Cerebral Palsy

Patient Hx
• The patient was the sole survivor of a twin pregnancy, delivered
secondary to fetal distress at 28 weeks gestation via cesarean
section. She spent 4 moths in the neonatal intensive care unit,
with history of ventilation, bronchial pulmonary dysplasia,
intercranial bleeding (grade 4), and severe feeding problem.
The patient was diagnosed with spastic diplegic CP with left
hemiplegia by age of 3.
 Cerebral Palsy
• Infantile Cerebral Paralysis or Little’s disease
• Defined as a persistent disorder of movement and posture
appearing early in life due to a developmental, non-progressive
disorder of brain
• Lesion affects the immature brain and interferes with the
maturation of the central nervous system
 ANATOMY, PHYSIOLOGY
Cerebrum
• 2 hemispheres – controls C/L side of the body

LEFT CEREBRUM RIGHT CEREBRUM

AKA Dominant AKA Non-dominant
Mathematical Music
Analytical Insight + judgement
Language Creativity
Logic Arts
 ANATOMY, PHYSIOLOGY
Lobes of Cerebrum
Frontal lobe Parietal lobe
Functions: Functions:
 Personality, behavior  Sensory function
 Motor Function  Body part awareness

 Judgment/Problem solving
 Expressive speech
 Concentration, Reasoning
 ANATOMY, PHYSIOLOGY

Lobes of Cerebrum

Occipital lobe Temporal lobe

Functions:
Functions:
 Primary Visual Area  Understanding speech
 Visual Reflex  Olfactory and Auditory
 Involuntary smooth eye  Learning, memory, emotional
movement affect
 ETIOLOGY
• There are five major categories of risk factors associated with
the diagnosis of CP
 Classification of Cerebral palsy
Anatomical Classification
Location Description

Hemiplegia Upper and lower extremity on one side of the

body
Diplegia Four extremities, legs more affected than the
arms
Quadriplegia Four extremities

Triplegia Both lower extremities and one upper extremity

Monoplegia One extremity

Double Hemiplegia Four extrimities, arms more affected than the legs
 Physiologic Classification
Spastic
2.Spastic Diplegia
Types: -Presents with bunny hopping and/or
1.Spastic Hemiplegia combat crawl
-Present with a typical hemiplegic -With toe walking or scissoring gait
posture
-Delayed walking until 3-4 years old
-Delayed milestone by 4-6months
-Strabismus
-Favorable ambulation by 3 years old
-Impaired sensation

3.Spastic Quadriplegia
-Most severe; poorest prognosis
-Characterize by seizures, Mental
retardation and strabismus
-(+) Straphanger sign
Dyskinetic Mixed
1. Athetoid
-Characterize by abnormal and involuntary -The most common is the spastic athetoid
movements type
-Affect subcortical structures and the basal ganglia
2. Ataxic
-Primary incoordination due to the disturbance of
kinesthetic or balance sense
-Affectation of the cerebellum and CN 8
 Reflexes
Primitive reflexes
• Flexor withdrawal- Toes extend, foot
dorsiflexes, entire LE flexes uncontrollably
• Crossed extension- Opposite LE flexes, then
adduct and extends.
• Moro- Extension, abduction of UEs, hand
opening, and crying followed by flexion,
adduction of arms across chest
• Startle- Sudden extension or abduction of UEs,
crying
• Grasp- Maintained flexion of fingers or toes
Brainstem reflexes
ATNR- Flexion of skull limbs, extension of the
jaw limbs, bow and arrow or fencing posture
STNR- With head flexion: flexion of UEs,
extension of LEs; with head extension: extension
of UEs, flexion of Les
STLR- With prone position: increased flexor
tone/flexion of a limbs; with supine: increased
extensor tone/ extension of all limbs
Positive supporting- Rigid extension
(cocontraction) of the Les
Associated reactions- Involuntary movement in a
resisting extremity
 EPIDEMIOLOGY

• CP is the most common cause of disability in developed

countries. The direct and indirect costs associated with CP are
3 to 4 times that of a neurotypical child.
• Despite treatment advances, the overall prevalence rates have
neither increased nor decreased in the past 20 years (2.11 per
1000 live births).
• When the overall prevalence is examined more closely,
dramatic increases are seen in children with very low birth
weight (59.6 per 1000 live births) and very early gestation
(111.8 per 1000 live births).
Differential Diagnosis
CP is a description of clinical findings. The initial evaluation of a
child with suspected CP should determine the diagnosis, if
possible, decide which tests are needed to make the diagnosis,
determine the etiology of the symptoms, determine comorbidities,
and develop treatment options. It is important to gauge the
emotional environment and the family's understanding of the
child's current medical issues
Diagnostic tools
Neuroimaging study (MRI preferred to CT)

• Determine if neuroimaging (EEG) abnormalities in combination with

history and examination establishes a specific etiology of CP.
• If developmental malformation is present, consider genetic evaluation.
 MEDICAL-SURGICAL MANAGEMENT
Medical Management:
• Muscle relaxants- relax hyperspastic or hypertonic ms. Ex.
Baclofen, Dantrolen sodium( for liver function complications;
check every 3 mos. Stimulants- given upon awakening in the
morning and at noon
• Ex. Methyl Phrenidate
• Anticonvulsants- for seizure and seizure abnormalities in EEG
• Phenothiazines- for hyperactive and emotionally disturbed
children, for tranquilization without sedation.
• Diazepam is the most effective to control athetosis and spasticity.
It is administered 2mg Tid and increase to as much as 5 mg 5xa
day.
 Surgical Management
Objectives:
• Diminished muscle spasm or spasticity Stabilized poorly controlled joints
Equalized the power of opposing muscle Correct or prevent deformity Orthopedic
Surgical Indications:
Goal:
• LE : functional independence in ambulation
• UE: for cosmesis, improve function of hand, increase gross function
• Surgery for Sitting:
1. Hip flexor lengthening
2. Hip adductor lengthening or release
3. Hip fusion, artificial joint replacement, resection of femoral head
4. Hamstring lengthening
5. Molded thoracic lumbar orthosis for early
Treatment for scoliosis:
6. Knee flexion contracture release
7.Anterior branch obturator neurectomy
8. Chronic cerebelar stimulation- implanted electrodes for
spasticity
Surgery for Standing:
1. Hamstring lengthening
2. 2. Achilles tendon lengthening
 PT Management
• LE Strength, Balance, Gait, and Decrease the spasticity
(incorporated with play).
1. AROME to Resistance Exercise c Ankle weights - LE
Strengthening at the same time addressing the spasticity and
balance.
2. Half Kneeling Exercise - if strength increases et. spasticity
decreases, then progress to gait training.
3. Assistive device; walker.
4. Orthosis-AFO for medial-lateral stability to the foot and ankle
while at the same time assisting with foot clearance during gait.
 PROGNOSIS
Molnar Prognostication Index

Based on the type of CP

Best prognosis- spastic hemiplegia or ataxic
Poor prognosis- quadriplegic, Flaccid/Rigid
Based on the onset of sitting
Good- if the patient can sit by 2 years old
Fair- patient can sit between 2-4 years old
Poor- if the patient cannot sit by 4 years old
 PROGNOSIS
Speech
Good prognosis – CP child can speak a word by 2 years old
Fair – CP child can utter a recognizable sound at 2 years old
Poor prognosis – CP child cannot utter words or sounds by 3 years old

Ambulation
Good prognosis for independent walking
Poor prognosis for independent walking
REFERENCES
• Physical Medicine and Rehabilitation (5th edition) by Randall Braddom
• Differential Diagnosis for Physical Therapist (5th edition)- Goodman
CASE STUDY

An outpatient physical therapist was seeing a 14 year old female diagnosed with spastic cerebral
palsy (CP). The patient was being seen once a month for 30 minutes. The outpatient physical
therapist was frustrated with a lack of improvement/ progress in the patient’s ambulation. The
patient was also being treated by a physical therapist at her school, who was seeing her once a
week for 30 minutes. Communication between the two therapists suggested that the patient’s
progress in all areas of functioning had plateaued over the last year.

The patient, a high school freshman, would like to attend her first high school social (a dance) in
approximately 4 weeks. The patient requested that the therapist assist her with improving her
walking so that she could walk into her first social at school. The patient and her mother also
voiced a goal to increase the patient’s ability to ambulate safely within her house.
 EXAMINATIONS,
TEST & MEASURES
 The patient’s ROM was assessed using a goniometer and the following data were obtained:
 
Pre intervention Post intervention Difference Normal
Values
Range of Motion in Left Right Left Right Left Right  
degrees

Hip flexion 19-131 24-133 18-138 28-142 8 13 0-120

Hip extension -19 -24 -18 -24 1 = 0-20
Hip abduction 0-35 0-17 0-38 0-16 3 1↓ 0-45

Hip adduction 0-10 0-7 0-10 0-8 = 1 0-30

Knee flexion 26-110 17-122 19-121 12-131 18 14 0-135
Knee extension -26 -17 -19 -12 7 5 0

Ankle dorsiflexion 0-3 0-1 0-6 0-5 3 4 20

Ankle plantarflexion 0-46 0-49 0-46 0-50 = 1 50

The patient’s muscle strength was also tested before and after the intervention using a dynamometer.
The following results were found:
  Pre intervention Immediately 2 weeks post 4 weeks
postintervention intervention postinterventi
on
Strength (N) L R L R L R L

Hip flexion 4.01 1.89 3.41 2.02 6.60 3.73 8.97

Hip extension 1.41 .53 1.11 .37 2.70 2.13 4.97
Hip abduction 1.74 .50 2.23 1.79 4.47 3.87 5.80

Hip adduction 3.94 3.86 5.59 4.68 10.00 9.80 9.90

Knee extension 1.23 2.52 2.41 2.58 4.43 4.10 4.37
  Immediately post 2 weeks post 4 weeks
Pre intervention intervention intervention post
intervention
Strength (N) L R L R L R L

Hip flexion 4.01 1.89 3.41 2.02 6.60 3.73 8.97

 A pedograph was also used to assess the patient’s gait and the following results were seen:

        Step Length  
Pedograph Velocity Cadence Stride length L R Base of
data (m/min) (steps/min) (cm) support (cm)

Pre 15.47 21.46 61.47 41.63 20.42 20.02

intervention

Immediately 25.83 22.95 76.78 56.03 21.34 24.23

postinterventi
on
2 weeks 22.09 26.46 72.24 44.60 27.15 23.19
postinterventi
on
4 weeks 26.78 25.66 73.56 52.76 28.23 23.02
postinterventi
on
Normal range Variable 90-120 70-82 35-41 53-41 5-10
BERG SCALE:

The patient’s functional balance skill was assessed using the BERG
Balance Scale. Initially, the patient scored 23/56 and showed good
balance during sitting items, difficulty with standing items, and inability
to do single leg stance activities.
Activity Specific Balance Confidence (ABC) Scale
How confident are you that you Pre test Post test
will not lose your balance or
become unsteady when you…

Walk around the house? 25% 60%

Bend over and pick up an 0% 0%
object from the floor?
Reach for a video off a shelf at 0% 25%
eye level?
Walk from the front door of 35% 40%
your house to a car parked in
the driveway?
Get into or out of a car? 60% 75%
Walk in a crowded place where 0% 10%
people may bump into you?

Walk put side on the grass or in 0% 80%

your yard?
DIAGNOSIS,SHORT TERM
& LONG TERM GOALS
Diagnosis
Pt. presents with spastic diplegia 2 to CP; assessment shows LOM on B hip and knee
extensors and ankle dorsiflexors; decreased strength on hip extensors and adductors;
decreased cadence, stride length, R step length, and increased base of support; BERG
Balance Scale score of 23/56 indicates increased risk of fall due to difficulty with
standing activities and inability to perform single leg stance activities; Activity Specific
Balance Confidence Scale shows decreased self-confidence particularly in bending
over, reaching, walking in a crowded place, and walking outdoors
Prognosis
Pt. has good rehab potential; has spastic diplegic CP which has better prognosis among
quadriplegic; Pt. uses power chair for mobility in the community and at school which indicates
GMFCS Level IV, previously was able to amb. indep. In the community with one forearm crutch;
responded well to the treatment plan as shown by the overall increase in LE ROM, muscle
strength, walking velocity, cadence, stride length, and step length; also showed increase in
confidence in her ability to function in terms of balance as seen in her ABC Scale results; Pt. will
be able to gain the required strength, ROM, and balance to participate in dancing during her
social; with continuous PT Rx, Pt. will be able to return to being a community ambulator and be
able to amb. safely and s difficulty at home and in school
Short Term Goals
1. Pt. will increase B hip and knee extension ROM and B LE strength after 1 week to
prepare for sit>stand activities
2. PT. will be able to stand up from her power chair indep. X10 after 2 weeks to
prepare for weight shifting activities
3. Pt. will be able to perform anteroposterior and mediolateral weight shifting after 2
weeks to prepare for single leg stance activities
4. Pt. will be able to perform anterior and lateral step ups x10 after 3 weeks
5. Pt. will be able to amb. c min. assist for 10 feet 3x a day after 4 weeks
Long Term Goals
1. PT. will be able to perform HEP for stretching and strengthening of B LE indep. And
without difficulty
2. Pt. will be able to amb. indep. on even and uneven surfaces With one forearm
crutch Safely and Continuously within her home
3. Pt. will be able to go up and down 2 flights of stairs indep., safely, and s difficulty
4. Pt. will return to being a community ambulator with one forearm crutch and amb for
10 consecutive minutes in a crowded place safely and without difficulty
 PLAN
(RATIONALE OF
INTERVENTION)
Plan HEP
1. Maintained stretch c tendinous 1. Heel slides
pressure on B LE 2. Long sitting
2. Active PNF D1 D2 flex/ext on B 3. Trunk rotations
LE 4. Sit > stand
3. Supine bridging
4. Quadruped c hip extensions
5. Tall kneeling
6. Sit>Stand
7. Wt. bearing (standing)
8. Wt. shifting
9. Single leg stance
10. Forward et lateral step up
11. Gait training (walking)