CP or Cerebral Palsy. Presented By B.S PT 2A1-1 at Our Lady of Fatima University.

1. MINI SEMINAR ON
CEREBRAL PALSY
PT Rehab at 401
October 01,2013
Time: 12NN-4:00PM

2. Ms. Kaye Suzane A. Villaco & Ms. Jen Berlyn A. De Vera
MASTER OF CEREMONY

4. THE SPEAKERS
Ms. Jelly R. Dela Cruz
Mr. Wrangel Marl S. Peralta

6. Cerebral Palsy
CP
Cerebral Paresis
Muscle weakness or poor control to the brain

7. William John Little
(1810-1894)
 English Orthopedic
surgeon
 Series of lectures
entitled “Deformities of
the Human Frame” was
first used in year 1849.

8. Sir William Oslers
“The Cerebral Palsies of Children
(1889)”

9. Publication by Neurologist Sachs
and Peterson (1890)

10. Sigmund Freud
 Famous Psychiatrist
 1893: Difficult in CP
is merely a symptom of
deeper effects the
influence of
development of the
fetus.

11. CP is known as Little’s Disease
1st discovered classification system of CP is a
puzzling disorder that affected children in the 1st year
of life called “Little’s Disease” now known as
“Spastic Diplegia”.

12. CP
 A group of permanent disorder of the development
of movement and posture.
 Causing activity limitation
 Attributed to non-progressive disturbance
 Occurred in developing fetal (fetus) or infant brain
before during of shortly after birth.

13. I. Epidemiology
 Study from Europe, the rate was more than 70 times
higher in infants with birth weight < 1500g than > 2500g.
 The surveillance of CP in Europe reports a M:F ratio of
1:33:1.
 Severe neuromotor disability
10% of surviving
infants born with gestational age ≤ 25 weeks in 1995 in
U.K & Ireland and evaluated at 30 months of age.
 Higher prevalence among black non-hispanic children
compared with white non-hispanic children.
Most frequently incidence of CP is between 1 & 2.3 per
1000 live births.

14.  Above incidence represents between 5% & 60% of all
cases proportion inversely with the degree of
development of the country.
 Although early diagnosis is helpful, it can falsely elevate
the incidence of CP because 50% of the children with CP
diagnosed before 2 years of age can have spontaneous
resolution of symptoms.
 CP incidence over a 30 year period (1960-1990) has been
slow decline in CP from 1960’s to the lowest incidence in
1970’s.
 Children with CP diagnosed in the 1980’s & 1990’s, a
greater proportion were more severely impaired.
Part 2 of I
(Epidemiology)

15. II. Anatomy
Pyramidal Motor
System

16. Extrapyramidal
System
Part 2 of II
(Anatomy)

17. Neonatal Stroke
Hypoxic Ischemic Encephalopathy

18. Cerebral Palsy & PVL
 premature infants.

19. Classification of CP:
1.
2.
3.
4.
5.
6.
7.
8.
Spastic
Dyskinetic (Athetoid,Choreiform,Ballistic,Ataxic)
Hypotonic
Mixed
Diplegia
Quadriplegia
Hemiplegia
Triplegia

20. Motor pathway injury in patients with
periventricular leukomalacia and spastic diplegia.
GABAA receptor binding pattern in age-matched patient subgroup (n = 8) compared with
normal control group. The receptor binding pattern is almost the same as the binding
pattern of the total patient group (uncorrected P < 0.05). CMA = cingulate motor area;
PCL = paracentral lobule; VC = visual cortex.

21. Child with Spastic Diplegia.

23. III. Pathophysiology
 Begins before birth.
 Brain injury or abnormality that happens prenatally or during
infancy.
 Child born prematurely or with low birth weight.
 Maternal illness (injuries or illness) in the child’s infancy that
affects the brain. A prenatal stroke (prevents blood flow to the
part of the brain).

24.  Cerebrum.
 Cerebral Palsy (muscle condition) caused by
damaged to the cerebrum.
 Babies that are deprived of oxygen during labor &
delivery (birth), asphyxia (oxygen deprivation)
during birth was the cause of brain damage.
 1980’s less than one tenth of CP cases caused by
oxygen deprivation during birth.
 Occurred before they were born during the first six
months of pregnancy.
Part 2 of III
(Pathophysiology)

25. Three possible reason of brain damage:
1. Periventricular Leukomalacia (PVL)
•
•
•
•
•
•
damage of the brain’s white matter
lack of Oxygen
caused of destruction of unborn
baby brain cells.
pregnant mother catching an infection, such as rubella
(German Measles).
having very low blood pressure.
giving birth too early (premature birth).
consuming an illegal drug during pregnancy.

26. 2. During the first six months of pregnancy the
embryo/fetus is particularly vulnerable to abnormal
brain development.
•
caused by mutations in the genes responsible for brain
development infections, such as toxoplasmosis
(parasite infection), herpes-like viruses and trauma to
unborn baby’s head.

27. 3. Intracranial Hemorrhage (bleeding inside the brain
caused by the unborn baby having a stroke).
•
bleeding in the brain can stop the supply of blood to
vital brain tissue, becomes damaged or it dies.

28. • factors cause a stroke in
a baby during pregnancy
& during the birth:
Blood clot in the placenta
that blocked the flow of blood
(clotting disorder) *see figure
1*
Mother had pre-edampsia
emergency cesarean (vacuum
extraction used during
delivery).
 Premature birth or lowweight baby.
FIG.1

29. Clotting Disorder.

30. Factors Contribute to a high risk of CP:
Multiple births.
Damage placenta.
Sexually Transmitted Disease (STDs).
Consumption of alcohol by the pregnant mother
Exposure to other toxic substances by the pregnant mother.
The pregnant mother did not eat properly.
Random malformation of the baby’s brain.
Small pelvic structure of the mother.
Breek delivery.
Brain damage after birth(infection such as meningitis, a head
injury, a drowning accident or poisoning).

31. IV. Clinical Manifestation
During the first 3 years of life.
Child with CP have sign and symptoms:
developmental milestones (crawling, walking or
speaking).

33. Abnormal muscle tone.
• Muscle Tone – automatic
ability to tighten and relax
muscle when required.
Muscles are
Flaccid (soft)
Muscles are
Hypertonic (stiff)

34. Difficulty of feeding and
sucking.
Feeding problems The baby may have
difficulties with sucking, swallowing and
chewing. She may choke or gag often.
Even as the child gets bigger, these and
other feeding problems may continue.
Difficulties in taking care of the baby
or young child. Her body may stiffen
when she is carried, dressed, or
washed, or during play. Later she may
not learn to feed or dress herself, to
wash, use the toilet, or to play with
others. This may be due to sudden
stiffening of the body, or to being so
floppy she 'falls all over the place'.
The baby may be so limp that her head
seems as if it will fall off. Or she may
suddenly stiffen like a board, so that
no one feels able to carry or hug her.

35. Lies down in awkward position.

37. Favors one side of the body over the other.

38. Over developed or undeveloped
muscles (has floppy or shift
movement).
At birth a baby with cerebral palsy
is often limp and floppy, or may
even seem normal.
Baby may or may not breathe right
away at birth, and may turn blue
and floppy. Delayed breathing is a
common cause of brain damage.
Slow development Compared to
other children in the village, the
child is slow to hold up his head, to
sit, or to move around.

39. Bad coordination &
balanced (ataxia).
The child who has 'ataxia', or poor
balance, has difficulty beginning to
sit and stand. She falls often, and
has very clumsy use of her hands.
All this is normal in small children,
but in the child with ataxia it is a
bigger problem and lasts longer
(sometimes for life).
Because children who have mainly
a balance problem often appear
more clumsy than disabled, other
children are sometimes cruel and
make fun of them.

41. Involuntary, slow writing movements
(athetosis).

42. Muscle are stiff & contract
abnormally (spastic paralysis).
The child who is 'spastic'
has muscle stiffness, or 'muscle
tension'. This causes part of his
body to be rigid, or stiff.
Movements are slow and awkward.
Often the position of the head
triggers abnormal positions of the
whole body. The stiffness increases
when the child is upset or excited,
or when his body is in certain
positions.
The pattern of stiffness varies
greatly from child to child.

43.  Hearing problems.
 Problem with eyesight.
 Bladder control problems.
 Bowel movement control problems.
Seizures.
 Problem swallowing.
 Range of movement are limited.

45. V. Clinical Evaluation: Diagnostic
 Clinical findings- motor abnormality.
•
•
•
•
•
tone
reflex
posture
motor performance
weak cry and suck

46. Weak cry and sucking of Infants.

47. Irritability
Lethargy
 The baby may cry a lot and seem very
fussy or 'irritable'. Or she may be very quiet
(passive) and almost never cry or smile.
 Lethargy in babies is not easy
to diagnose. However, sleeping
for longer periods of time than
normal, or a feeling of tiredness
even after taking a long nap, are
all signs of lethargy in babies.
One can determine whether a
baby is lethargic by noticing its
behavioral changes. Lethargic
babies, also referred to as listless
babies, appear to lack
enthusiasm. The baby seems
sluggish and drowsy, which can
be a sign of serious illness such
as pneumonia.

48. Infant born
prematurely or
low of birth
weight.

49. OBLIGATORY PRIMITIVE
REFLEXES

50. Tonic neck reflexes including the
asymmetric tonic neck reflexes.

51. The Moro.

52.  The spastic subtype of CP is the most common
affecting approximately 75% of children with CP.

53. Child with flexor
posturing.

54. Child with
Opisthotonic Posturing.

55. Child with Extensor
Posturing &
Scissoring .
*Note:
the athenoid posturing
of hands.

56. In 2004 an international multidisciplinary group revise the current classification
system. A report on the “Definition & classification of CP, April 2006”
-Four major dimensions of classification be used:
1.
2.
Motor abnormalities including
the nature & typology of the
motor disorder (specifically the
dominant type categorized as
spasticity, dystonia,
choreoatretosis or ataxia), as well
as functional motor abilities
(GMFCS & MACS to objectively
delineate the function between
lower & upper extremities).
Accompanying impairments
such as those involving
hearing, vision, cognition &
behavior, as well as later-onset
musculoskeletal issues &
seizures.
3.
4.
Anatomic distribution
(including each limb, the
trunk & the oropharynx) &
neuroimaging findings.
Causation & timing, which
should only be documented
when there is “reasonably firm
evidence” of a clearly
identified cause or timing of
injury.
*The group also recommended
that the terms diplegia &
quadriplegia be eliminated
because they are subjective & do
not provide information on truncal
or bulbar involvement.

57. Assessment Instruments.
 to quantify and monitor developmental milestone
and skills.

58. Child Health
Questionnaire.

60. The Gross Motor Function
Classification System
(GMFCS)
 Most widely used functional
classification system.
 A five-level scale with four
age bands that stratifies
children based on gross
motor ability.
 Have excellent interrater
reliability for both children
younger than 2 years &
children 2 to 12 years of age.

61. Palisano et al recently developed the
expanded & revised GMFCS, which
include a 12 to 18 year age & revision
of the 6to 12 year age band.

62. Gross Motor Functional Classification
System
Level 1: Walks without
restriction, limitations in HighLevel Skills.
• Walks independently by age 2
years without devices.
• Walks as preferred mobility by
age 4.
• Difficulty with speed,
coordination and balance for
high-level task.
Level 2: Walks without devices,
limitations in walking outdoors.
• Sits with the hand support by age
2.
• Craws reciprocally or walks with
device as preferred mobility by
age 4.
• Use hands to get up from the floor
or a chair by 6.
• Walks without devices indoors by
age 6.

63. Level 3: Walks with devices,
limitations walking outdoors.
• Sits with support by age 2.
• Cruises by age 4, walks with
device short distance.
• Does stairs with help by age 6.
• Walks indoors with a device by
age 12.
Level 4: Limited Mobility,
Power Mobility outdoors.
• Rolls by age 2 years.
• Sits with hand support by age 4.
• May walk short distances indoors
with device, poor balance.
• Preferred independent mobility is
a heel chair by age 12.
Level 5: Very limited SelfMobility, even with Assistive
Technology.
• Needs help to roll by age 2.
• Does not attain independent
mobility by age 12.
• With high-level technology, may
learn to use power mobility.

64.  Analogous scale to classify functional upper
extremity.
Manual Ability Classification
System (MACS).
 Five-level scale that classifies how children
with CP, ages 4 to 18 years, use their hands
when handling objects.

65.  Can
aid in determining
whether the injury was
prenatal, perinatal or post
natal.
Targeted laboratory test
and cerebral imaging
using tomography, MRI
and ultrasound.
Magnetic Resonance Imaging
(MRI)
Nuclear Magnetic Resonance

66. VI. Differential Diagnosis & Treatment.
A. Diagnosis
• Acute Poliomyelitis
- an acute viral disease usually
caused by a polio virus & marked
clinically by fever, sore throat,
headache, vomitting & often
stiffness of the neck.
- major illness of poliomyelitis
that affect CNS, stiff neck,
pleocytosis in spinal fluid &
perhaps paralysis.

67. • Becker’s Muscular Dystrophy
- a group of disease causing
muscle weakness (affects only
male).
Part 2 of VI(a) (Differential
Diagnosis & Treatment)

68. • Charcot- Marie-Tooth
Syndrome
- also known as Charcot-MarieTooth Neutropathy , hereditary
motor and sensory neuropathy
(HMSN) & peroneal muscular
atrophy (PMA).
- genetically and clinically
heterogeneous group of inherited
disorder of the PNS characterized
by progressive loss of muscle
tissue and touch sensation across
various parts of the body.
Part 3 of VI(a) (Differential
Diagnosis &Treatment)

69. • Kugelberg
- welander spinal muscular
atrophy.
- a rare inherited disorder causing
progressive degeneration of the
anterior horn cells of the spinal
cord.
Part 4 of VI(a) (Differential
Diagnosis &Treatment)

70. • Neonatal Brachial Plexus
Palsies.
- first known description (1799):
infant with bilateral arm
weakness.
- 1870’s: cases of upper trunk
nerve injury, attributing the
findings to traction on the upper
trunk, now called Erb’s Palsy (or
Duchenne – Erb’s Palsy).
- 1885: injury to the C8-T1 nerve
roots.
Part 5 of VI(a) (Differential
Diagnosis &Treatment)

71. • Stroke Motor Impairment.
- partial or total loss of function
of a body, usually limb(s).
- result in muscle weakness, poor
stamina, lack of muscle control or
total paralysis.
Part 6 of VI(a) (Differential
Diagnosis &Treatment)

72. • Traumatic Brain Injury (TBI)
- also known as intracranial
injury.
- occurs when an external force
traumatically injures the brain.
- head injury usually refers to TBI,
but a broader category because it
can involve damage to structures
other than the brain, such as scalp
and skull.
- males sustain TBI more
frequently than do females.
- causes include: falls, vehicle,
accidents and violence.
Part 7 of VI(a) (Differential
Diagnosis &Treatment)

73. VI. Differential Diagnosis & Treatment
B. Treatments
• Ultrasound
- identify very preterm babies at risk
of CP.
• MRI
- detecting while matter lesions in
older children.
- demonstrating the various injuries
(asphyxia) & anomalies that cal
lead to CP.
• CT scanning
- provide information about
structural congenital malformations
& vascular abnormalities &
hemorrhages especially in babies.
• Evoked Potentials
- electral signals produced by the
nervous system in response to
sensory stimuli.
- measuring them can help to detect
abnormalities of hearing and
vision.
• EEG
- detect damage from hypoxia and
vascular insult.

74. • Badofen
- relieves muscle spasm.
- given orally.
• Dantrolence
- work better than Badofen when
muscle spasm is severe.
• Physical method of spasticity
relief include heat, cold and
vibration.
• Splinting can help to improve
range of movements of joints; this
can be particularly effective for
ankle joints.
Part 2 of VI(b) (Differential
Diagnosis &Treatment)

75. VII. Physical Therapy Management.
• Therapeutic Management
o Physical Therapy (PT)
- one of the most important aspect of CP therapy.
- first referral made in CP child’s treatment.
- In general, PT trained to work with child to enable
them to obtain maximum physical function.

76. - focus mainly on activities involving the legs such as walking,
braces, using crutches & rehabilitation after surgery.

77. - helps a child’s family through reducing stress caused by caring
for the child.

78. PHYSICAL THERAPY PROGRAM

79. Age of 4
 Training
for positioning,
movement, feeding, play and
self calming.
 Through playing the skill of
CP patient developed.

80. Age of 5
 Self
care, maintaining daily
routines socialization.
 Physical activity and plans
for the child's schooling and
future careers.

81. Adulthood, age 18+
 They lived highly
functional adults.
 Experiencing a muscle and
joint pain.
 Exercise routine to stay
strong and to minimize joint
issues.

84. Documentation Committee:
Mr. Gideon Luczon
Mr. Kent Anthony Tumaca
Program Committee:
Ms. Manna Keziah Coquilla
Ms. Kaye Suzane Villaco
Technical Committee:
Ms. Sharmaine Joyce Sebastian
Ms. Jen Berlyn De Vera
Food Committee:
ALL MEMBERS 
Research Committee:
Ms. Jelly Dela Cruz & the
members

85. GROUP 4: CP
B.S PT 2A1-1
Leader:
Dela Cruz, Jelly R.
Members:
Coquilla, Manna Keziah
De Vera, Jen Berlyn
Luczon, Gideon
Marabe, Arjohn
Peralta, Wrangel Marl
Sebastian, Sharmaine
Joyce
Tumaca, Jent Anthony
Villaco, Kaye Suzane