REHABILITATION OF

:
CEREBRAL PALSY &
MOTOR DELAY
 REHABILITATION OF C.P
CEREBRAL PALSY
Static encephalopathy(=non progressive) caused by an insult to the
immature brain

REHABILITATION:
The process of making the child w/ disability maximally able again through
the application of rehab principles & techniques.

 REHABILITATION OF C.P
Principles of proper rehabilitation :
1. Proper evaluation ( individual treatment )
- to plan a therapy program.to assess
progress.
- to add observation to the diagnostic
picture.
2. Early treatment( increasing functional
deficits w/ age as secondary effects of
spasticity &other primary problems
3. Team work ( global dysfunction )
 EVALUATION OF CP CHILD
(A) Clinical evaluation
1. Functional : Postural control Mobility

Primitive reflexes Motor exam

2. Swallowing & dysphagia
3. Communication: Speech/ language Visual
Auditory Mentality
4. Chest 5. Urinary bladder 6. Bowel
7. Self -care activities (ADL) 8. psychosocial
 EVALUATION OF CHILD
WITH CP.
(B) Imaging
1. Serial X-rays:
Hips (dislocation spastic adductors)
Th-L-Spine (scoliosis, hyperlordosis in spastic CP
kyphoscoliosis in floppy CP)
2. MRI or CT brain (progressive motor deficits ?
tumors, hydrocephalus
 ASSESSMENT OF MILESTONES &
POSTURAL CONTROL
Understanding normal development allows to adaptive
equipment to assist child in gaining increase the
interaction with the environment.
Sitting balance at age 2 yrs. is an indicator of future
walking.
Observe how much parental support given to child.
child own ability in postural stabilization.
collapse on one side of his body, twist to one
side, tilt & turn to one side.
EVALUATION OF PRIMITIVE REFLEXES

Can be used as indicator of ambulation

Abnormal response for two of the following seven reflexes
by age 12 month has a poor prognosis for walking this are
Should be absent Should be present
ATNR parachute reaction
STNR foot placement
Moro response
Neck righting reflex
Extensory thrust
Presence of Moro or ATNR, seizures, ability to sit at 12
month indicate ambulation by age of 6 yrs.
 MOTOR EXAMINATION
GAIT
Hemiplegia Toe walk
Diplegia Bilateral equinovaras,
Knee flexed & in valgus
Scissoring
Cerebellar Ataxic
 MOTOR EXAMINATION
DEFORMITIES

Hemiplegia : adducted arm, flexed elbow, wrist & fingers

equinus foot.
Diplegia: adducted hip, flexed knee in valgus, bilateral EV
knee height discrepancy indicates hip dislocation.
Quadriplegia: combination
scoliosis & hyperlordosis in spastic CP
kyphoscoliosis in hypotonic CP
 MOTOR EXAMINATION
R.O.M.
Degree by goniometry:
Limited (= fixed deformity = ms. Contracture)
Not limited (+ deformity = threatening
deformity
= muscles imbalance)
ABNORMAL MOVEMENT
Dystonia, ( cervical = spasmodic torticollis )
Chorea & Athetosis
Tremors
 MOTOR EXAMINATION
MUSCLE TONE
Spasticity ( = clasp knife ):
- generalized or focal
- grade 0 (non) - 4 (severe) [Ashworth
scale]
Rigidity ( = lead pipe )
Hypotonia ( cerebellar )
Combination : the predominant symptoms
will contribute to diagnostic type referred for
treatment
 MOTOR EXAMINATION
MUSCLE STRENGTH
Grade 0 = No contraction detected
1 = Flicker of contraction w/ no movement.
2 = Joint movement possible only with
gravity eliminated.
3 = Muscle contraction possible against
gravity without resistance.
4= Muscle contraction against gravity &
less than normal amount of resistance.
5 = Normal power against gravity and
resistance.
 MOTOR EXAMINATION
MUSCLE STRENGTH
Values of muscles grading:
- To determine ambulation with or without
brace
( grade 3 antigravity muscles can ambulate
without brace
- Topographic classification for treatment plan
( strengthening exercise for weak muscles )
- Ex. must be low grade and non-fatiguing in
ms.<3/5
 SWALLOWING STUDY
Values: - To facilitate appropriate position for safe, effective feeding
- To increase ability to self feed.
Methods:
1. Video fluoroscopic swallowing study
- Requires speech - pathologist & radiologist
- Patient is given liquid & various consistency of solid food
impregnated w/ baruim & folowed by X-ray until be sure safe
effective swallowing
2.Fiberoptic evaluation of swallowing ( FEES )
Transnasal endoscopy of hypopharynx to observe foodway &
airway before & after( but not during ) the moment of swallowing.
3. EMG, manometry, scintigraphy & U.S: less commonly use.
 Assessment of speech
Speech problems :
Dysarthria (oral motor control problems ) :
Spastic
Hypokinetic (ataxic )
Hyperkinetic (dystonia,chorea)
Aphasia
Language delay (brain pathology, MR,
hearing impairment )
 VISUAL ASSESSMENT
Problems: Strabismus ( imbalance in eye ms. )
Hemianopsia(in dense hemiplegi w/
MCA occlusion)
Blindness ( anoxic cortical vision loss )
Effects: 1. More motor delay 2. Language
delay
3. Abnormal movements ( blindism )
4. More delayed postural mechanism
especially hypotonic CP
 AUDIOLOGICAL EVALUATION
Must be early so that important speech development
period not lost.
In infant (1-2 d. of birth):
Brain stem auditory evoked response
(BAER): Electrodes placed on
the child & presenting a stimulus picked up from a
computerized system.
A specific wave form response is recorded from the
brain stem if stimulus is heard.
Otoacoustic emission testing (OAE):
Echo from hair cell of normally
functioning cochlea picked by a microphone placed in
the middle ear & connected to micro computer.(middle
ear pathology is ruled out)
 AUDIOLOGICAL
EVALUATION
6 months children:
Behavioral testing in sound treated room
2-3 years children :
Play audiometry done by presenting
auditory stimulus through loud speaker
and associate the sound with light or toy
 CHEST EVALUATION

Vital Capacity is measured by spirometry

Ventilatory impairment may be caused by:
1. Rib cage abnormalities 2ry. to scoliosis &
hyperlordosis (spastic) or kyphoscoliosis (floppy)
2. Respiratory muscle dysfunction (spasticity or
hypotonic)
 ASSESSMENT OF BLADDER
DYSFUNCTION
Problems:
-incontinence,urgency,hesitancy (brain damage,motor
disability, impaired cognition )
-small capacity hypereflexic bladder
-detrusor sphincter dyssynergia
Assessment :
-Renal function with serial determination of post-voidal
volume
-Cytometric evaluation with associated EMG
monitoring of pelvic floor muscle
 ASSESSMENT OF BOWEL
DYSFUNCTION
Problems :
-Fecal incontinence or defecation
stress ( brain damage, motor
disability, impaired
cognition,incoordination of anal
sphincter or pelvic floor muscle )
-Constipation : exaggerated by
immobility & inadequate fluid intake
Assessment : anorectal manometry
 SCOPE OF CP REHAB.
1. Neurodevelopmental training.
2. Motor facilitation approach.
3. Treatment of spasticity.
4. Rehab. of swallowing problems.
5. Rehab. of speech problems.
6. Rehab. of auditory problems.
7. Rehab. of visual problems.
8. Rehab. of chest problems.
9. Rehab. of urinary bladder & bowel
problems.
10.Rehab. Of ADL &
11.Psychosocial rehab.
NEURODEVELOPMENTAL TRAINING

EQUIPMENT TRAINING
Criteria for selection:
1. to carry out tasks otherwise impossible with his ability.
2. appropriate support to participate in social & educational activities .
3. good alignment & correction of abnormal postures
4. adjust for child growth, removal of support with increasing ability.
5. modification for different children in schools & clinics
6. provide additional motor experience in different posture
7. Comfort and protect joints & skin.
 NEURODEVELOPMENTAL
TRAINING
Equipments varieties:
1. Wedges: Abductor W : prevent adduction
deformities
2. Trumble form wedges & trumbles.

3. Large inflatable ball set

4.Crawlers:
-platforms on wheels or wedges on wheels
-A canavas sling under child abdomen & supports
on casters, straps to hold thighs in flexion.
5. Sitters
 NEURODEVELOPMENTAL
TRAINING
6. Apparatus for supporting standing
a) Prone or supine standers to encourage weight bearing &
standing
b) Standing frames adjusting correct alignment:
-checked for height so that child does not grasp them w/
abnormal shoulder
hunching , excessive elbow flexion & radial deviation of wrist.
-supplied w/ strapping to correct flexed hip & knees
-feet held at right angles by a board &/or foot place.
c) Parallel bars

d) Mirrors
e) Stairs with bannisters: very in height.
f) Rumps, uneven ground, various floor services for gait training.
 NEURODEVELOPMENTAL
TRAINING
7.Walking aids
Walkers
Crutches
Braces & Calipers:
Knee gaiters (polyethylene knee moulds)
to keep knee straight abduction parts to
keep legs apart.
Elbow gaiters which keep elbow straight for
correct arm push & grasp of walkers.
MOTOR FACILITATION APPROACH

1. Bobath Method: inhibition of abnormal tone & posture of

released postural reflex while facilitating specific automatic
motor response (by special technique of handling) resulting in
performance of skilled voluntary movements.
2. Rood Method: Use of peripheral input of cutaneous sensory
stimuli (brushing, tapping, icing, heating, pressure, ms. stretch,
muscle contraction, joint approximation. or retraction)
Various nerves & sensory receptors are described & classified
into types ,location, effect, response, indication.
MOTOR FACILITATION APPROACH
3. Propioceptive Neuromuscular facilitation (Kabat & Knott)
Use of such mechanisms as maximum resistance , quick stretch &
spiral diagonal (mass) movements, sensory afferent stimuli (touch,
pressure, traction,compression & visual) to facilitate normal mov .
[special techniques: irradiation. stim. of reflexes,reversal(successive
induction), relaxation.].
4. Brunstrom Method ( hemiplegia): Produces motion by provoking
primitive movement pattern or synergitic pattern as follows :
-Reflex response used initially & later voluntary control
-Control of head & trunk by stim. of TNR, tonic labrinythine R
-Associated reaction : hyperextension of the thumb produces
relaxation of finger flexors.
MOTOR FACILITATION APPROACH
5. Motor relearning program of Carr & Shepherd:
functional training, practice, repitition, in the performance
of tasks & carry over those motor skills into functional
activities.
6. Forced use paradigm (= constraint - induced
movements therapy CIMT):
Non hemiplegic limb is restrained in a sling during 90% of
waking hrs. to force the patient to use the hemiplegic limb.
The minimum amount of motion in the paretic limb before
being enrolled into CIMT protocol is 20 of wrist extension
and 10 of extension of 2 fingers at MCP or IPJ.
 TREATMENT OF SPASTICITY
Positioning
Avoid prolong sitting (less hip & hamstring
flexion )
Prone lying at night (less hip flexion )
Abduction wedge at night & in wheelchair (less
hip adduction)
AFO splint
Standing frame
Molded thoracolumbar orthosis for early scoliosis
or kyphosis
Total contact support incorporated into a
 TREATMENT OF SPASTICITY
Drugs
Indication : generalised spacticity to aid in mobility
Types :
1. Dantrolene Sodium (Dantrium):
Inhibits Ca release in excitation-contraction coupling
Used in cerebral form of spacticity Dose: 25- 200mg
2. Baclofen (Lioresal ) [ presynaptic inhibition ]
Used in spinal form of spasticity Dose :5-40mg
3. Diazepam (Valium) [postsynaptic inhibition]
Used in spinal form of spasticity Dose :2-30mg
 TREATMENT OF SPASTICITY
PHYSIOTHERAPY

PHYSICAL AGENTS
Aim: a. Analgesia b. Ms. Relaxation c. Collagen extensibility
Modalities: 1) Ice 20mins.
2) Heat: Superficial : Dry: I.R. Moist: hot packs
Deep : S.W. U.S
ELECTRIC CURRENTS Aim: Ms. strengthening (galvanic & faradic) .
Analgesia ( TENS, IF)
EXERCISES For spasticity : Passive ROM Stretch (short ms.)
Strengthening (weak ms., antagonist),
resistive > 3/5
For hypotonia : Strengthening ( weak ms) Balance
For athetosis : Training to control simple joint motion
 TREATMENT OF SPASTICITY
Nerve/ Motor Point Block

Indications Localized spasticity poorly responsive to drugs or

PT,
interfering w/ mobility, bracing, hygiene & causing
pain
Contraindication:
- Absolute: Allergy Infection Pregnancy
- Relative: Coagulopathy
Problems:
-Loss of motor function of injected ms.
-Return of spasticity ( axon sprouting )
 TREATMENT OF SPASTICITY
Nerve/ Motor Point Block
Agents :
1- Botulinum toxin(Botox) [inhibits A.C at NMJ]
Used in motor point block of UL & LL
Antibodies are formed against it
2- Phenol [ produce coagulation of axon protein]
Used in nerve motor point block
Produces sensory dysesthesia.
3 - Alcohol [produce coagulation of axon protein]
Used in motor point > nerve block
Produces hyperaemia & transiant burning
 TREATMENT OF SPASTICITY
INTRATHECAL BACLOFEN PUMP
Indications: ambulatory or non ambulatory child > 28lbs.w/
spastic diplegia.
Method:
- Baclofen is delivered via pump implanted S.C.in
abdominal wall & surgically placed in subarachnoid space
(CSF) close to its site action ( receptors just 1mm under
the surface of spinal cord )
- Start with intrathecal test dose via lumbar puncture to
assess baclofen effect over 6-8hs (1grade drops of
spasticity)
. Advantage: avoid high dose of oral baclofen.
Risk: Infections e.g. meningitis, hypotonia & resp.problem
 TREATMENT OF
SPASTICIRY
SERIAL CASTING
Indications: focal contracture (especially elbows,

knees, ankles ).
Method:
Limb is stretched then casted in a lengthened
position ( can be combined with blocks )
Changed every few days or weeks to gradually

stretch contracted structures.

TREATMENT OF SPASTICITY
BRACES ( = CALIPERS = ORTHOSIS )
Aim: To correct deformity
To control athetosis
To obtain upright position
Types: AFO: For ankle instability w adequate Q > 3/5
Types: solid ( in ankle clonus )
Klenzak ankle joint w/spring(A,P)
w/ stop (A,P)
Accessories: varus strap valgus strap
KAFO: For correction of knee deform. & instab.
HKAFO: For ambulation w/ hip instability
. Shoe modification
 TREATMENT OF SPASTICITY
ORTHOPAEDIC SURGERY
1. Spastic equinovarus foot: combination of:
a. Achillis tendon lengthening ( equinus def. )
b. Split anterior tibial transfer: Splitting TA tendon
medial half left attached to its origin
lateral half tunneled into 3rd cuneiform & cuboid
2. Tight hip adductor: Adductor tenotomy or derotational
osteotomy
( + surgical reduction )
3. Scoliosis: surgical correction in ambulatory child
w/ curvature > 45 & vital capacity < 35%
 TREATMENT OF SPASTICITY

NEUROSURGERY
Dorsal Rhizotomy
- Ideal patient: young child (3-8 yrs.) w/ spastic diplegia
ambulatory w/ spastic gait.
- Method: - Surgical cutting of posterior (sensory) root
to
decrease sensory input to spinal cord
reducing
muscle tone (but decreases sensation)

- Must be followed by PT & OT

- Cutting anterior root produces atrophy &?
ulcer
 REHAB OF SWALLOWING
PROBLEMS
Team: speech language specialist, OT, Dietary
specialist.
Items:
Changes in posture & head position during feeding.
Oral motor exercise for the tongue & lips to
increase strength,
ROM, velocity, percision.
Use of thickened fluid & soft food in small boluse
Use of alternative feeding routes e.g. nasogastric
tube, gastrotomy or jejunostomy tubes with severe
aspiration or caloric need.
 REHAB OF SPEECH
PROBLEMS
Team : speech -language pathologist & nurse
Items : 1- oral option : electrolarynx
2 - non oral options :
- simple hand writing
- gestures
- augmentative communication
device (simple alphabet & picture
board
to sophosticated computer systems
3- treatment of hearing & visual problems
REHAB OF AUDITORY PROBLEMS

Team: audiologist, speech therapist, OT

Items:
Cochlear implants (for profoundly deaf):
to stimulate auditory nerve & provid awareness of
sound
Hearing aid :
- Do not help purely central hearing loss.
Used for ttt of profound sensorineural
hearing loss in infancy & early childhood
 REHAB OF AUDITORY
PROBLEMS
Assistive listening device:
Voice amplifiers used with or in place of hearing aids.
Speaker microphone is connected to the listeners
head set or hearing aid through a wire, FM radio waves
or IR light. The signal is amplified and
background noise is not picked.
Compensatory strategies:
Hand signs, lip reading, gestures, written
communication, speaking clearly at slow speed,
visual fire alarms,
enrichment of visual & tactile sensory environment,
protection of the
childs remaining hearing (use of ear plugs in swimming,
ototoxic drugs are avoided)
 REHAB OF VISUAL PROBLEMS
Training of postural reaction (large balls, rolls)

Use of compensatory stimuli (auditory, tactile,

vestibular, propioceptive) for:.
-Training of motor function of childs life e.g
dressing, feeding, bathing, roll over, creeping,
crawling (listen to sound, reach to sound, move
to sound).
-Training of body image movements enjoyment
(hand to hand, hand to mouth, hand to body)
Mother - child relationship ( kisses, touches,
stroking, talking to the baby) is important.
 REHAB OF VISUAL
PROBLEMS
Use of vibrating toys, bells & playthings placed for his
tummy legs & similar ideas.
Language development:
Important to talk & clearly label the body parts &
to encourage the childs language.

Visual enhancement (illumination, magnification, altered

contrast, glare reduction, expanders of visual field)
Visual substitution: Recorded talking books,

Computer w/ vebral output,

Braille book.
REHAB. OF CHEST PROBLEMS

Elimination of air way secretion by

manually assisted cough OR
mechanical insufflator or
exsufflator.
Respiratory ms. aid by manual force
(breathing ex) OR
mechanical ventillatory assistance(hypoxia)
Mouth intermittent positive pressure
ventillation (IPPV) in late stages.
 REHAB. OF U.B. PROBLEMS

Timed bladder emptying schedule

Regulation of fluid intake.
Use of diapers.
Adequate cleaning of perineum
Family education about transfer & dressing skill .

REHAB. OF BOWEL PROBLEMS

A timed toileting schedule for incontinence
Use of dietary fibers, adequate fluid intake, stool

softeners, supp., & enema for constipation

.
 REHAB OF ADL
Team : occupational therapist
Items :
- provision of self help devices
- training in activities of ADL
- provision of creative interest
- training in suitable work
 PSYCHOSOCIAL REHAB
Team : psychiatrist + social specialist
Items : - provision of recreational activities
e.g.- special olympics, athletic competition
- horse back riding programs

(recreational & therapeutic )

- computers ( for schools & recreation