CEREBRAL

PALSY-
REHABILITATIO
N VARUN THOMAS PAUL P
JUNIOR RESIDENT-1
DEPT OF PM&R
AIIMS RISHIKESH
GENERAL PRINCIPLES
 Multidisciplinary Approach Comprehensive Rehabilitation Team
 Potential members Physiatrist, Developmental Paediatrician, Orthopedist, Neurologist,
Physical therapist, Occupational therapist, Speech and language pathologist, Therapeutic
recreation specialist, orthotist, psychologist, social worker and a nutritionist.
 Step1: Determine the goals

(a). Short and long term goals to address neuromuscular concerns like maintaining ROM and
tone control
(b). Functional goals Self care skills, mobility and communication
(c). Goals related to societal participation
(d). Routine reassessment of goals as child grows and encourage child to take an active role in
goal setting when appropriate.
 TREATMENT STRATEGIES GOALS OF REHABILITATION
Infancy Supportive Nutritional Improve mobility Teach the child to use his remaining
measures for support, exercise potential
prolonging and Teach the child functional movement
optimizing
physical status and Gain muscle strength
life
Prevent Deformity Decrease spasticity
Childhood Maximum Medication,
independent exercise, Improve joint alignment
mobility botulinum toxin, Educate the parents To set reasonable expectations
bracing
Preschooler Maximum Medication, Do the exercises at home
independent exercise, Teach daily living skills Have the child participate in daily living
mobility, minimize botulinum toxin, activities
deformity bracing, surgery
Societal integration Provide community and social support
Adolescence Education, Schooling, sports,
vocation and psychosocial
integration into the support
community

Mild Moderate Severe

Appearance Function Comfort

Integration Self care skills Enhance care
MANAGEMENT PRINCIPLES IN NEUROMUSCULAR DISEASE BASED
ON VALUING CHILDHOOD
1. Consider the natural history of the disorder.
2. Appreciate the significance of sensation and perceptive disabilities.
3. Recognize the limitations of treatments.
4. Be cautious with comparisons.
5. Focus on appearance, function and comfort, not on deformity.
6. Provide functional mobility.
7. Establish appropriate priorities.
8. Focus on the child’s assets.
9. Shift priorities with age.
10. Maintain family health.
11. Avoid management fads.
12. Protect the child’s play experience.
THERAPY METHODS
PRINCIPLES OF THERAPY METHODS
Support the development of multiple systems such as cognitive, visual, sensory and
musculoskeletal
Involve play activities to ensure compliance
Enhance social integration
Involve the family
Have fun

Therapy Program
Infant Stimulating advanced postural, equilibrium and balance
reactions to provide head and trunk control
Toddler & preschooler Sretching the spastic muscles, strengthening the weak
ones and promoting mobility
Adolescent Improving cardiovascular status
CONVENTIONAL EXERCISES
 Active and passive range of motion exercises  To prevent dynamic and fixed deformity and to
maintain current ROM, attempt to improve gait and to improve Neuroplasticity.
 Stretching  Reduce risk of contracture development as a result of muscular imbalance and
hypertonicity. Sustained stretching can be achieved through use of positioning devices, orthoses
and serial casting. Also can use superficial and deep heating modalities during stretch. Splints,
casts or a tilt table (Passive stretching)
 Strengthening  Increase strength and use of muscle groups (no negative effects of increased
spasticity or reduced ROM). IndirectlyIncreased participation and improved self-esteem.
Strengthening in functional positions may transfer more readily to improvement in motor tasks
uncertain whether loading or the functional practice makes the difference.
 Fitness to improve the cardiovascular conditionAerobic ExercisesImproved physiologic
measures of aerobic fitness without adverse effects such as increased spasticity, fatigue or
musculoskeletal trauma. Promote activities such as wheelchair sports, swimming, matt exercises or
cycling.
 N E U R O MO T O R T H E R A P Y A P P R O A C H E S T O C E R E B R A L P
A L S Y

NEURODEVELOPMENTAL SENSORIMOTOR APPROACH SENSORY INTEGRATION VOJTA APPROACH PATTERNING THERAPY

TREATMENT (BOBATH’S) TO TREATMENT (ROOD) APPROACH (AYRES) (DOMAN- DELACATO)

CENTRAL NERVOUS SYSTEM Hierarchic Hierarchic Hierarchic Hierarchic Hierarchic

MODEL

GOALS OF TREATMENT • To normalize tone
• To inhibit primitive reflexes
• To facilitate automatic reactions
and normal movement patterns
• To activate postural responses • To improve efficiency of neural • To prevent cerebral palsy in • To achieve independent mobility
(stability) processing infants at risk • To improve motor coordination
• To activate movement • To better organize adaptive • To improve motoric behaviour • To prevent or improve
(mobility) once stability is responses in infant with fixed cerebral communication disorders
achieved palsy • To enhance intelligence

PRIMARY SENSORY SYSTEMS • Kinesthetic • Tactile • Vestibular • Proprioceptive All sensory systems are used
USED TO EFFECT A MOTOR • Proprioceptive • Proprioceptive • Tactile • Kinesthetic
RESPONSE • Tactile • Kinesthetic • Kinesthetic • Tactile

EMPHASIS OF TREATMENT Positioning and handling to Sensory stimulation to activate Therapist guides but child controls Trigger reflex locomotive zones to Sensory and reflex stimulation,
ACTIVITIES normalize sensory input motor response (tapping, brushing, sensory input to get adaptive encourage movement patterns (e.g. passive movement patterns,
Facilitation of active movement icing) purposeful response reflex crawl) encouragement of independent
movements

INTENDED CLINICAL Children with cerebral palsy Children with neuromotor disorders Children with learning disabilities Young infants at risk for cerebral Children with neonatal or acquired
POPULATION Adults post cerebrovascular such as cerebral palsy Children with autism palsy brain damage
accident (CVA) Adults post CVA Young infants with fixed cerebral
palsy

EMPHASIS ON TREATING Yes No No Yes No

INFANTS

EMPHASIS ON FAMILY Yes No No Yes Yes

INVOLVEMENT DURING Handling and positioning for Supportive role encouraged Family administers treatment at Family and friends administer
TREATMENT activities of daily living home daily treatment several times daily

EMPIRIC SUPPORT Few studies Very few studies Many studies Few studies Few studies
Conflicting results Conflicting results Conflicting results with school-age Conflicting results Conflicting results
children
Positive results for tactile and
vestibular input with infants
 Vojta Reflex Physical Therapy (Exercise 2 of 3) (youtube.com)
BOBATH CONCEPT – (Dr. Karel Bobath and Berta Bobath)
 Normal quality of tone is necessary for effective movement
 Specialized handling and positioning techniques used improve quality of tone and facilitate
movement patterns in execution of everyday tasks.
 Emphasis active participation of the child and practice of functional skills..
 Self organization facilitates posture and movement integration  use of postural control
strategies for motor learning and motor control improvement.
PHELPS : Uses extensive bracing, withdrawing support as motion is performed with a
minimum of tension, overflow and substitution.
DEAVER: Uses extensive bracing, limiting all but two motions of an extremity
 GOAL ATTAINMENT THERAPY
 Also referred to as ‘task-oriented approach’ , built on theories of
motor learning
 The development and learning of new skills: Interaction between
the child, the task to be performed and the particular environment
in which the task takes place.
 Goals for therapy are set in collaboration with child’s family and
sometimes also the child
 Set goals should be specific, measurable, attainable, relevant and
timed (SMART).
 Treatment success defined by Goal Attainment Scaling (GAS)
which is an individualized criterion referenced measurement that
quantifies the achievement of treatment or intervention goals for
different kinds of treatment issues.
 CONDUCTIVE EDUCATION
 Combined educational and task oriented approach for children with CP
 Specially trained ‘conductors’ in all aspects of motor and cognitive development
give education to homogeneous groups of children with motor disorders and
structures the activities, especially the self care activities.
 Training takes place in an educational setting. Important motivating factor is Group
work and strong emphasis is on the importance of anticipation, with forward
planning of activities, especially the self care activities.
 Educated on how to use his/her abilities for performing active movements and
generalizing this learning to different life situations.
 Attention paid to all aspects of child development- the physical, intellectual,
cognitive and social approach.
 More effective in improving social interaction and relationships
 Emphasis of intervention is on independence in attaining goals rather than on
quality of movement.
 CONSTRAINT-INDUCED MOVEMENT THERAPY
 Motor learning based approach that focuses on upper limb
function in children with hemiplegic CP.
 In Congenital or Acquired Hemiplegia as a result of sensory
and motor impairments  Developmental Disuse
 Increase spontaneous use of the impaired arm by restraining the
normal arm using a plaster, removable casts, bivalved casts, a
glove or a sling.
 Classic CIMT: Restraint of the unaffected limb in conjunction
with at least 3 hours per day of therapy for at least 2-3
consecutive weeks.
 Modified CIMT (mCIMT): More child-friendly approach with
the use of a mitt, splint, or bandage and varying frequencies/
duration of restraint.
 Disadvantage: Focus is on training unilateral dexterity, but
children with hemiplegic CP have impairments with
coordination of two-handed activities. CIMT does not address
this impairment directly and thus generalization of the training
may not apply.
 BIMANUAL TRAINING (BIT)
 Focus on improving the coordination of both arms using structured tasks in
bimanual play and functional activities with intensive practice.
 Hand arm bimanual training (HABIT) program. Also based on motor learning
theory and Neuroplasticity.
 Hand arm bimanual intensive therapy including lower extremities (HABIT-ILE)
combines upper and lower bilateral extremity training.
 Frequently used bimanual tasks and activitiesmanipulative games and tasks,
arts and craft and virtual reality (wii-fit, kinect).
 Frequently used bilateral lower extremity tasks ball sitting, standing, balance
board standing, virtual reality (wii-fit, kinect), walking/running, jumping and
cycling.
 Decreased time and progressively increasing postural challenge.
 Hybrid Therapy to reap individual unique benefits .
 FAMILY CENTERED MODELS
 Refers to how health care professionals interact and involve
children’s family in the care.
 Successful parent-therapist collaboration is characterized by
the following therapist competencies:
(1) Ability to listen, share and learn with families
(2) Ability to foster the parental role and expertise
(3) Ability to facilitate parent-centered decision making about
what is best for the child
 Three principles

(a) Respect that parents know and want the best for their child
(b) Every family is unique
(c) Optimal development occurs within a supportive family
and a community context
 TREADMILL TRAINING
 Provide repetitive task specific approach to facilitate attainment of
stepping and locomotion and a more normalized gait pattern.
 Goals: Increase lower extremity strength, increase speed, improve
symmetry of gait patterns, improve balance or to increase endurance
 Help clinicians overcome space constraints, reduce physical demands
and establish a convenient set-up for gait evaluation.
 In Partial Body Weight-supported Treadmill Training (PBWSTT) the
child is in a harness that supports their body weight, reduce some
effort required for walking over the treadmill and assists in production
of steps while child is supported in a safe environment.
 30 minutes twice daily for 2 weeks  improvement in walking speed
and energy efficiency.
 Backward Walking (BW) training better than Forward Walking (FW)
training :
(1) Leg muscles are active for a longer period of time  Greater
muscle strength gain
(2) Higher physiologic and perceptual responses required  improve
walking capacity and decrease standing asymmetry of body weight
distribution.
 ROBOT ASSISTED THERAPY
 Uses robotic devices that enable the patients to perform specific limb
movements and achieve a large amount of movement in a limited time.
 Human- machine interface has capability to motivate the child to
perform his/her therapy through playful games (car races) or perform
exercises that mimic ADLs.
 Allow patient to receive visual, auditory or sensory feedbacks.
 Robots give performance based assistance to the patient. As consistency
of assistance can be maintained, intensity and difficulty can be set as per
patient’s improvement.
 Repetitive, goal oriented, cognitive engaging tasks
 Increase functional strength and improve isolated movements and
improve quality of life
 Lokomat (Hocoma, CH), made of two active orthoses, a weightbearing
system and a treadmill has been proposed to improve walking and
physical fitness.
 VIRTUAL REALITY
 Use of interactive simulations created with computer to perform users in virtual
environments that appear, sound, and feel similar to real-world objects and
events by moving and manipulating virtual objects
 Provide ecologically valid opportunities for active learning, which are enjoyable
and motivating yet challenging and safe
 Free play is characterized by children’s spontaneous engagement in an activity
that is intrinsically motivating and self-regulatedchildren can develop a
learned helplessness and assume that they are unable to perform a task even
though they may have the required physical abilities due to limitiations in free
play
 Virtual reality can improve the patient’s motivation and achievement in ADLs.
 The technologies differ in both type and technical complexity.
 Use of standard desktop or laptop computer equipment, camera based video
capture gesture control devices (e.g., Microsoft’s Kinect), Nintendo Wii Fit
(http:// wiifit.com/) head-mounted displays, haptic and other sensor- and/or
actuator-based devices, and large screen immersive systems (e.g., Motek’s
CAREN http://www.motekmedical.com/), GestureTek VR games etc.
 Demonstration of the effectiveness of any virtual reality intervention depends on
the degree to which the attained skills transfer to the “real world.”
CARDIORESPIRATORY ENDURANCE TRAINING
 Many children, adolescents, and adults with CP have reduced cardiorespiratory endurance,
muscle strength, and habitual physical activity participation significant risks for negative
health outcomes and early, cardiovascular, and all-cause mortality.
 Exercise prescription for people with CP should include:

(1) A minimum frequency of two to three times per week

(2) An intensity between 60 and 95% of peak heart rate, or between 40 and 80% of the HRR, or
between 50 and 65% of VO2peak
(3) A minimum time of 20 minutes per session, for at least 8 consecutive weeks, when training
three times a week or for 16 consecutive weeks when training two times a week.
 A pre-workout warm-up and cool-down could be added to reduce musculoskeletal injury.
 A program of “functional exercises,” combining aerobic and anaerobic capacity and strength
training, in ambulatory children improves physical fitness and quality of life.
 DURABLE MEDICAL EQUIPMENT
 Focus is on maximizing function, improving safety, and enabling
independence using the ICF-CY model of health.
 Supportive or adaptive seating systems and standing frames can facilitate a
developmentally appropriate upright posture, strengthening, flexibility
across the lower extremities, weight bearing/bone density, upper limb
function, communication, feeding by freeing the child’s hands to perform
bimanual tasks, improving breath support, and optimizing the head and
trunk position to facilitate a safe swallow.
 Use of a wheelchair becomes applicable when a child either outgrows
commercially available strollers or additional support is necessary. Goal of
supportive seating is to provide an upright seated posture to facilitate
interaction with the environment and minimize deforming forces secondary
to postural abnormalities
 The gait trainer is a wheeled walker with a sling seat and various support
options, which allows the patient to propel the device without necessarily
having a coordinated, reciprocal gait pattern.
 Equipment to facilitate transfers and floor recovery, such as a mobile mechanical lift or overhead lift
device.
 In augmentative communication, meaningful communication and expression of needs are facilitated with
the use of computers, switch devices, sign boards, and similar adaptive equipment.
 Splinting and orthoses are commonly used in CP to manage spastic and flexible dynamic deformities of the
extremities.
 Lower limb orthosisSpecial consideration of ankle-foot alignment, ROM and tone.
 Goal of orthosis: Maintaining or increasing ROM, protection or stabilization of a joint, or promotion of a
functional activity.
 Upper extremity orthosis  Static and Dynamic Wrist Hand Orthosis
 Lower Extremity orthosis  Supramalleolar Orthosis, solid Ankle
Foot orthosis, hinged AFOs and Ground Reactive AFOs, Knee Ankle
Foot Orthosis and Hip Knee Ankle Foot Orthosis
 Rotational control orthosis: Twister cables and Rotation straps
 Twister cables: pelvic band with attached cables of twisted spring
steel with torque typically applied to provide an external rotation
force by attaching to the shoes/AFOs.
 Rotation straps: Elastic and attach to buckles on AFOs or to an eyelet
attachment on shoestrings  Provide internal or external rotation
forces depending on the application of wrapping the straps around
the lower extremities.
 Tone Reducing AFOs aid in gait by controlling the equinus
or equinovarus deformity.
o Designed to decrease abnormal reflexes
o Full length foot plate extends past the toe to discourage toe
flexion.
o Metatarsal support discourages stimulation to a particularly
reflexogenic area of the foot
o Most effective during gait, but use during rest prevents
contractures.
 KAFOs add direct control over knee flexion and extension
as well as varus and valgus but add bulk and weight.
 HKAFOs add direct control over hip position but do not
significantly improve gait but do decrease deformity.
 Spinal Orthosis Slow progression of scoliosis and delay
surgery until a more ideal time. Has positive effect on sitting
stability and function.
ELECTRICAL STIMULATION
 An attractive alternative for strengthening in children with
poor selective motor control.
NEUROMUSCULAR ELECTRICAL STIMULATION
(NMES)
 The application of an electrical current of sufficient
intensity to elicit muscle contraction.
FUNCTIONAL ELECTRICAL STIMULATION (FES)
 If NMES is used to make a muscle contract during a
functional activity, it is termed FES.
 Commercially available devices, commonly referred to as
neuroprostheses, are available to deliver asymmetrical
biphasic surface electrical stimulation to the common
fibular nerve, triggered by a tilt sensor, to improve foot
clearance during swing phase.
THRESHOLD ELECTRICAL STIMULATION (TES)
 A low-level electrical stimulus, often applied during sleep that does not result in a visible
muscle contraction.
 Proposed mechanism: Increasing blood flow during a time of heightened trophic hormone
secretion results in increased muscle bulk.
TRANSCRANIAL MAGNETIC STIMULATION (TMS) and TRANSCRANIAL DIRECT
CURRENT STIMULATION (tDCS)
 Experimental interventions that are showing potential benefit in both children and adults
with CP.
THERAPY THEORY/BENEFITS
Hyperbaric Oxygen Awaken dormant brain tissue
surrounding the original injury
Adeli suit Resistance across muscles can
improve strength, posture and
coordination.
Hippotherapy Riding a horse can improve muscle
tone, head and trunk control,
mobility in the pelvis and
equilibrium.
Craniosacral therapy Therapy is used to remove
impediments to the flow of
cerebrospinal fluid within the
cranium and spinal cord.
Feldenkrais Change of position and directed
attention can relax muscles and
improve movements, posture and
functioning.
Acupuncture Acupuncture can help to restore the
normal flow of qi, or energy.
CP, Cerebral Palsy
From Liptak GS: Complementary and alternate therapies for cerebral palsy, Ment Retard Dev Disabil Res Rev 11: 156-163, 2005.
ADVERSE EFFECTS EVIDENCE COMMENTS
Ear trauma, pneumothorax, fire, Uncontrolled studies show More evidence is required before
explosion improvements in treated children. recommendations can be made (e.g.
Controlled studies show what is the role of increased pressure
improvement in treated and control without supplemental oxygen?)
subjects.
Discomfort from suit, expense for No conclusive evidence either in
therapy and for travel to centers that support of or against the use of the
prescribe the suit Adeli suit.
Trauma from a fall, allergies Uncontrolled and controlled trials Horseback riding also increases
show beneficial effects on body social participation.
structures and functioning.
None known No studies showing efficacy in CP;
some question the basis of the
intervention.
None known No studies showing efficacy in CP;
studies in other conditions are
equivocal.
Forgotten needles, pain, bruising and Uncontrolled studies show Appears promising, but more studies
infection. improvements in several areas; two are required before specific
controlled trials also showed recommendations can be made
improvements.
THANK YOU