Cerebral Palsy (CP)

Shumaila Tahreem
Roll 22
Sem 10th , Batch06
IPMR, KMU. 1
 Cerebral Palsy
Cerebral Palsy (CP) is neurologic condition.

It is permanent but not unchanging

neurodevelopment disorder caused by
nonprogressive defect or lesion in immature brain

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 Classification , Etiology & pathophysiology
Classification based on area of body (motor impairment):

Diplegia
Hemiplegia
Quadriplegia

Classification based on
Movement Abnormality
(BRAIN lesion):
Spastic
Dyskinesia / athtoid
Ataxia
Hypotonic
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mixed
 Causes or factors
Could be prenatal, peri-natal and postnatal:

 Birth asphyaxia (full term infants)

 Disorders of coagulation and interauterine exposure to
infection
 insufficient cerebral perfusion
 Thyroid hormones
 Prenatal malnutrition, poor maternal maternal condition
 Head trauma resulting from a birth injury, fall
 Severe jaundice (Hyperbilirubinemia)
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Progress in Primary Prevention:
Work on prenatal health of mother at risk
poverty and maternal education

Prevention and intervention for premature delivery, fetal distress, neonatal

asphyxia & mechanical birth trauma

Diagnosis:
CP is diagnosed when a child does not reach motor mile stones and exhibits
abnormal muscle tone or qualitative differences in movement pattern.

 Neurologic status, primitive reflexes, posture (identify CP)

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 Impairment

1. Single-system Impairment:
Expressed in muscular system and skeletal system
Then further cateogrized in primary and 2ndry impairment
2. Multiple system impairments:

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 Single system impairment (primary )
• Insufficient force generation: level of EMG activity + force
output

• Spasticity and abnormal extensibility : tone

Muscle tone is the amount of tension or resistance to

movement in a muscle.

80% of all people with CP shows some spasticity

• Hypo or hyperextensibility ,contractures

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 Single system impairment(secondary)

Primary impairments leads to malalignment, abnormal weight

bearing which in turns affects orthopedic development of spine
and extremities.

 Torticollis
 Hip joint stability
 Other spinal deformity

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 Multisystem Impairments
1. Poor selective control of muscle activity
2. Poor regulation of activity in muscle group in anticipation of
postural changes & body development
3. Decreased ability to learn unique movement

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 Examination , Evaluation ,Intervention

1. Infancy
2. Preschool
3. School age to adolescent and transition to adulthood

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 Infancy
Infants grow and develop in response to being loved and nurtured
by parents and caregivers

• From time of birth, child with CP may not experience the usual
activities associated with infancy.
• Some parents of CP may not receive all aspects of +ive feedback
• Movement is important component in learning and interactive
process of infancy

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 PT examination , Evaluation
• History, environment of infant and capabilities and concerns of
family.
• Observation of active ROM ,passive ROM
• Passive movement with greater velocity
• Primitive reflexes

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 Goals ,Intervention
1. Family education:
 Educate family about CP
 Support their acceptance
 Foster collaborative goal setting
 PT should be realistic about prognosis
 Families values and concerns
2. Handling and care
 Parent skills
 Positioning, carrying, feeding, dressing technique
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3. Facilitating optimal sensorimotor development
 Focus on well-aligned postural stability coupled with smooth mobility to
allow emergence of motor skills e.g crawling,rolling, reaching etc
 These skills promote development of body awareness, spatial oreintation
and mobilty to play , social interact
 CP child doesn’t always proceed along the normal development sequence.
 Equipments may facilitate e.g infant with CP may unable to sit and balance
or infants with upper limb limited movement maybe unable to bring their
hand to their mouths to provide normal oral-motor sensory input.
Role of other disciplines:
 OT , speech therapist, community infant development worker.

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 Pre-School Period
Locomotor, coginitive, communication, selfcare and social abilities
develop to promote functional independence

• Dynamic process
• Child’s environment remains oriented not only towards family, parents and home
but also begins to interact with the world outside.

• Children with CP, limitation in motor activities causes

1. Restriction in Participation in learning
2. Reduce independence and socializing
• Concerns of parents
• Concern of Physical Therapist: independent mobility
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 PT EXAMINATION & EVALUATTION

• Assessment of activity & interaction of Impairment and activity in

relation to participation. (primary focus)
• Testing of force generating ability of muscle.
• Strength and endurance assessment.
• GMFM & PDMS used to monitor child’s progress in attaining motor
skills.

When skills are assessed, use of EQUIPMENT should

be taken in consideration
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 Cont…

• Mobility, transfers, communication ,social function, self-care,

adaptive equipments in the performance of ADLs.
• Assess and manage pain (in children with communication &
movement limitation).

Enviromental and Personal factors affects

evaluation process
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 PT goals, outcomes & Interventions

• Goal: limit impairments ,prevent secondary effect

• Intervention: optimal posture alignment, movements of body

conductive to different areas of developmemnt

Therapist must be willing to Respect the priorities of families

and other professionals to meet the GOALS.

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 GOALS & I/V:
1. Reducing Primary Impairment & Preventing 2 ndry
Impairment:
 Increase Force generation: Eccentric, concentric activities
 Spasticity:, muscle lengthening ex, BtA
 Effectiveness of Sx or Pharmacological Interventions
for spasticity may be enhanced with therapeutic interventions
 Hypoextensibility: manual passive stretching
 Threshold length for preventing contractures
 6hours/day
 Casting & Orthoses : with plaster material used to provide prolong stretch to lengthen hypoextensible muscle.
 Often used with BtA intervention
 Lower extremity Orthoses  prevent deformity, facilitate activity.
 AFOs, FO and during sleep
 Positioning & Alignment: Seating , standing and risks of diseases and contractures

Standing for 45minutes for 2 to 3 times a day control lower extremity flexor contracture
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And for 60mint/day 4 to 5 times facilitate BONE DEVELOPMENT
2. Interventions of Activity Limitation
A) Mobility
 Ambulation is major concern of PT during preschool years
 Ambulation skills and ambulation aids (e.g posterior walkers)
 Provision of alternative (power mobilty devices, adapted tricylce, manual w.chair) means to
allow children functional, independent mobility when ambulation is impossible.
B)Play
 primary productive activity for children should be motivating & pleasurable.
 Benefits: development of intellectual, language ,conceptual, perceptual skills. increase
independence, motivation , creativity ,social skills and selfesteem.
 Parents should not provide them overprotected environment.
C)Addressing a variety of health and well-being issues (oral motor control,
swalloing,feeding
 Drooling: 10% childern with CP due to dysfunction ORAL MOTOR activity
 Mx: positioning, feeding, behavior modification to stimulate swalloing 20
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D) Family Involvement
E) Role of Other Discipline :
OT : develop independence in activites such as toileting, playing, feeding etc.
ST
Psychologists: cognitive skills, intellectual abilities
Social worker & Behavior Therapist: ongoing support to their family and
awareness

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 School Age & Adolescent Period
• Typical disablities encountered during thesse years include a lack of
indepedence mobility ,poor endurance , slowness with selfcare etc.
• Adolescent may also not have opportunity to develop socially and
sexually.
PT examination & evaluation:_______
• Assessment of impairments ,Gross motor functions , endurance and
effieceny of movement etc

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 PT Goals , interventions
• Maintaining and Improving Participation and Level of activity .

• As CP is nonprogressive but there are changes related to accumaltive

physical overuse, more competitive life style, stresses of Increasing Size.

• Contractures rapidly develops during this period.

• Adolescents : should involve in goal setting, encourage them & identify

them their responsibilties by their own self
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 1. Reducing primary impairment & preventing 2ndry
impairment
A. Work on Impairment of Deficient muscle force generation activity
limitation and participation restriction
 Muscle weakness can contribute to Bone Deformity and lower extremity has shown to be
related to walking velocity

B. Electrical stimulation  reduce spasticity, increase force production, muscle

extensibility
 Stimulation for shorter duration at high intensities results in max.voluntary contractions

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C. BtA and pharmacological interventions i.e BACLOFEN
D. Casting : to prevent secondary impairment by increasing range of
joint movement by lengthening muscle with no associated loss in
strength.

E. Joint moblization: joint hypomobility resulting from capsular or

ligamentous tightness can br treated with manual therapy
techniques.

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 2. Activity, mobility and endurance
• Gait training often in conjunction with other interventions such as spasticity
intervention.
• Treadmill training with partial body weight support harness improvement in
walking as well as standing transfers in non-ambulatory children.
• Alternative form of mobility: manual w.chair, power mobility devices, power scooter
3. School and Community:
• School based therapy programs i.e support personnel, equipments for accessibility
necessary to meet physical needs of children.
• Positioning ,lifting, transferring should be instructed by PT to support personnel
• Educate school staff as well as class fellows
• Involve them in Recreational activities and sports e.g horse back riding, camping,
fishing

children and adults with disabilities have increased risk of abuse which results in physical, social
and behavioral consequences. 27
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 Transition to adulthood
• Adults strive to be independtly functioning & self-sufficient individuals
• People with CP can reliaze that their goals depends on factors such as
level of cognition, available sources and support etc.
• Many adults with CP continue to live with their families while some not.
PT examination and evaluation:
• Assess body function and structure as well as activity and participation.
• Address all level of function with an emphasis on working together with
family, healthcare team and other individuals.

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 PT goals, interventions
• Focus on participation
• If contractures, so monitoring and treatment
• Poor endurance  fatigue problem
Due to lack of physical activity , general health problems
• Adherence to exercise programs of stretching, strengthening and
aerobics
• Encouragement and opportunities should be provided

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