MANAGEMENT OF CHILDREN WITH

CEREBRAL PALSY
PT 5th year neurology lecture
Mrs Simpamba MM
 INTRODUCTION
• Management of cerebral palsy depends on the patients’ specific
symptoms.

• The needs of each child are different and may depend on the level of
severity, environmental and personal factors.

• The best clinical outcomes results from early detection and

intervention with intensive management.

• Management of cerebral palsy can be classified into medical,

rehabilitative and surgical.
• Management requires a multidisciplinary team involving the
following:
- Paediatricians,
- Nurses,
- Physiotherapists,
- Occupational therapists,
- Speech therapists,
- Social workers,
- Audiologists,
- Psychologists and
- Nutritionists.
 Aims of treatment
• The general goal of management in cerebral palsy is not to achieve normalcy.

The main goals include:

• Improve functional outcome

• Prevent secondary complications

• Sustain general health by managing associated impairments.

• Emphasis should be put on communication, activities of daily living, mobility

and participation.
 Focus of interventions

For example:

• Mild CP: Focus on appearance and integration

• Moderate CP: Focus on independence and self-care

• Severe CP: Focus on comfort and enhanced care

 Medical management
The initial role of the Pediatrician is to make a correct diagnosis

Includes assessment and management of the following:

• Associated impairments (Hearing, vision, Respiratory, etc. )

• Seizures
• Spasticity
• General pain management

• Cognitive and neuropsychological impairments

• Nutrition and gastrointestinal disorders

• Dental problems
 Common drugs for individuals with CP include:

- Skeletal muscle relaxants for stiffness and spasms (dantrolene,

Baclofen, Diazepam (Valium)

- Anti-anxiety agents may relieve excessive motion and tension

(child with athetosis, e.g Clonazepam, diazepam, etc.)

- Anti-convulsive drugs for those with epilepsy (Carbamazepine,

Phenobabitone, Valproic acid, etc.)
 Surgical management

Aims of surgery include the following:

• To improve function

• To decrease pain

• To correct deformities and stabilize joints

• To prevent further deformity

• To improve cosmetics
 Common surgical procedures
• Muscle lengthening
• Tenotomy (division) of contracted tendon

• Tendon Transfer Operation

• Insertion of baclofen pump

• Stabilization of joints (Arthrodesis)

• Selective Dorsal Rhizotomy (Spasticity)

• Bony correction such as hip dislocation including curvature of the spine

 Rehabilitation of CP

• The World Report on Disability (WHO, 2011) defines

rehabilitation as “a set of measures that assist individuals who
experience, or are likely to experience, disability to achieve and
maintain optimal functioning in interaction with their
environments”.
• Child rehabilitation aims at minimising disability, promoting independence and social
participation and educating the parents about the child’s problem.
• CP rehabilitation consists of:

- Physiotherapy,
- Speech therapy,
- Occupational therapy,
- Assistive devices (e.g. bracing)
- Adaptive technology,
- Special education
- Sports and recreation.
• Occupational therapy: Helps to improve ADLs (adaptive equipment
and environment), fine motor skills, visual-motor skills and visual
perceptual skills.

• Physiotherapy: Gross motor skills, balance, coordination and

strength required to perform other functions, including prevention
of contractures and deformities.

• Speech and language therapy: Help with speech and feeding

problems.
 Assistive devices and technology
• Assistive devices and technology refers to “any product, instrument,
equipment or technology adapted or specially designed for improving the
functioning of a person with a disability ” (WHO, 2015).

• Assistive technology enables people to live healthy, productive and

independent lives, including participation in education, labour market and
civic life.

• Includes high technology devices and low technology devices.

• Examples of high technology devices: (Programmed wheel chairs, electronic

feeding devices, computerized speech systems, cochlear implants, etc).
 Assistive devices
• Assistive devices are external devices that are designed, made, or adapted to assist
a person to perform a particular task

• Children with cerebral palsy may require assistive devises to help them improve
their function and prevent secondary complications.

• Examples of assistive devices used by children with CP:

 Braces, casts, and splints: to increase stability, improve alignment, prevent

contractures and preserve or improve function.

 Simple modifications like angled spoons, two handled cups etc. can be made to help
the child with independent feeding.
 Mobility devices: Powered or manual wheel chairs, walkers,
crutches, tricycles, etc.

 Positioning devices: Special chairs/standing frames, splints,

wedges, specialised beds to help with positioning.

 Communication devices to supplement the patients

communication abilities (Computerised, comm. Boards/cards,
etc).

 Hearing devices (Hearing aids)to improve communication

 Physiotherapy management
General Physiotherapy aims of treatment
• To normalize the tone
• To achieve normal milestones

• To maintain muscle length

• To correct the posture

• Teach activities of daily living

• Counselling of parents
 Common physiotherapy approaches for managing CP

1.Neurodevelopmental therapy (By Bobath): Aim at facilitation of normal

motor development and preventing secondary complications

2. Constraint induced movement therapy (University of Alabama):

Predominantly used in individuals with hemiplegic CP to improve the use of the
affected upper limb.

3. Patterning therapy (Fay, Delacato, and Doman): Facilitation of typical

motor development by passively repeating and putting the child through
the sequential steps of typical development, called patterning.
4. Sensory integration treatment approach (Jean Ayres): The basic
goal of this technique is to teach children how to integrate their sensory
feedback and then produce useful and purposeful motor responses.

5. Conductive education (Andras Peto): aimed at helping children

with motor disorders learn how to find ways to achieve personally
formulated goals.

6. The Vojta technique (Vaclav Vojta): An Early intervention

treatment method based on the maturational and hierarchical
theories. Involved activation of postural and equilibrium reactions to
guide normal development.
 PHYSIOTHERAPY ASSESSMENT
1. Subjective assessment

• Demographic characteristics

• Present complaint: What symptoms the child has

• Case history: When the mother noticed the symptoms, what has been done so far.

• Obstetric history: Prenatal and perinatal history

• Medical/Postnatal history

• Family/social history
 Prenatal history
• Age of mother
• Drugs during pregnancy

• Any trauma
• Abuse of drugs, smoking and alcohol

• History of infection during pregnancy

• History of previous abortions, still birth.

• Multiple pregnancies
 Perinatal history
• Place of delivery

• History of prolonged labour

• Type of delivery

• Presentation of baby at birth (e.g. breech)

• Delayed cry

• Weight of baby at birth

• Condition of mother before and after delivery

 Medical/Postnatal history
• History of neonatal infection, jaundice, hypoglycaemia, hydrocephalus and
microcephalus (Associated impairments).

• History of medications/drugs taken

• History of trauma to head

• Nutritional/feeding habits

• History of convulsions

• Developmental history
 Activities of daily living
• Self-care

• Feeding
• Dressing/undressing
• Toileting
• Play

• Communication
 Family/Social history
• Number of children in the family
• Parents/family head
• Occupation of parents/income
• Religion/beliefs

• Main caregiver
• Any family member with similar problem
• Smoking/alcohol consumption in family
 Objective assessment
General observation

• Behaviour of child: Alert, irritable, fearful, motivation, attention

span,

• Communication: Interaction with parents/caregiver

• Involuntary movements, posture, preferred position, gait,

deformities/contractures, scars, appliances, etc.
 4. Specific observation/examination
1. Sensory aspects: Vision, hearing, touch, reaction to being moved
and to certain sensations.

2. Reflexes
3. Balance and gait

4. Cognitive function
5. Head circumference
Passive and active movements to check for:

• Range of motion: Actively and passively

• Tone abnormalities (Spasticity)

• Contractures and deformities

 Assessment of motor function
Observation of child in different positions
• Supine:
• Prone:
• Rolling:
• Kneeling (Half/4-point):
• Pulled to sitting:
• Sitting – Long, side, high:
• Standing
• Walking/running/jumping
• Climbing stairs
 What to look for different positions
• Can child get in or out of that position? Assistance, any effort.

• Symmetry, position of head/trunk, alignment.

• Activity in both upper and lower limbs

• Involuntary movements

• Use of hands: Bilateral hand use, grasp and release, reaching out,
tremors/involuntary movements, spasms.
 Summary of findings

• Type of CP: Diagnosis

• Severity of CP: GMFCS
• Abilities and inabilities

• Associated impairments
• Tone abnormalities
• Developmental level
• Contractures and deformities
 Physiotherapy management
• Physiotherapy focuses on function, movement, and optimal
use of the child's potential.

• Physiotherapy also focuses on the child’s functioning settings

such as the home, school, recreation and community
environment.
 Consideration in management of CP
Consideration should be taken on the following major areas: handling,
positioning, and daily care.

• Handling: Refers to awareness of special requirements for carrying the

child.

• Positioning: Relates to specific adaptations that may be necessary in order

to deal with the child.

• Daily care: This includes all demands of infant and child care and other
ADLs such as bathing, dressing and feeding.
 Physiotherapy techniques
• Passive stretching

• Static weight-bearing exercises

• Muscle Strengthening Exercises

• Functional Exercises

• Body weight supported treadmill training

• Electrical Stimulation (TENS)

• Hippotherapy (Horse-back ridding)

 Age specific Physiotherapy
• Infants (Below 18 months): Early infant/early childhood stimulation which includes
handling, sensory stimulation and positioning.

• Early childhood (18-24 months): Crucial for motor development and function, and time
when parents are getting to understand their child’s condition.

• Middle childhood (5-10 years): Focus on cognitive development, ADLs, school and
community interaction (sports)

• Adolescence (10-16 years): Teaching specific tasks and skills using a cognitive
approach, new level of independence including therapy and ADLs.

• Young adults: Depending on cognitive, focus on independence in IADL including their

own health.
 Therapy settings for CP

• Home settings (Ideal for infant and early childhood and

after surgery)
• Out-patient hospital setting

• In-patient hospital/clinic setting

• School based therapy

• Special settings (E.g. Experimental labs)

 Treatment principles for severe spasticity
• Analyze the patterns of hypertonia and the way they interfere with postural
control and functional skills.

• Look at what changes and what does not change.

• Use lots of movement through slow wide ranges,

• Prevent or minimize contractures.

• Work slowly, wait for the child to react and aim for maximum activity from
the child.
Treatment principles for severe spasticity cont.
• Avoid fear and effort by using appropriate toys and your voice.

• Facilitate balance reactions by working for automatic balance

responses.

• Reduce fear of movement by adequately supporting the child,

control the movements, move slowly and wait for the child to
reach out
 Treatment principles for moderate spasticity
• Analyse the patterns seen and because the child is moving, the
patterns may change.

• Avoid using abnormal patterns of movement for function and

facilitate the more normal patterns of activity.

• Facilitate reliable balance reactions.

 Treatment principles for moderate spasticity cont.
• Concentrate on most appropriate stages of motor development
for each child.

• Work for mobile weight bearing to enable dynamic balance and a

variety of movements.

• Inhibit associated reactions (reduce the amount of effort used).

• Prevent contractures and deformities.

 Treatment principles for choreoathetosis
• Stabilize tone by working for co-contraction proximally and reduce
involuntary movements.

• Work for mid-range control and grading of movements.

• Work on activities which promote symmetry and mid-line orientation.

• Work for combination of patterns of flexion and extension.

• Facilitate sequences of movement and mobile weight bearing.

 Treatment principles for dystonic
• Reduce frequency and duration of intermittent spasms.

• Work for mid-line orientation and alignment of head, trunk and limbs.

• Be slow and give child time to adjust (Like for severe spastic child) and
avoid frequent change of positions.

• Manage associated problems such as drinking and eating.

• Use soft surfaces.

 Treatment principles for ataxia
• Increase postural control by weight bearing and joint compression
• Increase proximal stability
• Build up tone and sustain it
• Give child quality and control of movements in the trunk and limbs.
• Improve grading of movements
• Inhibit exaggerated balance reactions
• Facilitate selective and independent movements of limbs against the
trunk and use of trunk rotation.
• Use voluntary control of movements
 Treatment principles for hypotonia
• Look for the predominant patterns
• Work for sustained co-contraction against gravity
• Work for alignment and symmetry
• Use mobile weight bearing through all limbs and in all Positions
• Use lots of vocalisation to build up tone
• Sustain positions to give child sensory experience
• Improve respiration, check eating and drinking
• Use lots of sensory stimulation.
 References
• Anttila H, Autti-Ramo I, Suoranta J, Makela M, Malmivaara A. Effectiveness of physical
therapy interventions for children with cerebral palsy: a systematic review. BMC pediatrics.
2008 Apr 24;8(1):1.

• Hinchcliffe, A. Children with Cerebral Palsy: A manual for Therapists, Parents and
Community workers. 2nd Ed. 2007, Thousand Oarks, Sage Publications.

• Miller F, editor. Physical therapy of cerebral palsy. Springer Science & Business Media; 2007
May 26.

• World Health Organization, 2015. Assistive technology for children with disabilities:
Creating opportunities for education, inclusion and participation. A discussion paper.
Geneva: WHO Press.