2. Definition
It is defined as a group of disorders
resulting from permanent non
progressive cerebral dysfunction
developing before maturation of CNS
affecting the locomotor system
It is non-contagious motor conditions
that cause physical disability in
human development
3. Although brain lesions that result in
CP are not progressive, clinical picture
of CP may change with time
In addition to primary impairments in
gross & fine motor function, there may
be associated problems with
cognition, seizures, vision, swallowing, s
peech, bowel-bladder, & orthopedic
deformities
4. Criteria of diagnosis
◦ Neuromotor control deficit that alters
movement or posture
◦ Static brain lesion
◦ Acquisition of brain injury either
before birth or in first years of life
5. History
Formerly known as "Cerebral Paralysis,“
◦ First identified by English surgeon William Little in
1860. (Little’s disease)
◦ Believed that asphyxia during birth is chief cause
In 1897, Sigmund Freud, suggested that
difficult birth was not the cause but only a
symptom of other effects on fetal development
National Institute of Neurological Disorders &
Stroke (NINDS) in 1980s suggested that only a
small number of cases of CP are caused by lack
of oxygen during birth
6. Epidemiology
The incidence of CP is about 2 per 1000 live
births
The incidence is higher in males than in
females
Other associated problems include
◦ Mental disadvantage (IQ < 50): 31%
◦ Active seizures: 21%
◦ Mental disadvantage (IQ < 50) and not walking:
20%
◦ Blindness: 11%
7. During past 3 decades considerable advances
made in obstetric & neonatal care, but there
has been no change in incident of CP
The population of children with CP may be
increasing due to premature infants who are
surviving in greater numbers, higher
incidence
in normal-weight term infants (3), and longer
survival
overall.
8. Causes of CP
Prenatal (70%)
Peri-natal (5-10%)
Post natal
9. Prenatal
Maternal infections E.g. rubella,
herpes simplex
Inflammation of placenta (chorion
amnionitis)
Rh incompatibility
Diabetes during pregnancy
Genetic causes
Exposure to radiations
Maternal jaundice
11. Post natal
Brain damage secondary to cerebral
hemorrhage, trauma, infection or
anoxia
Motor vehicle accidents
Shaken baby syndrome
Drowning
Lead exposure
Meningitis
Encephalitis
12. Additional risk factors for CP
include
◦ Kernicterus
◦ methyl mercury exposure
◦ genetic causes
13. Classification of CP
Depending on the topographical
distribution
◦ Monoplegic
◦ Diplegic/ Paraplegic
◦ Triplegic
◦ Hemiplegic
◦ Tetraplegic / Double hemiplegia
14. Monoplegia is one single limb being affected.
Diplegia: LE affected, with little to no
upper-body spasticity.
◦ The most common form of spastic forms
◦ Most people with spastic diplegia are fully
ambulatory, but are "tight" & have scissors gait
◦ Flexed knees & hips to varying degrees, &
moderate to severe adduction are present
◦ Often nearsighted & intelligence is unaffected
◦ In 1/3rd of spastic diplegics, strabismus may be
present
15. Hemiplegia
◦ The most ambulatory of all forms, although
they generally have dynamic equinus on
affected side
Triplegia: three limbs affected usually
both LL & one UL
Quadriplegia: all four limbs more or
less equally affected.
◦ Least likely to be able to walk
◦ Some children also have hemiparetic
tremors (hemiballismus), & impairs normal
movement
16. Depending on tone or movement
patterns (physiologic)
◦ Spastic
◦ Athetoid/ dyskinetic
◦ Ataxic
◦ Flaccid/ Hypotonic
◦ Mixed
17. Spastic CP
It is the most common type of CP,
occurring in 70% to 80% of all cases.
The cerebral cortex is affected
Moreover, spastic CP accompanies any
of the other types of CP in 30% of all
cases
It can be monoplegia, diplegia,
triplegia, hemiplegia or quadriplegia.
18. Athetoid/ dyskinetic CP
It is mixed muscle tone
Often show involuntary motions
The damage occurs to extrapyramidal motor
system & pyramidal tract
It occurs in 10% to 20% of all cases
In newborn infants, high bilirubin levels in
blood, if left untreated, can lead to brain
damage in certain areas (kernicterus).
This may also lead to Athetoid CP
19. Ataxic CP
It is caused by damage to
cerebellum
They are least common types of
CP, occurring only in 10% of all cases
Some of these individuals have
hypotonia and tremors
20. Hypotonic CP
Hypotonic CP have musculature that is
limp, and can move only a little or not at
all (Floppy child)
The location of damage is wide spread in
the CNS
Although physical therapy is usually
attempted to strengthen muscles it is not
always fundamentally effective.
21. Mixed CP
Signs & symptoms of spastic CP is
seen with any other type of CP
◦ Most commonly mixed with Athetoid
22. Depending on functional level (Gross
Motor Function Classification System)
◦ It classifies acc. to age categorized
activity level
23.
24. pathology
Periventricular leukomalacia (PVL) is the
most common finding in CP
Corticospinal tract fibers to LL are medial to
those of UL in periventricular white matter.
◦ Thus children with PVL typically have spastic
diplegia (common type of CP)
25. Bilirubin encephalopathy in basal ganglia is seen in
athetoid CP following a diagnosis of kernicterus
Focal cortical infarcts involving both grey & white
matter are found in patients with hemiparesis, &
are typically related to MCA strokes
Brain malformations can be found on neuroimaging
in approximately 10% of children
26. Signs & symptoms (spastic)
Hypertonia
Exaggerated reflexes &
+ve barbinskis
Clonus
Poor voluntary movement
Scissoring gait
Low intelligence & loss of
memory
Epilepsy
Synergistic pattern
Contracture, deformity
& wasting
◦ Adduction & IR of
shoulder
◦ Flexion of elbow &
pronation of forearm
◦ Wrist flexion & thumb
inside hand
◦ Flexion & adduction of hip
◦ Knee flexion
◦ PF of ankle
27. Extrapyramidal CP
May affect limb, face, tongue
& speech
Characterized by continuous
muscular worm like movement
Postural instability
Decreased movement in prone
position
Fluctuation of tone from high
to low
Reflexes are usually normal &
muscles are able to contract
Decreased stability
Difficulty to look up
Emotional liability
Arms are more affected
Sucking & feeding problems
Delayed head & trunk control
May be either quadriplegic or
rarely hemiplegic
Subtypes -
dystonic, athetoid, choroid, h
emiballismic, rigid
30. Biological risk
Birth weight of 1500g or less
Gestational age of 32 weeks or less
Small for gestational age (less & 10th percentile of
weight)
Ventilator requirement for 36 hours or more
Intracranial hemorrhage
muscle tone abnormalities
Recurrent neonatal seizures (3 or more)
Feeding dysfunction
Symptomatic (TORCH)
Meningitis
Asphyxia with apgar score <3 in 1 min after birth or <6
in 5 min after birth
31. Established risk
Hydrocephalus
Microcephaly
Chromosomal abnormalities
Musculoskeletal abnormalities (CDH, AMC, limb
deficiencies)
Multiple births more than twins
Brachial plexus injuries
Myelodysplasia
Congenital myopathies
Inborn errors of metabolism
HIV infection
32. Environmental/ social risk
Single parent
Parental age less than 17
Poor quality infant parent
attachment
Maternal drug or alcohol abuse
Behavioral state abnormalities
(lethargy, irritability)
33. Detection of risk babies
Principles
◦ There should be definite objective
◦ Some form of action should be possible if the
test is positive
◦ The population should be defined
◦ Test should be sensitive
◦ Test should be specific
◦ Screening should start at foetal life &
continue into early childhood
Some test are for all children but some are for those
who are known to be at risk
34. Prenatal screening
Routine check up for mother during
pregnancy is beneficial for the
mother & the foetus
Health education
◦ Diet advice (avoid tobacco & alcohol)
◦ Exercise on prescription
◦ Sleep & working habits
35. Clinical examination
◦ Breast condition
◦ Height of uterus
◦ Position of foetus
◦ BP
◦ Samples of blood & urine
For special test condition sought are
◦ Phenylketonuria
◦ Glycosuria
◦ Albuminuria
◦ Rh incompatibility
◦ Congenital syphillis
◦ Rubella, AIDS
◦ Neural tube defect
36. Special test for screening
◦ USG from 8-12 weeks
For the assessment of the gestational period
Congenital abnormalities in various organ defect
◦ Amniocentesis from 16-18 weeks of pregnancy
To find chromosomal defect, if the test is positive
terminate pregnancy
◦ Chorionic villus sampling technique in 8-11
weeks of pregnancy
For chromosomal study
37. Post natal screening
Starts in the immediate neonatal
period & during the first two years
◦ To find biochemical defects
◦ Hearing & visual problems
38. Clinical methods (at birth)
◦ Examination of weight, height, head
circumference
◦ Gestational age
◦ Musculoskeletal defects
◦ Testicular descent
◦ At 6 weeks repeat test
39. Chemical methods
◦ Blood sample from heel prick at 2-5 days
of age & repeated where necessary
Respiratory conditions, cardiac pathology,
haemoglobinopathies can be detected
Neuromuscular pathologies (cpk level)
Metabolic disorders
Gene abnormalities
40. Electronic scanning
◦ USG, CT Scan, MRI
To find out
AVM, hemorrhage, cyst, leucodystrophies
etc
41. Diagnosis
The diagnosis of CP depends on
patient's history & on the basis of
significant delay in gross & fine motor
function, with abnormalities in tone,
posture, & movement on neurological
examination.
Once diagnosed with CP, further
diagnostic tests are optional.
42. MRI is preferred over CT due to diagnostic
yield & safety.
The CT or MRI also reveals treatable
conditions, such as
hydrocephalus, AVM, subdural hematomas
etc.
Diagnosis, classification, & treatment are
often based on abnormalities in tone
Apgar scores have sometimes been used as
one factor to predict whether or not an
individual will develop CP
43. Diagnostic tools
Movement Assessment of Infants (MAI): able
to predict CP at 4 months (identifies motor
delay)
Alberta Infant Motor Scale (AIMS) is able to
predict CP at 6 months (Identifies motor
delays & measures changes in motor
performance over time)
Bayley scale is able to predict CP at 1 year
(Identifies devt delay in gross & fine motor, &
cognitive domains)
45. Drugs
Oral medications such as
baclofen, diazepam, and trihexyphenidyl
as well as therapeutic botulinum toxin
(Botox)
Children with dystonic CP have dopa-
responsive dystonia, with improved
motor function using levodopa
Children with basal ganglia/thalamic
injury from perinatal asphyxia may
develop improved expressive speech &
hand use with trihexyphenidyl
46. Surgery
Dorsal rhizotomy reduces spasticity
Joint & Tendon release most often performed on
hips, knees, & ankles.
The insertion of a baclofen pump usually during
young adolescence.
◦ usually placed in left abdomen - a pump that is
connected to spinal cord,
◦ sends bits of Baclofen to relax muscle
Bony correction E.g. femur (termed femoral
anteversion or antetorsion) & tibia (tibial torsion).
2ndary complication caused by spastic muscles
generating abnormal forces on bones
47. Prognosis
CP is not a progressive but the symptoms
can become more severe over time
Prognosis depends on intensity of
therapy during early childhood
Tend to develop arthritis at a younger
age than normal because of pressure
placed on joints by excessively toned &
stiff muscles
48. Intellectual level among people with CP varies
from genius to intellectually impaired
◦ (it is important to not underestimate a person with CP
and to give them every opportunity to learn)
The ability to live independently with CP varies
widely depending on severity of each case.
◦ Some individuals with CP are dependent for all ADL.
◦ Some can lead semi-independent lives, needing
support only for certain activities.
◦ Still others can live in complete independence.
49. Persons with CP can expect to have a
normal life expectancy
Survival is associated with the ability to
ambulate, roll, & self-feed
As the condition does not directly
affect reproductive function, some have
children & parent successfully
There is no evidence of increased
chance of a person with CP having a
child with CP
50. Notable persons
Abbey Curran, American beauty queen
with CP who represented Iowa at Miss
USA 2008 and was the first
contestant to compete with a
disability
52. Pt assessment
Subjective Examination:
◦ Obtained from parents especially mother
or from relatives and through case-sheet.
◦ General details includes
Name
Age & Sex
Address
When did the mother first noticed the
dysfunctions
◦ Siblings having same type of symptoms
53. PT assessment
History
◦ Review of complications of pregnancy &
delivery, birth weight, gestation, any
neonatal & perinatal difficulties,
feeding problems, and other health-
related problems
◦ Developmental milestones
54. Prenatal History
◦ Age of mother
◦ Consanguity marriage
◦ Any drugs taken during pregnancy
◦ Any trauma & stress
◦ Any addiction – smoking or alcoholism
◦ History of TORCH infection
◦ History of previous abortions, still born or death
after birth
◦ Multiple pregnancies
◦ Status & cast of the mother
55. Perinatal History
◦ Place of delivery
◦ History preterm or post-term delivery
◦ History of asphyxia at birth
◦ History of prolonged labour pain
◦ Type of delivery (Forceps, vacuum
delivery)
◦ Presentation of child (Breech)
◦ Condition of mother at the time of
delivery
56. Postnatal History
◦ Delayed birth cry
◦ Weight of the child at birth
◦ History of trauma to brain during the first 2 years of life
◦ History of neonatal
meningitis, jaundice, hypoglycemia, Hydrocephalus or
Microcephaly
◦ Nutritional habits of the child (malnutrition), Feeding difficulties
◦ Any medical, surgical or physiotherapy treatment taken before
◦ What treatment was used?
◦ Was the treatment effective or not?
◦ What was the ability level of child at that time?
◦ What obstructs the child from progress?
◦ Apgar Score from the case-sheet
57. On Observation:
Behaviour of the child
◦ Whether child is alert, irritable or fearful in the
session or during particular activities
◦ Child becomes fatigued easily or not during activity
◦ What motivates his action – particular situation,
person or special plaything
Communication of the child
◦ With the parents
◦ Whether child initiates or responds with gestures,
sounds, hand or finger pointing, eye pointing or uses
words and speech
58. Other observations
◦ Involuntary movements
◦ Deformities & contracture
◦ Scar may be present
◦ Trophic changes may also be seen due to
poor positioning
◦ Postural faults
◦ Gait abnormalities
◦ Use of external appliances
59. Attention span
◦ What catches child’s attention
◦ For how much time child’s attention is
maintained on particular thing
◦ How does parent assist him to maintain
attention
◦ What distracts the child
◦ Does child follows suggestions to move
or promptings to act
60. ◦ Position of the child
Which position does the child prefer to be in?
Can child get into that position on his own or
with help?
With assistance, child makes any effort to go in
that position
Symmetry of the child (actively or passively
maintained)
If involuntary movements present, then in which
positions these movements are decreased or
increased
61. ◦ Postural control & alignment
How much parental support is given
Postural stabilization and counterpoising in
all postures
Proper & equal weight bearing
If the child’s center of gravity appears to be
unusually high, resulting in floating legs and
poor ability to raise head against gravity
Fear of fall in child due to poor balance
62. ◦ Use of limbs & hands
Limb patterns in changing or going into position
as well as using them in position
◦ Attitudes of limbs during playing & in all
positions
Whether one or both hands are used, type of
grasp and release
Accuracy of reach and hand actions
Any involuntary movements, tremors or
spasms, which interfere with actions, are
present
63. ◦ Sensory aspects
Observe child’s use of vision, hearing, of
touch, smell and temperature in relevant tasks
Does child enjoys particular sensations
Whether child enjoys being moved or having
position changed
◦ Form of Locomotion
How child is carried
Any use of wheelchair or walking aids
Which daily activities motivates child to
roll, creep, crawl, bottom shuffle or walk
64. ◦ Deformities
Any part of body, which remains in particular position in all
postures & in the movements
The positional preferences typically seen in spastic cerebral
palsies are for mid positions of body –
In the UL
Shoulder protraction or retraction, adduction and internal rotation,
Elbow flexion, Forearm pronation, Wrist & Fingers flexion
In the LL
Hip semi-flexion, internal rotation and adduction, Knee semi-flexion,
Ankle plantar flexion, Foot pronation or supination, Toes flexion
Athetoid or dystonic posturing usually incorporates
extremes of movement such as total flexion or extension
Windswept Deformity of hip – One hip flexed, abducted and
externally rotated; other hip flexed, adducted and internally
rotated and in danger of posterior dislocation
65. Higher cognitive function
◦ Drowsy & lethargic
◦ Decrease in intellectual function
◦ Mental retardation (mild to profound)
◦ Attention deficit & easily distractible
◦ Poor memory
◦ Poor comprehension of speech &
language
67. Special senses
◦ Visual & auditory defects
◦ Tactile & vestibular hyposensitivity or
hypersensitivity
68. On examination
Sensory Assessment
◦ It is difficult to assess sensation in
babies and young children with severe
multiple impairments.
◦ If any hearing or visual or psychological
abnormalities are present then
assessment done by specialist is required
69. Motor integrity
◦ Abnormalities of tone
Spasticity, hypotonicity, dystonia etc
◦ Muscular weakness
◦ Loss of voluntary control
◦ Decreased co ordination
71. ROM & flexibility
◦ Decreased in the ROM of the involved
limbs
◦ Tightness & contracture in hip
adductors, hamstrings, calf are very
common
72. Anthropometric measurement
◦ Height or length decreased (growth
retardation)
◦ Weight – decreased (thin & lean) or obese
◦ Head circumference – decreased (growth
retardation or microcephaly), increased
(hydrocephalus)
73. ◦ Growth Parameters
Height - Until 24 to 36 months of
age, length in recumbency is measured using
an infantometer. After the age of 2 years
standing height is recorded by a stadiometer
Weight kg Pounds
At birth 3.25 7
3-6 months Age in months +9/2 Age in months + 11
1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17
7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
74. Weight kg Pounds
At birth 3.25 7
3-6 months Age in months +9/2 Age in months + 11
1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17
7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
Weight
75. Head circumference of the child -
◦ The tape is used to measure
occipitofrontal head circumference
from external occipital protuberance to
glabella
Head cicumference Cm
At birth 35
3 months 40
1 yr 45
2 yrs 48
12 yrs 52
76. Developmental milestones
Age Developmental Milestones
4 to 6 weeks Social smile
3 months Head holding
6 months Sits with support
7 months Sits without support
5 to 6 months Reaches out for bright object & gets it
6 to 7 months Transfers object from one hand to other
6 to 7 months Starts imitating cough
8 to 10 months Crawls
77. 10 to 11 months Creeps
9 months Standing holding furniture
12 months Walks holding furniture
10 to 11 months Stands without support
13 months Walks without much of a support
12 months Says one word with meaning
13 months Says three words with meaning
15 to 18 months Joints 2 or 3 words into sentence
78. 13 months Feeds self with spoon
15 to 18 months Climbs stair
15 to 18 months Takes shoes and socks off
24 months Puts shoes and socks on
24 months Takes some clothes off
3 to 4 years Dresses self fully
2 years Dry by day
3 years Dry by night
3 years Knows full name and sex
3 years Rides tricycle
79. Joint Range of Motion (active & passive)
◦ Active head and trunk flexion, extension, rotation observed
during head raise in prone, supine, sitting, standing developmental
channels
◦ Active shoulder elevation, abduction, rotation, flexion and
extension movements are observed during functional examination
of creeping, reaching and other arm movements
◦ Active elbow flexion and extension observed during child’s reach
to parts of body or toys
◦ Active wrist and hand movements will be observed during
function development
◦ Active hip flexion and extension will be observed during all
functions
◦ Active knee flexion and extension seen with active hip flexion
extension
◦ Foot movements are also check during functional development
80. Posture
◦ Poor posture in all types of CP
◦ Kypho-Scoliosis, knock knee & flexion
deformity & inverted flat foot are
commonly seen
81. Balance & gait
◦ Compromised static & dynamic balance
◦ Balance severely affected in athetoid &
ataxic CP
◦ Independent walking is rarely achieved
by spastic quadriplegic & athetoid CP,
few diplegic CP can walk with aids,
hemiplegic CP can achieve independent
walking
82. Bowel & bladder involvement
◦ If the child is able to communicate &
understand, training can be helpful
◦ In profound MR and those unable to
communicate have dependent functions
86. PT aims
Family education
Handling & care
Promote infant & parent interaction
Encourage development of functional
skills & play
Promote sensory motor development
Establish head & neck control
Attain & maintain upright position
87. Family education
Educate families about CP
Provide support in their acceptance of child
Goal setting & programming should be done
with family
Be realistic about the prognosis & efficacy of
PT while remaining hopeful
Honesty & commitment towards child
Listening to parental concerns & recognizing
personal values & strength
88. Handling & care
Promote parents ease, skill & confidence in
handling child
Positioning, feeding & carrying techniques should
be taught
Promote symmetry, limit abnormal posturing &
facilitate functional motor activity
Use variety of movement & posture to promote
sensory function
Include position to allow lengthening of spastic or
hypoextensive muscles
Use positions to improve functional voluntary
movement of limbs
89. Mother & child
relationship
Activities should be done on mother's
lap, close to body & face so that her
touch & stroking & talking to baby not
only help motor development but also
body image, movement enjoyment by baby
& demonstrate love & security
Weaning of child to a PT should be
carefully done after mother-child bonding
& confidence is established
90. Introducing more than one therapist
or developmental worker may be
disconcerting to child & even parents
Not to overload with exercises, but
rather use corrective movements &
postures within ADL of child
91. Feeding & respiration
Position in a propped up sitting for feeding
For greater hip stability & symmetry
during feeding position in a high chair with
adaptation
Head & neck position should be in neutral
rotation & slight flexion to facilitate
swallowing
Deep respiration can be facilitated before
feeding by applying pressure in the thorax
or the abdominal area
92. Facilitate sensory-motor
development (body image)
Reaching, rolling, sitting, crawling &
transitional movements like standing &
pre walking are facilitated
◦ Promotes spatial perception, body awareness
& mobility, facilitate play, social interaction
& exploration of environment
Use of equipments that facilitates
function when impairment is preventing
development E.g. sitting on adapted
chair
93. Practice midline play, reach for
feet, suck on fingers
Do not give too many stimuli at once
Carefully introduce different surfaces
for child to roll on, creep, crawl, & walk
on with bare feet
Always give child time to experience
tactile & auditory stimuli & let him reach
& find out about himself whenever
possible
94. Improve proprioceptive &
vestibular function
They are compensatory stimuli for visual
impairment & also develop body image
Touch, pressure & resistance can be
correctly given to stimulate movement
giving clues as to direction & degree of
muscle action.
Do not use Rx with handling or other
proprioceptive stimuli from behind as
leaning back will facilitate extensor
thrusts
95. Visual development
Can be easily integrated with methods for
head control, hand function & all balance &
locomotor activities
Relate appropriate level of visual ability with
child's motor programme.
Also one may have to accept unusual head
position & other patterns which make it
possible for the child to use residual vision
Use favorite toys or colors to facilitate
visual function
96. Language development
Talk & clearly label body parts used
Delay is normal for a child who cannot yet
understand meaning of sounds, words &
conversation
Use simple & easy words with appropriate
examples & models
Communication is also fostered through
motor actions, touch & body language
relevant to sign system of a child
97. Facilitating motor
development
Postural stability of the head when
◦ lying prone (0-3 months)
◦ on forearms (3 months)
◦ on hands and on hands and knees (6
months),
◦ during crawling, half-kneeling hand
support (9-11 months)
◦ in the bear-walk (12 months) in normal
developmental levels.
98. Acceptance of prone position.
◦ Accustom child to prone
on soft surfaces, sponge rubber, inflatable
mattress, in warm water, over large soft
ball, over your lap
rock and sway a baby held in prone
suspension.
99. Postural stability of the shoulder girdle
◦ weight on forearms (3 months),
◦ on hands (6 months),
◦ on hands & knees & arms held stretched forward
along the ground to hold a toy at 5-6 months also
include postural stability.
Pivot prone with arms held extended in air
activates stabilizers (8-10 months).
Maintenance of half-kneeling lean or upright
kneeling (lean on hands) or grasp a support -
9-12 months stimulates shoulder girdle
stability
100. Postural stability of pelvis
◦ On knees with hips at right angles (4
months)
◦ on elbows & knees & on hands and knees
(4-6 months),
◦ on half-kneeling and upright kneeling
with support (9-12 months) in normal
motor levels.
101. Maintaining an upright
position
Use of adapted chairs & standing
frame
Use of orthosis can be delayed until
some voluntary movement is gained
Sitting on swiss ball, vestibular board
etc can be given to improve
challenges
103. Main aim is to reduce the primary
impairments & prevent the
secondary impairments
104. Increase force generation
(strengthening)
Creating demands in both concentric &
eccentric work
◦ Transitional movements against gravity, ball
gymnastics etc.
If a child has some voluntary control in
muscle group, capacity for strengthening
exists
Use of electrical stimulation or by
strengthening within synergistic
movement patterns
105. Ambulatory children with CP have
capacity to strengthen
muscles, although poor isolated control
or inadequate length
To participate in a strength-training
program, child must be able to
comprehend & to consistently produce
a maximal or near-maximal effort
106. Reduce spasticity
Positioning in anti synergistic pattern
Stretching of tight structures
MFR
ROM exercise
Rhythmic rotations
Splinting & serial casting
Dorsal rhizotomy
Botox injection
107. Increase mobility &
flexibility
ROM exercise
Maintain length of muscle by regular
stretching & splinting
◦ Prolonged stretching of 6 hours a day with
the threshold at which the muscle began to
resist a stretch
Strengthening exercise of prime
movers of a joint
108. Prevent deformity
Serial Casting techniques
Orthosis & night splints
Lycra splinting & taping techniques
◦ Skin reactions should be carefully
assessed
Allignment of the body in a variety
of positions in which they can
optimally function, travel & sleep
109. Improve physical activity
Exercise should be intensive, challenging &
meaningful & involve integration of skills into
function
Movement should be goal oriented & interesting to
maintain motivation
◦ Kicking a soccer ball
Feedback is important & feedforward is also
considered
CIMT also improves function in hemiplegic CP
Oromotor rehabilitation should also be provided
110. Improve ambulatory
capacity
Weight bearing, promoting
dissociation, & improving balance
Walkers & crutches may be used
◦ Posterior walkers encourages more upright
posture during gait
Treadmill training or body weight
support treadmill training
Adapted tricycle, wheelchair or
motorized wheelchair may improve
mobility in more disabled children
111. Improve play
Play is the primary productive activity of
children it should be motivating &
pleasurable
Motivates social skills, perception
conceptual, intellectual & language skills
Appropriate toys & play methods should
be suggested
Parents should encourage to let children
enjoy their typical play activities s/a
rolling downhill or getting dirty
113. Improve activity, mobility &
endurance
Gait training can be continued throughout
school age with other conjunction s/a
spasticity mgt
Architectural modification may be
required s/a ramps or rails
Orthosis increases energy expenditure
Regular exercise, proper diet & nutrition &
participation in recreational activities is
encouraged
114. School & community
participation
Positioning, lifting & transfer techniques
should be taught to the school personnel
Opportunities should be given to
participate in community & recreational
activities
Adapted games & athletic competition &
team participation improves self esteem
Introduce to Community fitness program
115. Barriers s/a transportation, finances,
time preferences & involvement,
interest should also be considered
carefully
Injury prevention will limit impairment
& disability
117. Improve functional skills
Maintain & improve cardiovascular fitness
Weight control, maintain integrity of joints &
muscles, help prevent osteoporosis
Fitness clubs, swimming, wheelchair aerobics
& adapted sports are options
Disability certificate should be provided to
reimburse handicap facilities & compensations
Introduce to help lines & community care
centers
118. Transition planning
Vocational training & occupational
training should be provided
Living arrangement, personal mgt
including birth control, social skill &
household management should be made
available
Continuation of professional health
service should be done
119. Characteristics Score 0 Score 1 Score 2 Acronym
Skin color/
Complexion
Blue or pale all
over
Blue at extremities
body pink
(acrocyanosis)
No cyanosis-
body & extremities
pink
Appearance
Pulse rate Absent <100 ≥100 Pulse
Reflexirritability
No response to
stimulation
grimace/feeble cry
when stimulated
cry or pull away
when stimulated
Grimace
Muscle tone None some flexion
flexed arms & legs
that resist extension
Activity
Breathing Absent
weak, irregular,
gasping
strong, lusty cry Respiration
Apgar score
120. Scoring
Test is done at 1 & 5 min after birth, & repeated later if
score is/ & remain low
◦ 3 & below- critically low,
◦ 4 to 6 - fairly low
◦ 7 to 10- generally normal.
A low score on 1 minute -requires medical attention
If score remains below 3 at times s/a 10, 15, or 30
min, there is a risk that child will suffer longer-term
neurological damage.
Purpose of Apgar test is to determine quickly whether a
newborn needs immediate medical care or not & not
designed to make long-term predictions
A score of 10 is uncommon due to prevalence of transient
cyanosis, & is not substantially different from a score of 9.
◦ Transient cyanosis is common, particularly in babies born at
high altitude.