Pediatric physical therapy is a specialized form of physical therapy where a pediatric physiotherapist deals with the wide variety of diagnoses which affect overall development of a developing child. Pediatric physiotherapy helps a number of children with Neurodevelopmental disorders, orthopaedic disorders, neuromuscular disorders, genetic disorders and metabolic disorders. Following conditions are treated successfully with pediatric physical therapy at ICD, New Delhi • Cerebral Palsy • Autism Spectrum Disorder • Spina bifida • Infantile spasm • Hydrocephalus • Seizure disorders • Traumatic brain injury • Bow legs • Knock knees • Spinal injury • CTEV, etc AS ICD has a dedicated team of physiotherapists with basic qualification in physiotherapy and advance training in pediatric physiotherapy, they are responsible for this unique pediatric physiotherapy program. You will never get overlapping of services with occupational therapist in ICD, New Delhi. When you are in ICD, Delhi, your child’s therapy program is always a combination of the following physiotherapy approaches according to the need of your child (Eclectic Approach). 1. Breathing / Scotson Technique 2. Stretching Protocol 3. Strength Training 4. Therapeutic Taping / Kinesotaping 5. Tone Reducing Positioning ( TRP) 6. Neuro-Enhancing Positioning (NEP) 7. Neuro-Developmental Therapy (NDT) 8. Neuro-Dynamic Facilitation Technique (NDFT) 9. Rood Approach 10. Vojta Approach 11. Proprioception Neuro-Faciltation Technique(PNF) 12. Brunnstorm Approach 13. Carr and Shepherd Approach 14. MNRI 15. FeldenKraish Method 16. Frankles Exercises 17. Goal Directed Functional Therapy 18. Vibration Therapy 19. Thera-Suit Therapy ( Modified Adeli Suit Therapy) 20. Biofeedback Therapy 21. Move Therapy

1. PHYSICAL THERAPY IN CEREBRAL
PALSY
Dr. Mansoor Alam
Child Developmental Specialist
Institute for Child Development
New Delhi

2. PHYSICAL THERAPY
Physiotherapy
+
Occupational Therapy
OR
Developmental Therapy
Functional Physical Therapy
Aim Oriented Management
Task Oriented Management
Goal Targeted Therapy

3. PHYSIOTHERAPY
It is a form of therapy where the child is treated with
physical exercises and a few but limited external
modalities to be independent especially in movement
or mobility

4. OCCUPATIONAL THERAPY
It is a form of therapy where the child is trained to get
independence or to become capable to lead a
productive life

5. DEVELOPMENTAL THERAPY
It is a form of therapy where the child with delayed
milestones is being stimulated to achieve milestones
based on abilities and limitations of the child

6. REHABILITATION THERAPY
VERSUS
HABILITATION THERAPY
Rehabilitation Therapy is the process of helping a person who
has suffered an illness or injury to restore lost skills and so
regain maximum self-sufficiency. Generally adults are the main
beneficiaries in case of rehabilitation services
Therapies meant for cerebral palsy are popularly known as
habilitation therapy
Habilitative therapy is a type of treatment or service that seeks
to help patients develop skills or functions that they were
incapable of developing on their own. This type of treatment
tends to be common for pediatric patients who haven’t
developed certain skills at an age-appropriate level.

7. PURPOSE OF PHYSICAL THERAPY IN CP
MANAGEMENT
Maximizing the potentials of the child to become
independent in Mobility and ADLs so that the child
can lead normal or near normal life

8. HOW DOES PHYSICAL THERAPY HELP
CHILDREN WITH CEREBRAL PALSY?
Physical Therapy (PT / OT / PT+OT) can
 Integrate primitive reflexes
 Neutralize muscle tone
 Increase ROM / Joint integrity
 Enhance Strength
 Enhance Balance
 Enhance Coordination
 Enhance Endurance

9. HOW DOES PHYSICAL THERAPY HELP CHILDREN
WITH CEREBRAL PALSY?
Physical Therapy (PT / OT / PT+OT) can
 Improve postural ability
 Increase independence
 Integrate Sensory Dysfunction
 Enhance Cognitive functioning
 Reduce physical discomfort and pain
 Overcome physical limitations and obstacles
 Decrease the chances of bone deformity

10. THERAPY APPROACHES
 The Bobath technique /Neurodevelopmental technique (NDT)
 Sensory Integration /Ayer’s Approach (SIT)
 Proprioceptive Neurofacilitation Approach / Kabat Approach (PNF)
 Sensorimotor technique / Rood's Approach
 Vojta Therapy / Vojta Approach
 Constraint Induced Manual Therapy (CIMT)

11. THERAPY APPROACHES
 Temple Fay (Progressive Pattern Movements)
 Phelps Technique (Muscle Education/Braces)
 Deaver Technique (Muscle Education/Braces)
 Phol Technique (Muscle Education/ Braces)
 Schwartz Technique (Muscle Education/ Braces)
 Gillette Technique (Muscle Education/ Braces)

12. THERAPY APPROACHES
 Eirene Collis Technique / Neuromotor Development
 Conductive Education
 Recreational Therapy
 Electrotherapy
 Adeli Suit Therapy / Theratog Therapy / Cage Therapy
 Move Therapy
 Eclectic Approach / Combination Therapy / Malina Approach

13. NEURODEVELOPMENTAL WITH REFLEX INHIBITION
& FACILITATION (KARL BOBATH)
NDT is characterized by hands-on “therapist-guided” facilitation of
movement to provide sensory input and improve postural control; the
goal is to regain typical motor behaviours and minimize atypical ones
Once the reflex patterns of abnormal tone are inhibited the child is
said to have been prepared for movement.
Reflex inhibitory patterns specifically selected to inhibit abnormal
tone associated with abnormal movement patterns and
abnormal posture.
Sensory motor experience – The reversal or break down of these
abnormalities gives the child the sensation of more normal tone and
movements.

14. NEURODEVELOPMENTAL WITH REFLEX INHIBITION
& FACILITATION (KARL BOBATH)
The therapist tries to attempt to change the patterns of spasticity so
that child is prepared for movement and mature postural reactions
uses key-points of control.
The key-points are usually head & neck, shoulder & pelvic girdles, but
there is also work from distal key- points.

15. LIMITATIONS OF NDT APPROACH
Most references available that advocate the usage of the
approach mainly for post stroke adult with hemiplegia.
There is no evidence that NDT can promote functional
improvement of children with cerebral palsy (Novak 2013).
“Inhibition of abnormal movement patterns”, this
terminology is no longer used "Inhibition" was recognised
to be a confusing term in the 1990s and no longer used in
the paediatric approach as it was not an accurate
description of intervention

16. SENSORY INTEGRATION (AYER’S APPROACH-SIT)
Highlights of the Approach
1. Sensory integration therapy exposes children to
sensory stimulation in a structured, repetitive manner.
2. The theory behind this treatment approach is that, over
time, the brain will adapt and allow them to process and
react to sensations more efficiently.
3. Difficulties in planning and organizing behaviour are
attributed to problems of processing sensory inputs within
the CNS, including vestibular, proprioceptive, tactile,
visual, and auditory.

17. SENSORY INTEGRATION (AYER’S APPROACH-SIT)
4. Children with sensory integration dysfunction
frequently use different sensory combination
strategies.
5. Treatment focuses on integration of neurological
processing by facilitating the individual to process the
type, quality, and intensity of sensation

18. PROPRIOCEPTIVE NEUROFACILITATION APPROACH /
KABAT APPROACH (PNF)
Highlights of the Approach
Mass Movement Patterns: Based on patterns
observed with functional activities in daily Life.
Mass Movements Patterns are mostly described as
Spiral and diagonal
Mass Movement patterns can be flexion or extension,
abduction or adduction, internal rotation or external
rotation or combination with synergetic muscles
groups

19. PROPRIOCEPTIVE NEUROFACILITATION APPROACH
(PNF-KABAT APPROACH)
Sensory (afferent) stimuli are skilfully applied to
facilitate movement.
Stimuli used are touch & pressure, traction &
compression, stretch, proprioceptive effect of muscle
contracting against resistance and auditory and visual
stimuli.
Resistance to motion is used to facilitate the action of
the muscles, which form the components of the
movement patterns.

20. PROPRIOCEPTIVE NEUROFACILITATION APPROACH /
KABAT APPROACH (PNF)
Special techniques that can be used in cerebral palsy
physiotherapy
 Irradiation
Muscle Irradiation is the ability of a muscle performing an
action to generate greater tension (i.e. force) by being
“innervated” from the surrounding muscles.
 Rhythmic Stabilization
 Stimulation of Reflexes
 Repeated Contractions
 Reversals
 Relaxation techniques – Hold Relax & Contract Relax

21. SENSORIMOTOR TECHNIQUE (ROOD'S APPROACH)
Highlights of the Approach
Techniques of stimulation, such as stroking, brushing,
icing, heating, pressure, bone pounding slow & quick
muscle stretch, joint retraction & approximation, muscle
contractions (proprioception) are used to activate, facilitate
or inhibit motor response in cerebral palsy physiotherapy.
Ontogenetic developmental sequence is strictly followed in
the application of stimuli.
a. Total flexion or withdrawal pattern (in spine)
b. Roll over (flexion of arm & leg on the same side and roll
over)

22. ROOD APPROACH

23. SENSORIMOTOR TECHNIQUE (ROOD'S APPROACH)
c. Pivot prone (prone with hyperextension of head,
trunk & legs)
d. Co-contraction neck (prone head over edge for co-
contraction of vertebral muscles)
e. On elbows (prone & push backwards)
f. All fours (static, weight shift & crawl)
g. Standing upright (static, weight shifts)
h. Walking (stance, push off, pick up, heel strike)

24. VOJTA THERAPY (VOJTA APPROACH)
Highlights of the Approach
1. Reflex creeping: The creeping
patterns involving head, trunk and
limbs are facilitated at various
trigger points or reflex zones.
2. Touch, pressure, stretch and muscle action against
resistance are used in triggering mechanisms or in
facilitation of creeping.
3. Resistance is recommended for action of muscles.

25. CONSTRAINT INDUCED MANUAL THERAPY-CIMT
Highlights of the Approach
1. CIMT is used predominantly in the individual with
hemiplegic cerebral palsy to improve the use of
affected upper limb.
2. The stronger or non-affected upper limb is
immobilized for a variable duration in order to force
use of the impaired upper limb over time

26. TEMPLE FAY (PROGRESSIVE PATTERN
MOVEMENTS)
Highlights of the Approach
1. Temple Fay suggested building up motion from reptilian
squirming to amphibian creeping, through mammalian reciprocal
motion 'on all fours ' to the primate erect walking
This approach is also called Patterning / Doman-Delacato Method
2. They developed progressive pattern movements which consist of
five stages.
 Stage 1: Prone lying
 Stage 2: Homo-lateral stage
 Stage 3: Contra lateral stage
 Stage 4: On hands and knee
 Stage 5: Walking pattern

27. PHELPS TECHNIQUE
(MUSCLE EDUCATION/BRACES)
Hch
Highlights of the Approach
Dr. W M Phelp emphasized on team work and habilitation. He
encouraged physiotherapists, occupational therapists and
speech therapists to form themselves into cerebral palsy
habilitation team.
He chose fifteen modalities and specific combinations of these
modalities were used for the specific type of cerebral palsy
1. Massage for hypotonic muscles, but contraindicated in
children with Spasticity and athetoid.
2. Passive motion through joint range for mobilizing joints and
demonstrating to the child the movement required. Speed of
movement is slower for children with spasticity, increased for
rigidity.

28. PHELPS TECHNIQUE
(MUSCLE EDUCATION/BRACES
3. Active assisted motion.
4. Active motion
5. Resisted motion followed according to the child's capability.
6. Conditioned motion is recommended for babies, young children
and mentally retarded children
7. Confused motion or synergistic motion which involves resistance
to a muscle group in order to contract an inactive muscle group in
the same synergy. Mass movements such as the extensor thrust
or the flexion withdrawal reflex are usually used. For example,
using the hip- knee flexion-dorsiflexion synergy, inactive
Dorsiflexors are stimulated by resistance given to hip flexors.

29. PHELPS TECHNIQUE
(MUSCLE EDUCATION/BRACES
8. Combined motion in training motion of more than
one joint such as a shoulder and elbow flexion.
9. Relaxation techniques used are those of conscious
'letting go' of the body and its parts (Levitt 1962),
tensing and relaxing parts of the body. These methods
are mainly used with athetoid. They attempt to lie still or
relaxed or use contract -, relax relaxation for grimacing
and other involuntary motion.
10. Movement from relaxation is conscious control of
movements once relaxation has been achieved. It is
mainly used for children to control involuntary movements.

30. PHELPS TECHNIQUE
(MUSCLE EDUCATION/BRACES
11. Rest – Periods of rest are suggested for athetoid and
children with spasticity.
12. Reciprocation in training movement of one leg after the
other in a bicycling pattern in lying, crawling, knee walking
and stepping.
13. Balance - Training of sitting balance and standing in braces.
14. Reach, grasp and release used for training of hand function.
15. Skills of daily living such as feeding, dressing, washing and
toileting. Many aids were devised by the occupational therapists.

31. PHELPS TECHNIQUE
(MUSCLE EDUCATION/BRACES
Special Consideration for Braces / Calipers
He prescribed special braces to correct deformity, to
obtain the upright position and to control athetosis.
The bracing is extensive and worn for many years.
The children are taught to stand and step long leg
braces with pelvic bands and back supports, or
sometimes spinal brace.
As they progress, the back supports are removed
then the pelvic band and finally they wear below - knee
irons.
The full - length brace has locking joints at hip and
knee so that control can be taught with them locked
or unlocked.

32. PHELPS TECHNIQUE
(MUSCLE EDUCATION/BRACES
Emphasis on Muscle Education
 Children with Spasticity are given muscle education
based on an analysis of whether muscles are spastic,
weak, normal or zero cerebral, or atonic.
 Muscles antagonistic to spastic muscle are activated.
This is to obtain muscle balance between spastic
muscles and their weak antagonists.
 Athetoids are trained to control simple joint motion and do not
require muscle education.
 Ataxic may be given strengthening exercises for weak
muscle groups.

33. PHELPS TECHNIQUE
(MUSCLE EDUCATION/BRACES
Advocated Chemodenervation
 Alcohol injections were used
to diminish Spasticity
Advocated Orthopedic Surgery
 Early orthopedic surgery were recommended.

34. DEAVER TECHNIQUE
(MUSCLE EDUCATION/BRACES)
Highlights of the Approach
This technique based on extensive use of braces.
He uses braces for ambulation, eliminating brace elements as
the child's control improves.
He concentrates on self care or activities of daily living,
particularly the independent use of wheelchairs.
He focused a special attention on teaching the hand activities by
the same idea of eliminating all but two arm's maneuvers and
gradual removal of restriction as control is established:
The major aims of his treatment system are:
Maximal use of the hands.
Usable speech.
Normal or near-normal appearance.

35. PHOL TECHNIQUE
(MUSCLE EDUCATION/BRACES)
Highlights of the Approach
1. General relaxation is first induced then isolated
relaxation is taught.
2. Muscle consciousness, function and coordination
are the three principles for the training of voluntary
muscle control.
3. The activities observed in the normal sequence of
development are the base of the functional phase of
his program.
4. Braces are not used, while crutches or canes
may be used for the walking training.

36. SCHWARTZ TECHNIQUE
(MUSCLE EDUCATION / BRACES)
Highlights of the Approach
 He believed that the progression of the emotional
and intellectual level will be followed by the
progress in the physical motor level. This technique
based on simplifying the external environment and
providing motivation. He made specific devices to
eliminate obstacles
 The motivation is provided by successful
performance of play activities.
 He did not preferred to use braces, but crutches
and canes were used for independent
locomotion.

37. GILLETTE TECHNIQUE
(MUSCLE EDUCATION/BRACES)
Highlights of the Approach
 This technique based on how to gain good skeletal alignment
for cerebral palsied children. Therefore, stretching is
performed daily to correct or to prevent contractures in spastic
muscle groups.
 A specific exercise program (as forms for normal child to play)
is designed to provide optimal range, tone, strength and
functional activities.
 He recommended braces and splints to prevent or correct
deformity, control movement and provide a stable base for
balance.
 For the child who has involuntary movements, he provided a
teaching program by breaking the chain of abnormal reflex,
which may allow more purposeful acts.
 He preferred the proprioceptive training (balance and position
sense) for ataxic cases to compensate lack of balance,
equilibrium, coordination and proprioceptions.

38. EIRENE COLLIS TECHNIQUE
(NEUROMOTOR DEVELOPMENT)
Highlights of the Approach
 The mental capacity of the child would determine
the results.
 Early treatment was advocated.
 Management of CP child throughout the day
(feeding, dressing, toileting and other activities.
 Strict developmental sequence.
 She disliked the separation of treatment into
physiotherapy, occupational therapy and speech
therapy:
 She established the idea of the "cerebral palsy
therapist“ and emphasized on eclectic approach

39. CONDUCTIVE EDUCATION
Highlights of the Approach
Conductive education is a comprehensive method
of learning by which individuals with
neurological and mobility impairment
learn to specifically and consciously
perform actions that children without
such impairment learn through
Normal life experiences

40. RECREATIONAL THERAPY
Hydrotherapy
Please note, swimming is not hydrotherapy or
aqua therapy
Hippo therapy

41. ELECTROTHERAPY
 EMS / NEMS / TES / FES
 EMG Biofeedback
 Therapeutic Ultrasound

42. ADELI SUIT THERAPY
The suit uses a system of elastic bands and pulleys
that create artificial forces against which the body can
work, to prevent muscular atrophy and reduce
osteoporosis. It consists of a vest, shorts, knee pads,
shoes and sometimes a head piece, all connected in
a prescribed pattern with bungees of appropriate
tension.

43. MOVE ( MOVEMENT OPPORTUNITIES VIA
EDUCATION)
 MOVE uses the combined approach of education,
therapy, and family knowledge to teach the skills of
sitting, standing, walking and transitioning between.
It is an integrated curriculum-based approach to the
development of motor skills and independence and
utilises the expertise of education and therapy to
address the functional needs of students.

44. CURRENT SCENARIO
Role Significance
 Best Physiotherapy: 60%
 Best Occupational Therapy: 60%
 Best Developmental Therapy: 80%
 Combination Therapy: 90%-100%

45. CURRENT SCENARIO
Dark Zone of Physical Therapy World
# Lack of Team Spirit
# Poorly trained in Pediatrics- Both Theoretical and
practical- Poor Course Contents and Assessment Skills
# Limited Knowledge in Reflex Integration
# Limited Knowledge in Assistive Technology
specially use of orthoses, postural and mobility aids
# Too much of Passive therapy or No contact Therapy
# Poor with documentation-specially hip surveillance
# Disliking to work for ADL Training
# Excessive or no use of electrotherapy
# No knowledge about side effects- Limitations of the
Approaches or Techniques

46. MALINA- AN ECLECTIC APPROACH
 An eclectic therapy is a therapeutic approach that
incorporates a variety of therapeutic principles and
philosophies to create the ideal treatment program
to meet the specific needs of the child with cerebral
palsy.
 Although most physiotherapists use an eclectic
approach to the treatment of CP, there have been
several major influences on therapeutic practice
during the last 50 years, including the Bobath
concept, conductive education and sensory
integration.

47. MALINA APPROACH
Highlights of the Approach
 Eclectic Approach
 Advance and updated
 Evidence based
 Extracted from the previous and well known pediatric
physical therapy approaches
 Amalgamation of selected result oriented key points
 ICF oriented
 Exclusive for pediatric habilitation
 Holistic Approach- Suitable for both HBS and CBS
 Need Extensive Training

48. MALINA APPROACH
Highlights of the Approach
Key Worker Model / Appointing a Team Leader
Life Span Approach
Multidisciplinary / Interdisciplinary / Trans disciplinary
Approach- Need Based
Based on Functional Classification System
GMFCS / MACS / FMS / VFCS / CFCS / EDACS
5 Steps Management Approach- Standard of Practice
 Screening
 Assessments
 Diagnosis Making- Domain Oriented
 Intervention Program
 Evaluation Technique

49. MALINA APPROACH
Highlights of the Approach
Documentation using internationally accepted screening and
assessment forms for universal acceptance
Usage of self designed / indigenous forms in case of non-
availability or non-affordability of standard and universally
accepted forms
Use of POMR / POL and SOAP methods
Goals Setting based on SWOT / SMART Approach
Use of GAS for re-evaluation and proceeding further
Parents- Professional Partnership Management
Home Management Program with 360 degree input through
parents empowerment training

50. MALINA APPROACH
Difference between Treatment Plan and Treatment Program
Treatment / Management Plan
Long Term Plan
Intermediate Plan / Short Term Plan
Immediate Plan
Treatment plans can provide a comprehensive outline of the
child’s abilities and allows for interdisciplinary teams to work
together to provide the care needed.
Treatment / Management Program
Treatment Programs have a series of activities based on the needs of
the individual with the following components
Preventive Measure
Functional Measure
Developmental Measure

51. MALINA APPROACH
Specific Age Oriented Protocol
 Neonatal Therapy
 Infant Stimulation Program
 Early Intervention Program
 Intensive Therapy Protocol
 Maintenance Therapy Protocol
Procedure Oriented Protocol
 Post Botulinum Injection Therapy / PBT
 Post Orthopedic Surgical Therapy
 Post Neurosurgical Therapy
 Post Implant Therapy ( ITBP / DBS / Cochlear implant)
 Post HBOT
 Post SCT

52. MALINA APPROACH
Template of a Therapy Program
1. Handling / Lifting / Carrying Techniques
2. Breathing Exercises
3. Usage of Assistive Technology
a. Postural Aids
b. Orthotic Aids
c. Mobility Aids
d. Adaptive Aids
4. Reflex Integration / Sensory Stimulation and Integration
5. Muscles Education
a. ROM Exercises / Stretching
b. Strength Training

53. MALINA APPROACH
6. Postural Enhancement Through Positioning (Task Analysis Oriented)
a. Static Positioning / Anatomical Positioning
b. Neuroenhancing Positioning
c. Functional Positioning
d. Transitions
7. Equipotherapy
a. Use of Prone Wedge
b. Use of Bolster
c. Use of Swiss Ball / Medicinal Ball
d. Use of Vestibular / Balance Board
e. Use of Bench / Peto Bar / Malina Bar
f. Use of Swings
g. Use of Thera-band / Thera-loop / Thera-tube
h. Use of Trampoline
i. Use of Cycle (Both Static and Dynamic)
j. Uses of Aligner-Postural and Mobility Aligner

54. MALINA APPROACH
8. Mobility Training / Gait Training
a. Therapeutic Mobility
b. Functional Mobility
c. Floor Mobility
d. Off Floor Mobility
e. Aided Mobility
f. Ambulation
9. Electrotherapy
EMS
EMG Biofeedback
10. Hand Function Enhancement
a. Play
b. ADL
c. Hand Writing
d. Vocational Training

55. MALINA APPROACH
Postures
1. Lying Posture
Supine
Prone
Side Lying
2. Sitting Posture
Long Legs Sitting
Cross Legs Sitting
Side Legs Sitting
Squatting
High Sitting
3. Kneeling Postures
Quadruped
Kneeling Upright
Half Kneeling
4. Standing
Front Support Standing
Back Support Standing
Independent Standing
Mobility
1. Pivoting on abdomen
2. Rolling
3. Creeping
4. Crawling / Bottom Shuffling
5. Kneel Walking
6. Lateral Cruising / Side
Walking
7. Walker / Rollator Walking
8. Tripods / Quadripods Walking
9. Stick / Cane walking
10. Independent Walking
11. Wheel chair Mobility

56. GROSS MOTOR FUNCTION CLASSIFICATION
SYSTEM (GMFCS)

57. FUNCTIONAL MOBILITY SCALE

58. MANUAL ABILITY CLASSIFICATION SYSTEM-
MACS

59. THANKS FOR LISTENING
 For all queries, doubts and explanations, please contact
us @
Institute for Child Development
C-27, Malviya Nagar
New Delhi-110017
Landline Number: 011-41012124
Mobile Number: 7838809241
Mail: helpicd@gmail.com
Website: www.icddelhi.org