REHABILITATION OF CEREBRAL PALSY

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REHABILITATION OF CEREBRAL PALSY MOTOR DELAY

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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.

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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 )

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(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 CP CHILD
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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

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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.

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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.

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MOTOR EXAMINATION

• GAIT
• Hemiplegia Toe walk
• Diplegia Bilateral equinovaras,
• Knee flexed in valgus
• Scissoring
• Cerebellar Ataxic

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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

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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

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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

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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.

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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.lt3/5
• -N.B (I) grade drops form muscle power
  following tendon lengthening.

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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.

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Assessment of speech

• Speech problems
• Dysarthria (oral motor control problems )
• Spastic
• Hypokinetic (ataxic )
• Hyperkinetic (dystonia,chorea)
• Aphasia
• Language delay (brain pathology, MR, hearing
  impairment )

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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

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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)

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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

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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)

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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

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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

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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
  contoured seating system

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TREATMENT OF SPASTICITY

• Drugs
• Indication generalised spacticity to aid
  in mobility
• Types
• 1. Dantrolene Sodium (Dantrium)
• Inhibits Ca release in excitation-contractio
  n 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

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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 gt 3/5
• For hypotonia
  Strengthening ( weak ms) Balance
  
• For athetosis
  Training to control simple joint motion

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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 )

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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 gt nerve block
• Produces hyperaemia transiant burning

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TREATMENT OF SPASTICITY

• INTRATHECAL BACLOFEN PUMP
• Indications ambulatory or non ambulatory child gt
  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

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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.

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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 gt 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

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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 gt 45 vital
  capacity lt 35

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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

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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.

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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

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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

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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)

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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.

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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.

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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.

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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
• .

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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

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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