cerebal palsy 1 9/10/2012 - faculty.psau.edu.sa joint) and shows limited asymmetric pelvic tilt or...

9/10/2012Cerebal Palsy 1

Definition

Is an umbrella term covering a group of

nonprogressive but often changing motor impairment

syndromes that may or may not involve sensory

deficits, that are caused by a nonprogressive deficits,

lesion, or anomaly of the developing the brain, and

that can be in part a developmental diagnosis.


Definition 2

Is a neurodevelopmental impairment caused by a non-

progressive lesion in single or multiple locations in the

immature brain. This lesion leads to a persistent

disorder of movements and posture appearing early in

infant’s life.


Etiology

There is no one specific cause.

List of congenital problems can result in the infant and child with CP;

Schizencephaly “segmental deficit that cause a cleft in the brain”.

Lissencephaly “decrease cerebral gyri”.

Cortical dysgenesis “disorder of brain cortex formation”


Etiology

Half of the created neurons die off (apoptosis), in particular during midgestation.

Axons and synapses are also eliminated during normal development for the first decade or more.

This shaping of NS is guided by neurochemichalprocesses and neural activity.

When there are changes in the formation of the developing nervous system, the result can be an infant with CP.


Etiology

Immature brain has much more plasticity, the

response to injury is much different and makes

diagnosis and prognosis difficult.

Prenatal events are responsible for about 75%

of all CP. Prenatal asphyxia is cause 6% to 8%

of CP. 10% to 18% of CP is caused postnatally.


Etiology

The potential cause of cerebral palsy are known to be

occur in the;

Antenatal or prenatal stage.

Perinatal or neonatal stage.

Postnatal or postneonatal stage.


Antenatal causes of CP

Vascular event such as a middle cerebral artery infarct.

Maternal infarctions during the first and second

trimesters such as rubella, cytomegalovirus, and

toxoplasmosis.

Less common: metabolic disorders, maternal ingestion

of toxins, and rare genetic syndromes.


Perinatal causes of CP

Obstructed labor.

Cord prolapse.

Antepartum hemorrhage.

Hypoxic-ischemic encephalopathy.

Neonatal stroke, usually MCA.

Severe hypoglycemia

Untreated jaundice and severe neonatal infection.


Postneonatal causes of CP

Metabolic encephalopathy;

Storage disorder.

Intermedullary metabolism disorder.

Metabolic metabolism.

Miscellaneous disorder.

Toxicity such as alcohol.

Infections;

Meningitis, septicemia, and malaria.


Postneonatal causes of CP

Injuries;

Cerebrovascular accident.

Following surgery for congenital malformations.

Near-drowing.

Trauma.

Motor vehicle accident.

Child abuse such as shaken baby syndrome.


Classification

They classify it according to;1. Topography.

2. Types (the best for PT).

3. Severity.

4. Pathology.

5. Cerebral imaging techniques.

Types of CP;1. Spastic (70%).

2. Dyskinetic and movement disorders (Athetosis) (20%).

3. Ataxic (10%).

4. Hypotonic.


a) Spastic CP

Spasticity is a disorder of tone characterized by initial increased resistance to stretch.

Within this types there are;

Diaplegic CP: both legs are affected and more affected than arms.

Hemiplegic CP: one side of the body is more affected than the other.

Quadreplegic CP “tetraplegic”: all four limbs are affected.


b) Dyskinesia and movement

disorders

It’s a group of disorders where the movement is generally uncontrolled and involuntary and includes;

Athetosis.

Regidity.

Tremor.

Dystonia.

Ballismus.

Choreoathetosia.


Term Definition

Athetosis is involuntary movement, slow and writhing. Abnormal in

timing, direction and spatial characteristics. Usually are

large motion of the more proximal joints.

Rigidity less common, felt as resistance to both active and passive

movement, is not velocity dependent

Tremor rhythmic movement of small magnitude, usually in

smaller joints.

Dystonia is involuntary movement, slow and writhing. Abnormal in

timing, direction and spatial characteristics. Usually are

large motion of the more proximal joints.

Rigidity less common, felt as resistance to both active and passive

movement, is not velocity dependent.

Tremor rhythmic movement of small magnitude, usually in

smaller joints.


c) Ataxic CP

Is primarily a disorder of balance and control in

the timing of coordinated movements along with

weakness, coordination, a wide-based gate, and a noted

tremor.

This type results from a deficits in cerebellum.

Often occur in combination with spasticity and

athetosis.


d) Hypotonic CP

Not correlated with a particular neural lesion.

Can be permanent but is more often transient in the

evolution of athetosis or spasticity and may not

represent a specific type of CP.


The gross motor function

classification system (GMFCS)

Standardized system to measure the “severity of movement disability” in CP children.

There are five levels;

Level 1, Walks without Limitations.

Level 2, Walks with Limitations.

Level 3, Walks Using a Hand-Held Mobility Device.

Level 4, Self-Mobility with Limitations; May Use Powered Mobility.

Level 5, Transported in a Manual Wheelchair.


Assessment and Evaluation

Purpose of assessment is to;

Discover the functional abilities and strength of the

child.

Determine the primary and secondary

impairments.

Discover the desired functional and participation

outcomes of the child and/or family.


1. Assessment of movement

Observation. Held by the arms of mother or caregiver.

Come into the clinic with wheelchair.

Enter the clinic ambulatory.

Examine individual aspect of motor function. Functional antigravity control;

Supine, prone, side-lying, sitting, quadruped, kneeling, half kneeling, standing and walking.


Continue

If the child processes higher level skill;

Climbing stairs, navigating ramps or curbs, unilateral

stance, running, jumping, hopping, galloping and

skipping.

Child who functions from a wheelchair;

Alignment and mobility of body, shifting of weight,

propulsion of wheelchair, management of wheelchair and

its parts and transfer to and from wheelchair.


2. Assessment of postural

control

Find answers to the following questions;

1. Dose the child have a variety of ways to transition

between postures or only stereotypic choices?

2. Dose the child actively push into the supporting

surface with the pelvis and extremities?

3. Is the child able to repeat movements or tasks and

make small changes in his or her motor

performance?


3. Assessment of postural

tone

Tone; is how the muscle and group of muscle feels under the clinicians

hands when the joints of a body part are moved through a particular

range.

Tone; describe the impairments of spasticity and abnormal extensibility.

Stiffness; describe the resistance to movement felt when a limb or the

trunk is moved in space.

“feel” the child transition between postures and move the limb through

the space.

The most effective and efficient means of treatment is to gain postural

stability and the need for compensatory stiffness is eliminated.


Stiffness signs

Increased stiffness;

Distal fixing (toe curling and fisting).

Difficulty moving a body segments through a range.

Asymmetric posture.

Retracted lips and tongue.

Decreased stiffness;

Excessive collapse of body segments.

Loss of postural alignment.

Inability to sustain a posture against gravity.

Fluctuating stiffness level;

sign of booth increased and decreased stiffness, mainly seen in athetosis and ataxia CP.


4. Musculoskeletal

assessment Due to spasticity, increased or decreased stiffness, weakness, or

static positioning the child may exhibit a muscle shortening and/or soft tissue contracture, and over time bony deformities.

There are a lot of points we should take care of;1. Goniometric measurements.

2. Evaluation of the spine.

3. Thoracic movement.

4. Evaluation of the shoulder girdle and upper extremities.

5. Examination of the hip and pelvis.

6. Femoral anteversion.

7. Examination of the knee.

8. Tibial torsion.

9. Examination of the foot.

10. Discrepancy in leg length.


5. Evaluation of gait The child ambulate by acquiring antigravity movement

components of the neck, trunk, and extremities while in prone, supine, and side-lying positions.

Stability is increased as the strength is gained.

Immature gait pattern is characterized by; Uneven step length.

Excessive flexion of hip and knee during swing phase.

Immobility of pelvis without pelvis tilting or rotation.

Abduction and external rotation through swing phase.

Wide base of support.

Pronation of the foot.

Contact with the floor with foot flat.

Hyperextension of the knee throughout stance phase.


Mature component of gait

Its providing a useful framework for evaluating the gait in CP children;

Pelvic tilt.

Pelvic rotation.

Knee flexion at midstance.

Heel strike.

Mature mechanism of the foot and knee.

Mature base of support.

Synchronous movement of the upper extremities.


Gait in cerebral palsy

In spastic diplegia;

have limited mobility in (lumber spine, pelvis and hip joint) and shows limited asymmetric pelvic tilt or pelvic rotation during gait.

In order to compensate the lack of mobility, these children tend to shift their weight and maintain balance by using excessive mobility through the head, neck, upper trunk and upper extremities.



Hips; Flexed during stance.

Full extension of hip is never achieved.

Excessive adduction and internal rotation, in severe cases the medial aspect of the knees may approximate.

Knees; Either flexed or hyperextend during stance depending on the

function of pelvic, lumbar, and ankle musculature.

Feet; Valgus outside the lateral dimension of the trunk.

Or, close together in narrow base of support in planter flexion with heels off the floor.



In hemiplegia;

Asymmetry.

Shifting weight to the involved side is brief and incomplete.

Limbs on the involved side is retracted and rotated

posteriorly.

Arm swing occurs on the uninvolved side.

Shoulder hyperextension and elbow flexion on the involved

side.

Lower extremities, stiffness in extension and greater

mobility in flexion.

Ambulate without assistive devices.



In athetosis;

Low postural tone fluctuate to higher level of stiffness.

Lower extremities usually lifted high into flexion and

placed down in stance into extension with adduction,

internal rotation, and planter flexion.

Hip slightly flexed.

Lumber spine hyperextended.

Thoracic spine rounded with capital hyperextension.


Therapeutic intervention

“Tx”

Must be guided by functional outcome and/or the participation outcomes.

The interventions are;

Therapeutic exercise.

Neurodevelopmental treatment (Bobath).

Sensory integration (SI).

Electrical stimulation (ES).

Conductive education.

Alternative interventions.

Neuromedical and neurosurgical interventions.

Orthopedic surgical interventions.

Orthotics (Bracing).


1. Therapeutic exercise

Therapeutic exercise should be developed in relation;

Assessment of the child.

Identified long-term and short-term functional outcomes.

The functional abilities.

The impairment goals of the child.

“Strength training” improve identified parameters of gait and improve muscle performance.



Four point must do to have an effective strength training program;

1. Understand the process.

2. Child put maximal or near-maximal effort.

3. Be motivated and be able to accomplish the task.

4. Family support the child and the program.

Start the program according to the situation of the child, wither against gravity or with gravity eliminated.



External support

The therapist hands or a piece of equipment used to provide initial support to;

Maintain alignment.

Reduce the stiffness.

Initiate weight shift.

Support movement.

The support point start from proximal to distal; trunk, shoulder, or pelvis points provide greater amount of support and stability.


2. Neurodevelopmental treatment

(Bobath)

Clinical application of NDT is used for neurological impaired children CP and hemiplegia in adult.

Bobath’s found that the general characteristics found on CP patients are; Retardation of normal motor development with persistence of

primitive total pattern of earliest childhood.

Release of tonic reflexes.

Poor head control and Lack of trunk rotation.

Normal active movement delay.

Absence of balance and other adaptive reactions.


2. Neurodevelopmental treatment

(Bobath)

The aim of treatment;

1. Inhibit abnormal reflex activity and facilitate normal postural reaction, which are:

Righting.

Equilibrium.

Protective reaction.

2. Guide the child through the normal sequence of motor development;

Rolling over, sitting, quadruped, crawling, standing, and walking.


2. Neurodevelopmental

treatment (Bobath)

3. Normal integration of both sides of the body is

sought while associated reactions are avoided.

4. Normal responses once elicited, are always

repeated. Opportunity is given to practice the new

ability in functionally meaningful ways.

5. Voluntary control of normal responses is

encouraged.


3. Sensory integration (SI)

Sensory integration is done very carefully and stopped

if the response becomes abnormal or hyperactive.

The kinds of sensory integration includes;

1. Weight bearing with pressure and resistance.

2. Placing and holding.

3. Tapping e.g. joint compression.


4. Electrical stimulation

It has been conducted toward the patients who are unable to follow a muscle training program or who are too weak to do strengthening in isolation.

The two methods that have been used;

1. Neuromuscular electrical stimulation (NMES).

It could be functional electrical stimulation (FES).

2. Threshold electrical stimulation (TES).


4. Electrical stimulation

Studies found that NMES was effective in

strengthening the quadriceps of 13-year-old with

spastic diplegic cerebral palsy for the development of

new skills like stair climbing.

TES is a low-level , subcontractionelectrical

stimulation applied during sleep. To increase the blood

flow to result of muscle bulk enlargement.


5. Conductive education

Address all aspect of development;

Motor, cognitive, communication, psychological and

activity of daily living.

In order to improve the child’s “orthofunction” which

is; the capacity of individual to respond to

biologic and social demands made upon them.

Aimed toward the independence of the child.


5. Conductive education

The ideal program meets; 5 days/week, 6 hours/day,

with the length varying between 5 weeks to 1 year.

Common features across programs include;

Group work using a highly structures framework.

The use of task series.

The use of rhythmic intention.

The use of specific equipment.


6. Alternative interventions

Its to improve the functional level and to break the routine

of child’s tired of going to therapy sessions.

1. Therapeutic aquatics “hydro”.

2. Hippotherapy “horse approach”.

3. Yoga.

4. Karate.

5. Dance classes.

6. Tumbling “sliding”.

To build on the child’s strength toward functional skills.

Its more “fun” and not therapy in the mind of child.


7. Neuromedical and

neurosurgical interventions1. Muscle relaxants.

2. Neuromuscular blocks.

3. Selective dorsal rhizotomy.

4. Intrathecalbaclofen pump.


8. Orthopedic surgical

intervention

1. The spine.

2. The hip;

Subluxation/dislocation.

Adduction tightness.

Flexion tightness.

Internal rotation deformity.

3. The knee; knee flexion deformity.

4. The ankle and foot;

Equinus deformity.

Pesvalgus.

Varus deformity.


9. Orthotics “Bracing”

Physical therapy contribution must include assessment of;

Available range of motion “passive and active”.

Foot alignment and flexibility both in weight bearing and non-weight bearing.

Voluntary control of movement in the leg, ankle, and foot.

Current functional abilities.

Desired functional and participatory outcomes of the child and family.


9. Orthotics “Bracing”

Types;

1. Inhibitive casts.

2. Dynamic ankle-foot orthosis.

3. Articulating ankle-foot orthosis.

4. Floor reaction orthosis.

5. Supramalleolar orthosis.

6. Shoe insert.


Additional points

Home management.

CP in schools.

Its multidisciplinary approach;

General pediatrician, neurologist, orthopedic surgeon,

podiatrist, ophthalmologist, physiatrist, and the medical

complications indicate such as; gastroenterologist, ear-

nose-throat specialists, nutritionists, and psychiatrists.


Case study


Thank you


Reference,

Pediatric physical therapy, JAN S. TECKLIN, fourth

edition. Chapter 5, page (179 to 230)


cerebal palsy 1 9/10/2012 - faculty.psau.edu.sa joint) and shows limited asymmetric pelvic tilt or...

Documents