis for ambulation
 Dyskinetic CP
• Increased tone
• Opisthotonus
• Longer period of hypotonia
• Persistence of Moro & ATNR
• AbN mov’t occurs in all affected
extremities occur by 18 mo.
• UE > LE
• Involvement of the fae &
ororpharyngeal muscles causes:
– Dysphagia
– Drooling
– Dysarthria
 Dyskinetic CP

• Severe neuromuscular dysfunction

• Attain walking after 3 y/o
• In ambulatory child  good UE
• Non ambulatory  need assistance
 Associated Deficits

• Mental Retardation
• Seizures
• Oromotor dysfunction
• GI problems
• Dental
• Visual impairments
• Hearing impairments
• Cortical sensory deficit
• Pulmonary problems
 Mental Retardation

• Most serious associated d/a

• 30-50% of the pt.
• Greatest retardation with rigid,
atonic & severe cases spastic
quadriplegia
 Seizure Disorders

• Most frequent in postnatal

acquired hemiplegia, congenital
hemiplegia & spastic quadreplegia
 Oromotor Dysfunction

• Difficulty sucking
• Dysphagia
• Chewing difficulty
• Poor lip closure
• Tounge thrust
• Drooling
• Dysarthria
• MC in spastic quad. & dyskinetic
 GI Problems
• Gastroesophageal reflux
• Constipation
 Dental Involvement
• Enamel dysgenesis
• Malocclusion
• Caries
• Gingival hyperplasia
 Visual Impairments
• Strabismus
• Refractory errors
• Hemianopsia
 Hearing Impairment

• Infection
• Medication
• Bilirubin encephaloipathy
 Reflexes
Reflex Stimulus Response Age of
Supression
Moro Neck Shoulder ABD, 4-6 months
extension elbow and
finger E 
arm F and
ADD
Rooting Stroking of lips Moving of 4 months
head towards
the stimulus
Positive Light pressure Leg extend for 3-5 months
Supporting or WB on partial support
plantar of BW
surface
Automatic Vertical  Alternate 3-4 months
Neonatal plantar contact automatic
 tilt body steps with
forward or support
side to side
 Reflexes
Reflex Stimulus Response Age of
Supression

Neck Righting Neck rotation in Sequential body 4 months

supine rotation from
shoulder to
pelvis 
direction of the
face
Tonic Head position in Supine  4-6 months
labyrinthine space 45 extensor
degrees from Prone  flexor
horizontal

ATNR Head turning to Extremities 6-7 months

side extend on chin
side; flex on
occiput side

STNR Neck flexion Arm flex & neck 6-7 months

Neck extension ext
Arm ext & neck
flex
 Reflexes
Reflex Stimulus Response Age of Supression

Palmar grasp Touch or pressure Flexion of all fingers 5-6 months

on palm or Hand fisting
stretching finger
flexion
Plantar grasp Pressure on sole Flexion of all toes 12-14 months
distal to MT heads
 Postural Reflexes
Reflex Stimulus Response Age of
Emergence

Head Righting Visual and Align face/head Prone 2 months

vestibular vertical, mouth Supine 3-4
horizontal months

Head & Body Tactile, vestibular Aligns body parts 4-6 months
Righting proprioceptive in anatomic
position relative to
each other &
gravity
Protective Displacement of E, ABD of lateral Sitting ant 5-7
Extension or COG outside the extremities mos
Parachute supporting base in towards Lateral 6-8 mos
sitting & standing displacement to
prevent falling Posterior 7-8 mos
Standing 12-14
mos
Equilibrium or Displacement of Adjustment of Sitting 6-8 mos
Tilting COG tone & posture of Standing 12-14
trunk to maintain mos
balance
Therapeutic Management
• Management in infancy includes :
– Proper positioning and alignment
– Proper handling techniques
– Proper parent instruction
Early Intervention

• To prevent or minimize adverse developmental

outcome
• Must provide :
• Infant-caregiver interaction
• Family support for coping
• Parental education for child handling
• Treatment to promote motor and other
developmental skills
Treatment Approaches
W.M. Phelps
• Specific diagnosis classification of each child
as a basis for specific treatment methods.
• Fifteen modalities
1. Massage for hypotonic ms. CI: children w/
spasticity and athetoids
2. Passive motion through jt. Range for
mobilizing jts. And demonstrating to the
child the movt required.
• Speed – slower:spasticity,
increase:rigidity
3. active assisted motion
4. active motion
5. resisted motion followed accdg. To child’s capability.
6. conditioned motion is recommended for babies, young
children and mentally retarded children.
7. Confused motion or synergistic motion
8. Combined motion
9. relaxation techniques
10.mov’t from relaxation is conscious control of mov’ts once
relaxation has achieved
11. rest
12. reciprocation
13. balance – sitting balance and standing in
braces
14. reach and grasp and release used for training
hand fxn
15. skills of daily living such as feeding, dressing,
washing, and toileting.
• Braces and calipers. Correction of deformity and
to obtain to obtain upright position and control
athetosis.
• Muscle education
Progressive Pattern Movements
Temple Fay
• Stage 1. Prone lying.
• Stage 2. Homolateral stage.
• Stage 3. Contralateral stage.
• Stage 4. on hands and knee
• Stage 5. walking pattern

(The progressive pattern mov’t are first practice 5

mins periods atleast five times daily.)
Synergistic Movement Patterns
Signe Brunnstrom
• Reflex responses
– Used initially and later voluntary control of
these reflex patterns in trained.
• Control of head and trunk.
– Stimulation of attitudinal reflexes such as
tonic neck reflexes, tonic lumbar etc.
• Associated reactions
– Used as well as hand reactions, e.g. hyperex.
Of thumb produces relaxation of the finger
flexor
Proprioceptive Neuromuscular
Facilitation
Herman Kabat
• Mov’t patterns
1. Flexion or extension
2. Abduction or adduction
3. Internal or external rotation
• Sensory (afferent) stimuli
• Touch & pressure, traction &
compression, stretch
• Resistance
• Use to facilitate the action of the ms.
w/c form the component of the mov’t
patterns
• Special techniques:
– Irradiation – predictable overflow of action
from one ms. grp to another w/in a synergy
by reinforcement of action of one part of
body stimulating action in another part of
the body.
– Rhythmic stabilization
– Stimulation of reflexes
– Repeated contractions
– Reversals
– Relaxation techniques – HRAM and CR, ice
treatments
– There are various combinations of techniques
• Functional work or mat work – use in
training rolling, creeping, crawling, walking
and various balance position of sitting ,
kneeling, and standing (Levitt
1969,1970b)
Neuromotor Development
Eirene Collis
Basis for assessment and treatment

• Mental capacity
• Early treatments
• Management – “treatment” misleading beside the
physiotherapy session “management” of the child
throughout the day.
• Strict developmental sequence – the child was
not permitted to use motor skills beyond his
level of development.
• CP therapist – dislike the separation of tx into
PT, OT, ST.
Neurodevelopmental Treatment
with Reflex Inhibition and
Facilitation
Karl Bobath
• Features of approach are:
– Reflex inhibitory patterns – selected to
inhibit abn, tone assoc. w/ abn. mov’t
patterns and abn. posture
– Sensory motor experience.
• Reversal or breakdown of these abn.
Gives the child the sensation of more
normal tone and mov’ts.
• Feedback and guide more normal motion.
• Inhibition, facilitation and voluntary
mov’t.
Facilitation techniques

• key points of control

– to change pattern of spasticity so that the
childs id prepared for movt and more mature
postural reactions.
– Head and neck, shoulder and pelvic girdle,but
there is also work from distal key
– Abnormal tone is the cornerstone of this
approach
• Developmental sequences
– strict followed in the past , but now greatlyt
modified accdg. to each child
• all day management
– Parents and others are advised on daily
management and trained to treat the
children.
Sensory Stimulation for
Activation and Inhibition
Margaret Rood
• Afferent Stimuli
– Techniques of stimulation: stroking, brushing
(tactile), icing, heating (temp.), pressure,
bone pounding, slow and quick muscle stretch,
jt. Retraction and approximation, ms.
contractions (proprioception), are used to
activate, facilitate, or inhibit motor
response.
• Muscles
– classified accdg. To various physiological
data, including whether they are for light
work muscle action or heavy work ms. action.
• Reflexes
– tonic labyrinthine reflexes, tonic neck,
vestibular reflexes, withdrawal patterns.
• Ontogenic developmental sequence
– Total flexion or withdrawal pattern (in spine)
– Roll over ( flexion of arm and leg on the same
side and roll over)
– Pivot prone ( prone w/ hyperex. Of head,
trunk, and legs.)
– co-contraction neck (prone head over edge
for co-contrcxn of vertebral ms.)
 – On elbows (prone and push backwards)
– All fours ( static, wt. shift and crawl)
– Standing upright (static, wt. shift and crawl)
– Walking ( stance, push poff, pick up, heelk
strike)
• Vital functions.
– A developmental sequence of respiration,
sucking, swallowing, phonation, chewing and
speech, is followed. Techniques of brushing,
icing, and pressure are used.
Reflex Creeping and other
Reflex Reactions
Vaclav Vojta
 Reflex Creeping
• Creeping pattern involving head, trunk, and limbs
are facilitated at various trigger points or
reflex zones.
• creeping is an active response to the
appropriate triggering form the zones with
sensory stimuli.
• There are 9 zones fore triggering reflex
locomotion.
 Reflex Rolling
• Reflex rolling are also used with special methods
of triggering.
 Sensory Stimulation
• Touch, pressure, stretch, and muscle action,
against resistance are used in many of the
trigerring mechanisms or in facilitation of
creeping.
 Resistance
• Resistance is recommended for action of muscle.
• Phasic action (through range) may be provoked
on,, say, a mov’t of a limb creeping up or
downwards.
• tonic action , stabilizing action, is obtained if a
phasic mov’t is prevented by full resistance
given by the therapist
Conductive Education
Andras PerÖ
 Conductor
• Acting as mother , nurse, teacher and therapist.
• Specially trained in the habilitation of motor
disabled children in a four-year course.
• May have one or two assistant.
 The Group
• Group of children, about fifteen to twenty, work
together.
• Fundamental in training system
 All-day Programme
• A fixed time-table is planned to include getting
out of bed in the morning, dressing, feeding,
toileting, movement training, speech, reading,
writing and other schoolwork.
• Movements. takeplace mainly on and beside
slatted plinths(tables/beds) and with ladder
backed chair.
• Rhythmic intention. used for training the
elements or mov’t.
• Individual session. Participation
• Learning principles. Conditioning techniques and
group dynamics MOT.
ADJUNCTS TO THERAPY
Butler and Major
• Neuromuscular ES or FES
• Lycra suits and splinting
• Specialized medical treatments
• Deaver
– Extensive bracing
– As motor control is obtained, voluntary
motion will be emphasized for performance
of ADLs
• Doman and Delacato
– Program following the evolutionary process
– Attempts to train cerebral dominance and
normalization of function
Music Therapy
 Music Therapy
• the skillful use of music as a therapeutic tool to
restore, maintain, and improve mental, physical,
and emotional health.
• Rhythmic movement helps develop gross motor
skills (mobility, agility, balance, coordination) as
well as respiration patterns and muscular
relaxation
• goals and objectives are accomplished through
musical activities such as:
– singing
– playing instruments
– moving to music
– improvising
– composing, and
– listening
• Singing helps to improve speech and language
skills, such as:
– vocalization
– verbalization
– articulation
– language expression and reception
– rhythm, and
– breath control
• Playing instruments improves gross and fine motor
skills:
– coordination
– balance
– dexterity
– range of motion, and
– strength
• social skills:
– participation
– self-esteem, and
– cooperation
• Connecting song, language, and
movement dramatically increases
learning.
• Music is a valued tool for stimulating the
right side of the brain and encourages
bilateral activity between the brain
hemispheres.
• Music enhances attending skills and
reduces distraction.
• Music is motivating and fun, which is
useful when working with a child who
demonstrates low motivation to learn.
Reasons why music therapy is successful

• Rhythms of sound have a powerful impact on

cognition. Songs and rhymes are things that
most adults remember from childhood.
• Music is processed by a different area of the
brain than speech and language, therefore, a
child may be able to more easily absorb
information and skills presented with music.
• Memorizing songs and rhymes is helpful in
developing literacy skills.
• The rhythm and repetition in songs can help
the student internalize the sounds and
patterns of language.
Play Therapy
"Play permits the child to resolve in symbolic form
unsolved problems of the past and to cope directly
or symbolically with present concerns. It is also his
most significant tool for preparing himself for the
future and its tasks."

Bruno Bettelheim
Play therapy

• Play is an essential activity for all children. This

is where real learning begins.
• In the home setting, “putting them on the floor”.
• child's earliest independence comes from
exploring the world.
• Time spent lying on the floor with a few toys
around will be a valuable opportunity to exercise
early self-help in play and mobility.
guidelines to help in toy selection:

• 1. Multi-sensory appeal
– Does the toy respond with lights, sounds, or
movement to engage the child? Are there
contrasting colors? Does it have a scent? Is
there texture?
• 2. Method of activation
– Will the toy provide a challenge without
frustration? What is the force required to
activate? What are the number and
complexity of steps required to activate?
• 3. Places the toy will be used
– Will the toy be easy to store? Is there space
in the home? Can the toy be used in a variety
of positions such as side-lying or on a
wheelchair tray?
• 4. Opportunities for success
– Can play be open-ended with no definite right
or wrong way? Is it adaptable to the child's
individual style, ability, and pace?
• 5. Current popularity
– Is it a toy that will help the child with
disabilities feel like "any other kid?" Does it
tie in with other activities like books and art
sets that promote other forms of play?
• 6. Self-expression
– Does the toy allow for creativity, uniqueness,
and making choices? Will it give the child
experience with a variety of media?
• 7. Adjustability
– Does it have adjustable height, sound volume,
speed, and level of difficulty?
• 8. Child's individual abilities
– Does the toy provide activities that reflect
both developmental and chronological ages?
Does it reflect the child's interests and age?
• 9. Safety and Durability
– Does the toy fit with the child's size and
strength? Does it have moisture resistance?
Is the toy and its parts sized appropriately?
Can it be washed and cleaned?
• 10. Potential for interaction
– Will the child be an active participant during
use? Will the toy encourage social
engagement with others?
Functional Training
• Range of motion exercises
• Maintain joint and soft tissue mobility
• Slow and gentle stretching
• Strengthening exercises
• Resistive exercises
• Age appropriate play program
• Postural and motor control training
• Should follow developmental sequence
• Balance training from symmetric to
asymmetric patterns
• Skill performance training
• To develop optimal motor performance,
individual motor control should be
established
• Uses all synergists optimally and with
minimal interference by the antagonists
• Should be done under direct control
• Requires:
(1)Accurate perception of motion
(2)Precision of movement
(3)Repetition of precise pattern
Orthoses
• Specific goals :
• Control abnormal tone and related
deviations
• Enhance function
• Protects tissue postoperatively
• Common orthoses used :
• AFO (ankle foot orthoses)
– Solid AFO
– Hinged AFO
• UE orthoses
Management of Spasticity
• Range of motion exercises
• Therapeutic exercises
• Modalities
– Heat
– Cold
• Casting and splinting
• Biofeedback
• Medications
• Benzodiazepines
• Dantrolene
• Baclofen
• Clonidine
• Tizanidine
• Intrathecal baclofen
• Intramuscular neurolysis
• Botox injection
• Surgery
Orthopaedic Surgery
• Goals :
• Improve function and appearance
• Prevent or correct deformities
• Reflect a functional approach to problems
of alignment
• Hip surgery
• Varus derotational osteotomy
• Knee surgery
• Hamstring tenotomy, transfer or
lengthening
• Foot surgery
• Tendon lengthening or transfer
• Arthrodesis
• Osteotomy