• DEFINITION AND RISK FACTORS
• ASSOCIATED PROBLEMS IN CEREBRAL PALSY
• ANATOMIC MOTOR CONTROL STRUCTURES
• GAIT PATTERN IN CEREBRAL PALSY
CAN BE DEFINED AS
- Non progressive injury to the immature brain
- Leading to motor dysfunction
- Lesion is not progressive,but
- The clinical manisfestations change over time
PRENATAL PERINATAL POSTNATAL
LOW BIRTH WEIGHT PROLONGED & DIFFICULT
INFECTIONS(TORCH) PREMATURE RUPTURE OF
DRUG ABUSE PRESENTATION
BLEEDING IN THIRD
VAGINAL BLEEDING AT THE
TIME OF LABOR
PLACENTAL INSUFFICIENCY BRADYCARDIA SEIZURES
ASSOCIATED PROBLEMS IN CP
• Visual impairments
• Intellectual impairment
• Learning disabilities
• Hearing problems
• Communication problems
• Oromotor problems
• Respiratory problems
• Bladder and bowel problems
• Social and emotional disturbances
SYMPTOMS OF CEREBRAL PALSY
THE SYMPTOMS OF CP VARY FROM PERSON-TO-
PERSON AND RANGE FROM MILD TO SEVERE. SOME
PEOPLE WITH CP MAY HAVE DIFFICULTY WALKING
AND SITTING. OTHER PEOPLE WITH CP CAN HAVE
TROUBLE GRASPING OBJECTS.THE SYMPTOMS CAN
BECOME MORE SEVERE OR LESS SEVERE OVER
TIME. THEY ALSO VARY DEPENDING ON THE PART
OF THE BRAIN THAT WAS AFFECTED.
e SOME MOTOR SIGNSmore
common signs include
• delays in reaching motor skill milestones, such as
rolling over, sitting up alone, or crawling
• variations in muscle tone, such as being too floppy or
• delays in speech development and difficulty speaking
• spasticity, or stiff muscles and exaggerated reflexes
• ataxia, or a lack of muscle coordination
• tremors or involuntary movements
• excessive drooling and problems with swallowing
• difficulty walking
• favoring one side of the body, such as reaching with
• neurological problems, such as seizures, intellectual
disabilities, and blindness
WHO’S AT RISK FOR CEREBRAL
• Certain factors put babies at an increased risk for CP.
• premature birth
• low birth weight
• being a twin or triplet
• a low Apgar score, which is used to assess the
physical health of babies at birth
• breech birth, which occurs when your baby’s
buttocks or feet come out first
• Rh incompatibility, which occurs when a mother’s
blood Rh type is incompatible with her baby’s blood
• maternal exposure to toxic substances, such as
methylmercury, while pregnant
TYPES OF CEREBRAL PALSY
• There are different types of CP that affect various
parts of the brain. Each type causes specific
movement disorders. The types of CP are:
• Spastic cerebral palsy
• Spastic CP is the most common type of CP,
affecting approximately 80 percent of people
with CP. It causes stiff muscles and exaggerated
reflexes, making it difficult to walk.Many people
with spastic CP have walking abnormalities, such
as crossing their knees or making scissorlike
movements with their legs while walking. Muscle
weakness and paralysis may also be present.The
symptoms can affect the entire body or just one
side of the body.
DYSKINETIC CEREBRAL PALSY
• People with dyskinetic CP have trouble controlling their body
movements. The disorder causes involuntary, abnormal
movements in the arms, legs, and hands.
• In some cases, the face and tongue are also affected. The
movements can be slow and writhing or rapid and jerky.
They can make it difficult for the affected person to walk, sit,
swallow, or talk.
• Hypotonic cerebral palsy
• Hypotonic CP causes diminished muscle tone and overly
relaxed muscles. The arms and legs move very easily and
appear floppy, like a rag doll.
• Babiess with this type of CP have little control over their
head and may have trouble breathing. As they grow older,
they may struggle to sit up straight as a result of their
weakened muscles. They can also have difficulty speaking,
poor reflexes, and walking abnormalities.
ATAXIC CEREBRAL PALSY
• Ataxic CP is the least common type of CP. Ataxic
CP is characterized by voluntary muscle
movements that often appear disorganized,
clumsy, or jerky.
• People with this form of CP usually have
problems with balance and coordination. They
may have difficulty walking and performing fine
motor functions, such as grasping objects and
• Mixed cerebral palsy
• Some people have a combination of symptoms
from the different types of CP. This is called
• In most cases of mixed CP, people experience a
mix of spastic and dyskinetic CP.
• Cerebral palsy results from an insult to a part of the brain
associated with motor control.
• Therefore,with spastic cerebral palsy,the brain areas most
affected are the cerebral cortex and corticospinal tracts.In this
condition, spasticity occurs.
• The basal ganglia is the brain area most affected in dyskinetic
cerebral palsy. Basal ganglia lesions result in abnormal
involuntary movements such as athetosis and dystonia.
• The cerebellum,which coordinates movement or its associated
pathways are most affected in ataxic cerebral palsy. The lesions
in this area result in ataxia, difficulty with balance &
proprioception,intention tremors & dysmetria.
• The location of damage in brain is divided into upper
motor neuron and lower motor neuron.
• Upper motor neuron- Includes neurons in brain and
spinal cord (CNS) that control movement of muscles.
• It can cause +ve or –ve signs:-
1. +ve sign:muscle overactivity & spasticity.
2. -ve sign:weakness or loss of dexerity.
• Lower motor neuron- Includes neurons from ventral
horn of spinal cord grey matter that exit spinal cord &
attach to skeletal muscles.The nuclei of cranial nerves
in brainstem are also lower motor neurons because
they directly attach to muscles in head and neck.
• Spastic Hemiplegia-Atrophic cerebral hemisphere with
dilated lateral ventricle contralateral to affected site.
• Deep tendon reflexes are increased.
• Spastic Diplegia- PVL of white matter mainly lower limb
• Reflex integrity- Abnormal DTR abnormal superficial
• Cranial nerve integrity- Strabismus or squint(
occulomotor nerve ).
Visual defects( optic nerve ).
Auditory defects ( auditory nerve ).
Feeding & swallowing problems.
LEVELS OF INVOLVEMENT:-
• Spinomuscular level- In disorders at this level,the loss of motor power is focal &
segmental,with complete paralysis of muscle or group of muscles that are
supplied by peripheral nerve or anterior horn cells in spinal cord.
Deep tendon reflexes are diminished or absent.
Pyramidal tract signs, abnormal involuntary movements,& Ataxia arebsent.
These may be trophic changes in skin,nails & bone.
• Spinal level- Scoliosis is common .Curve has greater sagittal plane
deformity(kyphotic or lordotic).It is associated with pelvic obliquity.
• Neural level- At the neural level of motor system,the peripheral nerve roits are
affected.In process affecting nerves,the sensory fibres are usually involved,with
resultanat anesthesia and hypoaethesia.Otherwise,the clinical findings are
atrophy, degeneration etc.
• Myoneural level- When the pathological process arise at the myoneural junction
like in paralysis.In disease of primarily muscular origin ,the motor system is
involved at the muscular level.
• Muscular dystrophies are familiar example of disturbances at the muscular level
in diseases with spinomuscular involvement.
• There is loss of contractibility without loss of excitability that is,the muscle fibres
are degenerated and are replaced by fibrous tissue.
• Extrapyramidal level- In disorders of motor system extrapyramidal level,there is
generalized involvement of muscles of the limbs and trunk.Muscle tone is
hypertonic.Motion of the limbs is hyperkinetic,with loss of associated or
autonomic movement.There are no sensory deficit.
Example-Athetoid cerebral palsy.
• Pyramidal (Corticospinal level)- At the pyramidal
level ,motor deficit arises from involvement of
motor nuclei of cerebral cortex. The paresis is
associated with Hypertonicity or spasticity of
muscles. Spastic cerebral palsy illustrates the
pyramidal level of motor involvement.
• Cerebellar level – lesions at the cerebellar level
are characterized by loss of cordination and
Control,or ataxia. Thrre is no real loss of motor
STEPS PROCESS OF DIAGNOSING
1. Parental observation
2. Clinical observation
3. Motor skill development analysis
4. Medical history review
5. Documenting associative conditions,co-
mitigating factors and ruling-out other
6. Obtaining test results
1. Parental observation- In severe cases parents may notice
symptoms of cerebral palsy within just days of birth.The majority
of cases,however are diagnosed after parents observed
developmental delays, unusual behaviour,or limited mobility.
2. Clinical observation- Clinical observation most often begins at
the pediatricians office.Pediatrician will get input from
parents,and conduct an initial examination to measure the
child’s development to standard developmental milestone
3. Motor skill analysis- Cerebral palsy is caused by injury to the
brain before,during or after delivery.Motor skill delays are one of
the most common indicators of cerebral palsy.Healthcare
providers will evaluate muscle tone , reflexes,
coordination,balance and both fine and gross motor functions.
4. Medical history review- Conducting a thorough medical history
review for the child and both parents is essential in obtaining a
diagnosis. Healthcare providers will review the full medical
history, including pre-and post- natal care, complications during
delivery and other factors that may contribute to a brain injury.
5. Documenting associative conditions- After reviewing the full medical
history,healthcare providers will address and document any associative
disorders, including genetic, nervous system, metabolic,muscles,or
degenerative nervous disorders.
6. Obtaining test results- In addition to observing the child and
reviewing the medical history,healthcare providers will order
specialised test,such as CT scans,MRIs,cranial ultrasounds and
7. Diagnosis- Recieving a diagnosis of cerebral palsy can be difficult for
parents.Many parents believe that their child will “outgrow” the
disorder,while others experience anxiety about their child living a full
life as a disabled person.While there is no cure for cerebral palsy,early
diagnosis and continued care are the best option for improving the
child’s quality of life.
The Babinski reflex occurs after the sole of the foot
has been firmly stroked.
The big toe then moves upward or toward the top
surface of the foot.
The other toes fan out.
This reflex is normal in children upto 2 yrs. Old.
It disappears as the child gets older it may
disappear as early as 12 months.
ANKLE CLONUS TEST
Clonus at the ankle is tested by
rapidly flexing the foot into
dorsiflexion, including stretch to
the gastrocnemius muscle.
Subsequent beating of the foot will
result, however only a sustained
clonus is considered as abnormal.
Clonus causes large motion that are
usually associated initiated by a
• EXAGGERATED STRETCH REFLEX
• Physiologically spasticity is defined as a motor
disorder characterized by a velocity
dependent increase in the tonic stretch
reflexes with exaggerated tendon jerks,
resulting from hyperexcitability of the stretch
reflexes as one component of the upper
motor neuron syndrome.
CEREBRAL PALSY ASSOCIATED
Almost all children with cerebral palsy
have atleast one health issue caused by
or connected with cerebral palsy
According to the Centers for Disease
Control and Prevention (CDC), around
35% of all children with cerebral palsy
will experience seizures. There are
different types of seizures, and the
symptoms will depend upon what form
the child experiences.
Types of seizure
• Absence seizures: Children with absence seizures may stare into
space and have small and subtle body movements, such as eye
blinking and lip smacking.
• Atonic seizures: Children with atonic seizures have temporary loss
of muscle control and may collapse onto the floor without warning.
• Clonic seizures: Clonic seizures are marked by jerking muscle
movement in the arms, face, and neck.
• Myoclonic seizures: Children with myoclonic seizures will have
temporary jerking in the arms and legs.
• Tonic-clonic seizures: Tonic-clonic seizures are the most severe type
of seizures, marked by body shakes, loss of consciousness, the body
stiffening, and in some instances, loss of bladder control.
• Means difficulties with swallowing. Children with cerebral
palsy are at risk of dysphagia due to poor muscle and motor
1.It may include heartburn
2.Unusual weight lose
5.Gagging and coughing when attempting to swallow
6.Feeling stomach acid in the throat
8.Food stuck in the chest area and/or throat
Oral Health Issue
• Cerebral palsy doesn’t cause mouth
abnormalities or deformities, but it can
cause oral issues , such as excessive gagging,
problems with drinking and eating, gingivitis,
involuntary cheek and tongue biting, and
Common cognitive issues (not all children will experience each
issue) associated with cerebral palsy include:
• Attention deficit disorder (ADD)
• Challenges with behavior
• Emotional problems (inability to connect with others
• Psychological issues
• Depression, anxiety, and mood swings
• Problems with comprehension and decision-making skills
• Memory and learning issues
• Recognition issues
• Digestive Issues
Behavioral and Emotional Problems
• One in four children with cerebral palsy will
experience some form of emotional and/or
behavioral problems. These issues depend on
how severe your child’s other associated
disorders are.Examples of emotional and
behavioral problems include:
• Withdrawing from social activities
• Arguing with peers
• Acting out in class
• Quick to anger
Physical and Mobility Issues
are synonymous with cerebral palsy. The
issues can range from mild spastic
movements to more severe issues such as
being unable to walk without assistance or
needing a wheelchair to get around.
Physical and mobility issues also depend on
the type of cerebral palsy the child has,
such as spastic, athetoid, ataxic, etc.
• Around 7% of children with cerebral palsy
have autism, a much higher rate than the 1%
of children without cerebral palsy that
develop autism. There are various forms of
autism, ranging from mild to
severe. Asperger’s Syndrome, considered a
mild form of autism, is one of the most
prevalent forms of the disorder that children
with cerebral palsy have.
Some more associated disorder of CP
• Digestive Issues
• Skin condition
• Respiratory issues
• Sleep issues and disorders
• ADHD(Attention Deficit Hyperactivity
GAIT PROBLEM IN CEREBRAL
Gait Phases Muscular actions
A. Stance Phase
1. Initial contact Ankle dorsiflexion
2. Loading response Knee extension
Ankle plantar flexion
3. Mid stance Ankle plantar flexion
4. Terminal stance Ankle plantar flexion
B. Swing phase
1. Pre swing Hip flexion Iliopsoas
2. Initial swing Ankle dorsiflexion
3. Mid swing Ankle dorsiflexion Tibialis anterior
4. Terminal swing Knee flexion
Gait pattern in children with cerebral
• Abnormal gait pattern at one level may be
attributable to a primary problem located around
a joint but it may also be a compensatory strategy
for problems at the other level of the body.
• It order to be able to differentiate the abnormal
pattern as a primary problem or secondary
staretagy the gait analysis has to be
supplemented with the clinical examination
including ROM,Spasticity,Muscle strength and
• Equinus Gait: One level deviation (no hip and knee
– characterized by absence of heal strike during gait
– isolated equinus gait is common in hemiplegics
• Equinus is either:
– true equinus
• defined by the foot position in relationship to the tibia being less
– apparent equinus
• defined by a foot position that is normal in relationship to the
tibia, however heel strike does not occur due to more proximal
deviations (flexion of the knee most common)
• Deformity includes hip flexion, knee flexion,
and equinus ankle deformity ( could result
in apparent ankle equinus)
• Multi-level gait deviations where treatment of
underlying spasticity should be considered
• A combination of hip flexion, knee flexion, and excessive ankle dorsiflexion (the
latter may be represented by flatfoot or calcaneus)
• Common in diplegic CP
– often an iatrogenic consequence of isolated lengthening the achilles in a jump
gait pattern if the other levels of gait deviations are not addressed properly
• Levels of deviation
– Calcaneal contact pattern throughout stance phase
– Increased knee flexion throughout stance phase due to disruption of the ankle
plantar flexion-knee extension couple
• Compensated crouch gait
– refers to tertiary deviations that allow the knee extensor mechanism to be off-
loaded during stance phase (e.g. pelvic or truncal forward tilt) - this may be
well-tolerated by younger children with CP and low body mass
• Uncompensated crouch gait
– occurs secondary to persistent overloading of the extensor mechanism. This
occurs in all crouch eventually, if untreated
STIFF KNEE GAIT
• Common in spastic diplegic CP
• Characterized by limited knee flexion in swing phase due
to rectus femoris firing out of phase (seen on EMG)
• note the above gait decriptions are stance phase deviations
– gait analysis reveals quadriceps activity from terminal stance
throughout swing phase
– Stiff knee gait can be a compensation due to deviations at the
hip; surgical management will not help this subset of stiff-knee
• Rehabilitation is the name given to all
diagnostic and therapeutic procedures
• Which aim to develop maximum physical
,social and vocational function in a diseased or
a diseased or injured function
GOALS OBJECTIVES OF REHABILITATION
IMPROVE MOBILITY Teach the child to use his remaining potential
Teach the child functional movement
Gain muscle strength
PREVENT DEFORMITY Decrease spasticity
Improve joint allignment
EDUCATE THE PARENTS To set reasonable expectations
Do the ecercises at home
TEACHH DAILY LIVING
Have the child participate in daily living activities
SOCIAL INTEGRATION Provide community and social support
• OT aims to improve hand and upper extremity
function in the child through play and
• There are recreational programs such as art
and crafts ,music,dancing,drama,wheelchair
• Other means of rehabilitation include speech
therapy,hearing aids and implants,drugs like
botulinum injections and analgesics for pain
• Upper extremity orthoses:
These are used almost exclusively to prevent deformity and
Mostly used in children with quadriplegic pattern
involvement who develop significant wrist and elbow
The orthotics may stretch the muscles and provide some
stimulus for them to grow if the stretch can be maintained
for many hours each day.
The exact amount of time an orthoses should be worn to
be beneficial is 4 to 8 hours of brace wear a day.
• The principal deformity at
the elbow that is
amenable to bracing is
flexion . In children with
strong spastic flexion
deformity, the use of a
bivalve custom molded
high temperature plastic
orthosis is required.
Hand and wrist orthoses
• Wrist and finger flexion
combined with thumb
abduction and flexion are
very common deformities
with cerebral palsy.
• Wrist extension orthoses
are used mainly after
surgical reconstruction to
protect the tendon transfers
for some additional months
after cast immobilization
has been discontinued.
• In these splints , all fingers
and wrist are maximally
extended to comfort level
of individual children.
• These are good to help
stretch the forearm muscles
during adolescent growth
• These splints can be made
with a dorsal or volar
Thumb abduction and flexion is
another common deformity.
In children with quadriplegic
pattern CP , thumb deformity is
combined with flexion and
wrist flexion contractures.
Using small , soft thumb
abduction splints or low
temperature molded abduction
splints , the thumb can be
positioned out of the palm in
such a way that children can
develop finger grasp.
swan neck splints
imbalance in the fingers
may cause the fingers to
become locked, with
hyperextension of the
A metal or plastic figure
of eight splint to prevent
this hyperextension can
Most children with CP who develop
scoliosis are non-ambulatory children
with quadriplegic pattern
There is a role for the use of spinal
orthotics to support sitting in children
who are not independent sitters.
The perfect orthoses is a soft
thoracolumbar sacral orthosis(TLSO)
with metal or plastic stays that are
embedded in a soft plastic material.
They have very limited use in CP.
Rarely used in children with back-
kneeing that is causing knee pain
or a worsening deformity, a
limiting knee extension KAFO can
be used , with free knee hinge that
Also used in children with severe
knee flexion contractures to
prevent recurrence of the flexion
ANKLE FOOT ORTHOSES
Ankle equinus is the most commonly recognized
joint malposition in children with CP. Orthotic
control of this equinus position is the oldest
treatment of the motor impairments of CP.
The use of AFO improves stability in the stance
phase of gait and improved ankle position in swing
and at foot contact.
The role of foot orthosis is to control deformities of
foot, mainly plano-valgus and equino- varus deformity.
The supra-malleolar design extends above the ankle on
the lateral side with the goal of controlling varus or
The UCBL orthotic design is used for children with
hypotonia and ataxia and who have moderate
• Enhance familial bonding and support
• Therapy along with peers
• Non agressive therapy
• Don’t give false hopes
• REHABILITATION is successful if
CHILD IS HAPPY
PARENTS ARE WELL ADJUSTED