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  3. 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
  5. ASSOCIATED PROBLEMS IN CP • Seizures • Visual impairments • Intellectual impairment • Learning disabilities • Hearing problems • Communication problems • Oromotor problems • Respiratory problems • Bladder and bowel problems • Social and emotional disturbances
  7. 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 too stiff • 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 one hand • neurological problems, such as seizures, intellectual disabilities, and blindness
  8. WHO’S AT RISK FOR CEREBRAL PALSY? • Certain factors put babies at an increased risk for CP. These include: • 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 Rh type • maternal exposure to toxic substances, such as methylmercury, while pregnant
  9. 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.
  10. 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.
  11. 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 writing. • Mixed cerebral palsy • Some people have a combination of symptoms from the different types of CP. This is called mixed CP. • In most cases of mixed CP, people experience a mix of spastic and dyskinetic CP.
  13. • 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.
  14. • 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.
  15. • 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 fibres. • Reflex integrity- Abnormal DTR abnormal superficial reflexes. • Cranial nerve integrity- Strabismus or squint( occulomotor nerve ). Visual defects( optic nerve ). Auditory defects ( auditory nerve ). Feeding & swallowing problems.
  16. 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.
  17. • 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 power.
  18. STEPS PROCESS OF DIAGNOSING CEREBRAL PALSY 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 conditions 6. Obtaining test results 7. Diagnosis
  19. 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 guidelines. 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.
  20. 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 laboratory tests. 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.
  21. DIAGNOSIS BABINSKI REFLEX:- 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.
  22. 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 reflex.
  23. • 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.
  24. CEREBRAL PALSY ASSOCIATED DISORDER Almost all children with cerebral palsy have atleast one health issue caused by or connected with cerebral palsy Seizures 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.
  25. 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.
  26. Dysphagia • Means difficulties with swallowing. Children with cerebral palsy are at risk of dysphagia due to poor muscle and motor function control. Symptoms 1.It may include heartburn 2.Unusual weight lose 3.Backpain 4.Drooling 5.Gagging and coughing when attempting to swallow 6.Feeling stomach acid in the throat 7.Hoarse voice 8.Food stuck in the chest area and/or throat
  27. 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 more.
  28. Conginitive Issues 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 emotionally) • Psychological issues • Depression, anxiety, and mood swings • Problems with comprehension and decision-making skills • Memory and learning issues • Recognition issues • Digestive Issues
  29. 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 • Depression • Anxiety
  30. 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.
  31. Autism • 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.
  32. Some more associated disorder of CP • Digestive Issues • Skin condition • Respiratory issues • Sleep issues and disorders • ADHD(Attention Deficit Hyperactivity Disorder)
  33. Normal Gait Cycle
  34. GAIT PROBLEM IN CEREBRAL PALSY Gait Phases Muscular actions A. Stance Phase 1. Initial contact Ankle dorsiflexion Hip extension Knee flexion Tibialis anterior Gluteus maximus Hamstrings 2. Loading response Knee extension Hip abduction Ankle plantar flexion Quadriceps Gluteus medius Gastrocnemian 3. Mid stance Ankle plantar flexion (isometric) Gastrosoleus 4. Terminal stance Ankle plantar flexion (concentric) Gastrosoleus B. Swing phase 1. Pre swing Hip flexion Iliopsoas Rectus femoris 2. Initial swing Ankle dorsiflexion Hip flexion Tibialis anterior Iliopsoas Rectus femoris 3. Mid swing Ankle dorsiflexion Tibialis anterior 4. Terminal swing Knee flexion Hip extension Ankle dorsiflexion Knee extension Hamstrings Gluteus maximus Tibialis anterior Quadriceps
  35. Gait pattern in children with cerebral palsy • 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 SMC.
  36. Classification • Equinus Gait: One level deviation (no hip and knee involvment) – 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 than plantigrade – 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)
  38. JUMP GAIT • 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
  40. CROUCH GAIT • A combination of hip flexion, knee flexion, and excessive ankle dorsiflexion (the latter may be represented by flatfoot or calcaneus) • Common in diplegic CP • Pathophysiology – 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
  42. 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 • Evaluation – gait analysis reveals quadriceps activity from terminal stance throughout swing phase • Complications – Stiff knee gait can be a compensation due to deviations at the hip; surgical management will not help this subset of stiff-knee gait
  43. REHABILITATION • 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
  44. COMPONENTS OF REHABILITATION • Physiotherapy • Occupational therapy • Bracing • Assistive device • Adaptive technology • Sports and recreation • Environment modification
  45. 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 SKILLS Have the child participate in daily living activities SOCIAL INTEGRATION Provide community and social support
  46. OCCUPATIONAL THERAPY • OT aims to improve hand and upper extremity function in the child through play and purposeful activity • There are recreational programs such as art and crafts ,music,dancing,drama,wheelchair dancing, • Other means of rehabilitation include speech therapy,hearing aids and implants,drugs like botulinum injections and analgesics for pain
  47. ORTHOTIC MANAGEMENT OF CEREBRAL PALSY • Upper extremity orthoses:  These are used almost exclusively to prevent deformity and reduce contractures.  Mostly used in children with quadriplegic pattern involvement who develop significant wrist and elbow flexion contractures.  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.
  48. ELBOW ORTHOSES • 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.
  49. 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.
  50. resting splints • 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 period. • These splints can be made with a dorsal or volar forearm component.
  51. Thumb splint  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.
  52. swan neck splints Extensor tendon imbalance in the fingers may cause the fingers to become locked, with hyperextension of the proximal interphalangeal joint(PIP). A metal or plastic figure of eight splint to prevent this hyperextension can be made.
  53. spinal orthoses  Most children with CP who develop scoliosis are non-ambulatory children with quadriplegic pattern involvement.  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.
  54. knee orthoses  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 prevents hyperextension.  Also used in children with severe knee flexion contractures to prevent recurrence of the flexion contractures.
  55. 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.
  56. foot orthoses  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 valgus deformity.  The UCBL orthotic design is used for children with hypotonia and ataxia and who have moderate planovalgus deformity.
  57. MESSAGE • 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