CEREBRAL PALSY

Cerebral palsy describes a group of disorder of the development of the movement and posture,causing activity limitation,that are attributed to non progressive disturebance that occurred in developing featal or infant brain. -CP may result in spastic,athetoid ataxic or hypotonic or mixed tone. -The distribution of cp may include diaplegia, hemiplegia and quadriplegia. COMPLICATIONS 1)Conginitive imparement 2)Mental retardation 3)Seizures 4)Feeding and commnication problem 5)Respiratory compromises 6)GIT abnormality contributing to digestion problem 7)Bowel and bladder controll problem 8)Dental issue 9)Hearing and vision problem. General Treatment Ideas
Child with Spasticity

Treatment for the child with spasticity focuses on mobility in all possible postures and transitions between these postures.The tendency to develop contractures needs to be counteracted by range of motion, positioning, and development of active movement. Areas that are prone to tightness may include shoulder adductors and elbow, wrist, and finger flexors in children with quadriplegic involvement,whereas hip flexors and adductors, knee flexors, and ankle plantar flexors are more likely to be involved in children with diplegic involvement. Children with quadriplegia can show lower extremity tightness as well. These same joints may be involved unilaterally in hemiplegia. Useful techniques to inhibit spasticity include weight bearing; weight shifting; slow, rhythmic rocking; and rhythmic rotation of the trunk and body segments. Active trunk rotation, dissociation of body segments, and isolated joint movements should be included in the treatment activities and home program. Appropriate handling can increase the likelihood that the child will receive more accurate sensory feedback for motor learning. First Stage of Physical Therapy Intervention: Early Intervention (Birth to 3 Years) Theoretically, early therapy can have a positive impact on nervous system development and recovery from injury. The ability of the nervous system to be flexible in its response to injury and development is termed plasticity. Infants at risk for neurologic problems may be candidates for early physical therapy intervention to take advantage of the nervous system's plasticity. The decision to initiate physical therapy intervention and at what level (frequency and duration) is based on the infant's neuromotor performance during the physical therapy examination and the family's concerns. Several assessment tools designed by PTs are used in the clinic to try to identifY infants with CP as early as possible. Early intervention usually spans the first 3 years of life. During this time, typically developing infants are establishing trust in their caregivers and are learning how to move

about safely within their environment. Parents develop a sense of competence through taking care of their infant and guiding safe exploration of the world. Role of the Family The family is an important component in the early management of the infant.These include the following: 1. Parents are the most important people in the child's life. 2. Parents have the right to make decisions regarding their child. 3. Parents have legal rights for input and decision making in the educational process. 4. Parental participation is essential for optimizing early intervention. 5. Positive parenting experiences support keeping children at home. 6. Parents can be empowered to use community resources effectively. 7. Parental involvement can ensure more fully coordinated services. 8. Parental involvement is economical. Handling and Positioning Handling and positioning in the supine or "en face" (faceto-face) posture should promote orientation with the head in the midline and symmetry of the extremities. A flexed position is preferred so the shoulders are forward and the hands can easily come to the midline. Reaching is encouraged by making sure that obiects are within the infant's grasp. The infant can be encouraged to initiate reaching when in the supine position by being presented with visually interesting toys. Positioning with the infant prone is also important because this is the position from which the infant first moves into extension. Active head lifting when in prone can be encouraged by using toys that are brightly colored or make noise. Some infants do not like being prone, and the caregiver has to be encouraged to continue to put the infant in this position for longer periods. Carrying the infant in prone can increase the child's tolerance for the position. The infant should not sleep in prone, however, because of the increased incidence of sudden infant death syndrome in infants who sleep in this position (American Academy of Pediatrics, 1992). Carrying positions should accentuate the strengths of the infant and should avoid as much abnormal posturing as possible. The infant should be allowed to control as much of her body as possible for as long as possible before externalsupport is given. Feeding and Respiration A flexed posture facilitates feeding and social interaction between the child and the caregiver. The face-to-face position can be used for a child who needs trunk support. Be careful that the roll does not slip behind the child's neck and encourage extension. Deeper respirations can also be encouraged before feeding or at other times by applying slight pressure to the child's thorax and abdominal area before inspiration. This maneuver can be done when the child is in the side lying position or with bilateral hand placements when the child is supine. The tilt of the wedge makes it easier for the child to use the diaphragm for deeper inspiration, as well as expanding the chest wall. Therapeutic Exercise Gentle range-of~motion exercises may be indicated if the infant has difficulty reaching to the midline, has difficulty separating the lower extremities for diapering, or has tight heel cords. Infants do not have complete range of motion in the lower extremities normally, so the hips should never be forced into what would be considered full range of

adduction or extension for an adult. Parents can be taught to incorporate range of motion into the daily routines of diapering,bathing, and dressing. Strengthning,stretching and exercise to improve cardiovascular condition may be given. Sports activities are helpful in decreasing stiffness and contracture in adolscent using the wheelchair. Motor Skill Acquisition The skills needed for age-appropriate play vary. Babies look around and reach first from the supine position and then from the prone position, before they start moving through the environment. Adequate time playing on the floor is needed to encourage movement of the body against gravity. Gravity must be conquered to attain upright sitting and standing postures. Body movement during play is crucial to body awareness. Movement within the environment is necessary for spatial orientation to the external world. Although floor time is important and is critical for learning to move against gravity. Functional Postures The two most functional positions for a person are sitting and standing because upright orientation can be achieved with either position. Some children with CP cannot become functional in standing because of the severity of their motor involvement, but almost every child has the potential to be upright in sitting. Function in sitting can be augmented by appropriate seating devices, inserts, and supports. When motor control is insufficient to allow independent standing, a standing program can be implemented. Upright standing can be achieved by using a supine or prone stander, along with orthoses for distal control. Standers provide lower extremity weight bearing while they support the child's trunk. The child is free to work on head control in a prone stander and to bear weight on the upper extremities or engage in play. In a supine stander, the child's head is supported while the hands are free for reaching and manipulation. The trunk and legs should be in correct anatomic alignment. Standing programs are typically begun when the child is around 12 to 16 months of age. The goals are to improve bone density and development and to manage contractures. Stuberg (1992) recommends standing for at least 60 minutes, four or five times per week, as a general guideline. Salter (1983) had previously reported that standing three times daily for 45 minutes controlled contractures and promoted bone development in children with CP. Independent Mobility Mobility can be achieved in many ways. Rolling is a form of independent mobility but one that may not be practical except in certain surroundings. Sitting and hitching (bottom scooting with or without extremity assistance) are other means of mobility and may be appropriate for a younger child. Creeping on hands and knees can be functional, but upright ambulation is still seen as the most acceptable way for a child to get around because it provides the customary and expected orientation to the world. Power Mobility Mobility within the environment is too important for the development ofspatial concepts to be delayed until the child can move independently. Power mobility should be considered a viable option even for a young child. Some children as young as 17 to 20 months have learned to maneuver a motorized wheelchair (Butler, 1986, 1991). Just because a child is taught to use power mobility does not preclude working concurrently on independent ambulation. This point needs to be stressed to the family. Other mobility alternatives include such devices as prone scooters, adapted tricycles,battery-powered

riding toys, and manual wheelchairs. The independence of moving on one's own teaches young children that they can control the environment around them, rather than being controlled. Second Stage of Physical Therapy Intervention:Preschool Period Physical therapy goals during the preschool period are to 1. Establish a means of independent mobility 2. Promote functional movement 3. Improve performance of ADLs such as grooming and dressing 4. Promote social interaction with peers Independent Mobility If the child with CP did not achieve upright orientation and mobility in some fashion during the early intervention period, now is the time to make a concerted effort to assist the child to do so. For children who are ambulatory with or without assistive devices and orthoses, it may be a period of monitoring and reexamining the continued need for either the assistive or orthotic device. Some children who may not have previously required any type of assistance may benefit from one now because of their changing musculoskeletal status, body weight, seizure status, or safety concerns. Their previous degree of motor control may have been sufficient for a small body, but with growth, control may be lost. Any time the PTA observes that a child is having diffilculty with a task previously performed without problems, the supervising therapist should be alerted. Although the PT performs periodic reexaminations, the PTA working with the child should request a reexamination any time negative changes in the child's motor performance occur. Positive changes should, of course, be thoroughly documented and reported because these, too, may necessitate updating the plan of care. Gait Ambulation may be possible in children with spastic quadriplegia if motor involvement is not too severe. The attainment of the task takes longer, and gait may never be functional because the child requires assistance and supervision for part or all of the components of the activity. Therefore, ambulation may be considered only therapeutic, that is, another form of exercise done during therapy. Specific gait difficulties seen in children with spastic diplegia include lack of lower extremity dissociation, decreased single-limb and increased double-limb support time, and limited postural reactions during weight shifting. Children with spastic diplegia have problems dissociating one leg from the other and dissociating leg movements from the trunk. They often fix (stabilize) with the hip adductors to substitute for the lack of trunk stability in upright necessary for initiation of lower limb motion. Practicing coming to stand over a holster can provide a deterrent to lower extremity adduction while the child works on muscular strengthening and weight bearing . If the child cannot support all the body's weight in standing or during a sit-to-stand transition, have part of the child's body weight on extended arms while he practices coming to stand, standing, or shifting weight in standing. Practicing lateral trunk postural reactions may automatically result in lower extremity separation as the lower extremity opposite the weight shift is automatically abducted. The addition of trunk rotationto the lateral righting may even produce external rotation of the opposite leg. Pushing a toy and shifting weight in stepstance are also useful activities to practice lower extremity separation. As the child decreases the time in double-limb support by taking a step of appropriate length, she can progress to stepping

over an object, or to stepping up and down off a step. Single-limb balance can be challenged by using a floor ladder or taller steps. Having the child hold onto vertical poles decreases the amount of support and facilitates upper trunk extension (Fig. 6-9). Many children can benefit from using some type of assistive device such as a rolling reverse walker during gait training (Fig. 6-10). Orthoses may also be needed to enhance ambulation. Orthoses The most frequently used orthosis in children with CP who are ambulatory is some type of ankle-foot orthosis (AFO). The standard AFO is a single piece of molded polypropylene. The orthosis extends 10 to 15 mm distal to the head of the fibula. The orthosis should not pinch the child behind the knee at any time. All AFOs and foot orthoses should support the foot and should maintain the subtalar joint in a neutral position. Hinged AFOs have been shown to allow a more normal and efficient gait pattern. Ground reaction AFOs have been recommended by some clinicians to decrease the knee flexion seen in the crouch gait of children with spastic CP. Other clinicians state that this type of orthotic device does not work well if the crouch results from high tone in a child with spastic diplegia Knutson and Clark found that foot orthoses could be helpful in controlling pronation in children who do not need ankle stabilization. Dynamic AFOs have a customcontoured soleplate that provides forefoot and hindfoot alignment. An AFO may be indicated following surgery or casting to maintain musculotendinous length gains. The orthosis may be worn both during the day and at night. Proper precautions should always be taken to inspect the skin regularly for any signs of skin breakdown or excessive pressure. The PT should establish a wearing schedule for the child. Areas of redness that last more than 20 minutes after brace removal should be reported to the supervising PT.A child with unstable ankles who needs medial lateral stability may benefit from a supramalleolar orthosis (SMO). This orthotic device allows the child to move freely into dorsiflexion and plantar flexion while restricting mediolateral movement. An SMO may be indicated for a child with mild hypertonia (Knutson and Clark, 1991). In the child with hypotonia or athetoid CP, the SMO may provide sufficient stability within a tennis shoe to allow ambulation. General guidelines for orthotic use can be found in Knutson and Clark (1991) and in Goodman and Glanzman (2003). Assistive Devices Some assistive devices should be avoided in this population. For example, walkers that do not require the child to control the head and trunk as much as possible are passive and may be of little long-term benefit. When the use of a walker results in increased lower extremity extension and toe walking, a more appropriate means of encouraging am bulation should be sought. Exercise saucers can be as dangerous as walkers. Jumpers should be avoided in children with increased lower extremity muscle tone. If a child has not achieved independent functional ambulation before age 3 years, some alternative type of mobility should be considered at this time. An adapted tricycle, a manual wheelchair, a mobile stander, a battery-powered scooter, and a power wheelchair are all viable options. Power Mobility. Children with more severe involvement, as in quadriplegia, do not have sufficient head or trunk control, let alone adequate upper extremity function, to

ambulate independently even with an assistive device. For them, some form of power mobility, such as a wheelchair or other motorized device, may be a solution. For others, a more controlling apparatus such as a gait trainer may provide enough trunk support to allow training of the reciprocal lower extremity movements to propel the device Third Stage of Physical Therapy Intervention:School Age and Adolescence Physical therapy goals during the school years and through adolescence are to 1. Continue independent mobility 2. Develop independent skills related to ADLs and instrumental ADLs 3. Foster fitness and development of a positive self-image 4. Foster community integration 5. Develop a vocational plan 6. Foster social interaction with peers Independence Strength Studies have shown that adolescents with CP can increase strength when they are engaged in a program of isokinetic resistance exercises. Strengthening has been shown to improve gait and motor skills in adolescent and school-age children with CP. The programs vary in the frequency of the interventions and overall duration. Gains were shown after a short program (4 weeks) consisting of twice-weekly circuit training in 4- to 8-year-olds. The use of traditional electrical stimulation or functional electric stimulation has also been reported in the literature with positive results.Although therapeutic electrical stimulation has been promoted to improve muscle mass in children with CP, a recent study concluded that it had no significant effect on gait or motor function in children with spastic diplegic CP. Fitness Students with physical disabilities such as CP are often unable to participate fully in physical education. If the physical education teacher is knowledgeable about adapting routines for students with disabilities, the student may experience some cardiovascular benefits. The neuromuscular deficits affect the ability of a student with CP to perform exercises. Community Integration Accessibility is an important issue in transportation and in providing students with disabilities easy entrance to and exit from community buildings. Accessibility is often a challenge to a teenager who may not be able to drive because of CP. Every effort should be made to support the teenager's ability to drive a motor vehicle, because the freedom this type of mobility provides is important for social interaction and vocational pursuits.