Cerebral Palsy Flashcards
Definition
Disorder of movement, non-progressive
• Brain damage in early life.
• Lead to paralysis, spasticity, abnormal control of movement
or posture
• The brain damage can occur while the mother is still
pregnant, during birth or just after childbirth, while the child
is still a baby.
• Once the brain is damaged, there is no medication to cure it.
Other disturbances
sensation, cognition, communication, perception and
seizures disorder.
• Severity may be from total dependency minimal dependency
• NB remember the brain damage is not progressive, although
the motor behaviour changes
Brain damage may occur:
Prenatal
• Perinatal or
• postnatal
Aetiology
Before birth/Prenatal
• Genetic disorder
• Maternal health factors
• Teratogenic agents- drugs, chemical exposure,radiation
• Placental disruption- asphyxia
• Lack of growth factors affecting fetal growth in uterohormones,insulin,proteins
• RH blood type incompatibility between mother and infant.
• Infections ( German measles)
• Attempted abortion
• Malnutrition in pregnant mothers
Aetiology cont.
During birth/perinatal
The infant may not receive enough oxygen during labour or
birth.
• Difficulties during labour
• Premature birth/ low birth weight
• Multiple births
Aetiology cont.
Neonatal and postnatal
Severe and untreated jaundice shortly after birth
• Infections- Meningitis
• Tumours
• Accidents/trauma
• Lack of oxygen (drowning)
• Epilepsy
Clinical signs
Exact manifestation of the lesion will depend on the following
factors:
Whether condition occurred before or after birth
Size of lesion
Type of lesion
Location of brain
Early signs
At birth the baby can be limp or floppy or very stiff
• Delayed development
• May not use hands, or use only one hand
• May have feeding difficulties
• Body may stiffen when carried, dressed, washed or during
play
• Irritable or very passive and quite
• Communication difficulties
Classification
Different types of CP:
CP is classified according to the following:
• Type of movement disorder
• Parts of the body affected
• Severity of the movement problems
Athetoid
The damage is usually on the basal ganglia
• There is uncontrolled movements that occur on it
• Voluntary movements is too fast, far and uncontrolled
• Constantly changing muscle tone, spastic pattern come and
go. Poor balance, falls easily
• Sitting and standing may be problematic
• It is mostly noticeable when the child starts to move.
Hypotonia
Decreased muscle tone coupled with resistance to passive
movement
• Deep tendon reflexes may be diminished or decreased
• Child takes up all available support
• Poor head and trunk control
• Child doesn’t move much
• Joints are hypermobile
• Child does not respond even to strong stimulation
• Associated problems such as poor vision, hearing, speech
• Less sensory input
Ataxic
No involuntary movements when sitting still, but clumsy,
awkward voluntary movements
• Poor balance and coordination, movements are unsteady and
shake
• Difficulty learning to sit and stand
• Very clumsy with hands, intention tremor may occur with
active movement
• Walk flexed forward with wide base and takes irregular steps,
uses arms for balance.
• Caused by damage to cerebellum
Poor grading of movement
• Inadequate balance reaction
• Intention tremor and jerky quality of movement
• Co-contraction is poor causing difficulty in holding steady
posture
• Postural tone is fairly low to normal
• Proximal fixation is not effective to for carrying out selective
movements
Assessment
• Clinical observation
Observe function and dysfunction
Observe quality of movement against the following:
Postural alignment and symmetry
Postural stability and mobility
Motor patterns
Grading of movement
Motor planning
Contractures and deformities
Sensory issues
Examples of primary problems
Abnormal muscle tone
• Involuntary movement
• Impaired sensation
• Sensory integration problems
• Possible seizures disorders
• Visual perception problems
Examples of secondary problems
Contractures
• Poor balance
• Poor mobility or gait
• Impairment of visual, processing, hearing , or speech
• Difficult with bladder and bowel control
• Intellectual disability, learning disability
• Breathing problems
• Skin integrity problem
• Difficult in feeding, eating and swallowing
Understanding movement and
development
In order to help a CP child in reaching the full potential in
functional activities
We can modify and modulate his responses by our handling
Understand the difficulties children with CP experience in
maintaining postural control against gravity in different
position
Postural tone
• Postural reaction: righting reaction , equilibrium reactions and
saving reaction
Sequences of movements
1. Sitting up from supine
The method is influenced by fitness and strength of abdominal
muscles. Lift and bend head forward, chin tucked in rounding
spine at the same time, bring shoulders and arms forward, hips
flexing. Legs will remain on supporting surface.
With weaker abs, legs would flex and straighten just before
sitting up.
SEVERE SPASTICITY MODERATE SPASTICITY
• Pathological reflex activity and abnormal
motor patterns are at their strongest in
supine.
• Child lacks anti gravity flexor tone and is
unable to make postural changes in
order to align body symmetrically.
• Child unable to flex neck, trunk and hips.
• Quality of performance varies and
depends on developmental level,
distribution of abnormal postural tone
and postural reaction present.
• Child with hemiplegia has an
assymetrical, unstable posture. in
supine, all the body weight will be on
the unaffected side.
• Child needs to push up with the
unaffected arm and the effort involved
in doing so, increases the tone in the
affected side.
- Getting into sitting from prone
Starting from symmetrical position, we extend our spine and
hips, while bringing our arms towards our body. We push on our
hands and roll our hips over to flex the legs into sitting.
SEVERE SPASTICITY MODERATE SPASTICITY
• Abdominal postural tone, asymmetrical
unstable posture and lack of anti gravity
extensor tone restrict movement in this
position.
• Attempts at extension, results in hip
flexion, shifting weight forward.
• Child with spastic diplegia may present
with asymmetry of flexion when lying in
prone, with one leg more flexed than
the other and hip raised on side of
flexed leg.
• Thus the child lacks stability, mobility
and his weight is shifted to one side.
• Any movement will be asymmetrical and
trunk rotation will be limited, forcing
him to push back on his knees.
• Child may end up in “W” sitting position
Rolling from supine to prone
Initiate movement by lifting head and shoulders off supporting
surface and then there are a variety of possibilities. Some lead
from head and shoulders, some from pelvis and legs, some bend
the top leg and flex the bottom leg, some keep both legs
straight. Arm position will also vary
Moderate spasticity Fluctuating tone and involuntary
movements
• Method of rolling is affected by severity
of abnormal postural tone, absence of
postural reactions, contractures and
deformities.
• Child will roll to preferred side and
rotation will be absent.
• Child with diplegia will usually initiate
rolling by using a pattern of total flexion
of his neck, upper trunk and arms which
will increase spasticity in lower limbs
• Initiate rolling from hips and legs, which
increases extension of head and trunk,
retraction of the shoulders and the
outward rotation of his arms.
Bridging and pushing backwards along the
floor
• Keeping your head on the support with the chin tucked in,
shifts the weight back onto shoulders. Bend the knees and by
pushing the feet against the floor lifts and hold the bottom
the air.
Severe spasticity Moderate spasticity
• Abnormally extended and adducted
legs, lack of pelvis stability and mobility,
inability to isolate movement at knees
and feet.
• Unable to bridge or pull self backward.
Will sometimes attempts by pushing
against a solid object
• Sufficient abdominal, trunk and pelvic
control to manage semi bridge.
Asymmetrical bridging should be
discouraged because it reinforces
asymmetrical weight bearing.
Fluctuating tone and involuntary
movements
• Supine with head extended, chin up and shoulders retracted.
Hips and legs flexed, abducted and outwardly rotated, which
makes it impossible to bridge and extend. Unable to take
weight on arms to creep, often chooses pushing backwards as
form of locomotion. This will reinforce extension in the neck,
trunk and arms.
- Creeping
• Once the baby has sufficient head control, trunk extension
and stability at his shoulder and pelvis girdle to shift from side
to side in prone position.
• Shifting his weight on to his chest (upper trunk) and forearms
as he reaches forward with the other hand to pull himself
forward. At the same time, he shift his weight in the lower
part
Moderate spasticity Fluctuating tone and involuntary
movements
• Child can lift head but maintains it in
hyperextension. His arms are close to his
sides with shoulders raised to stabilise
the head.
• Hips and back are excessively extended
and adducted, feet plantar flexed, pelvis
tilted posteriorly.
• He lacks mobility at the hips, trunk and
pelvis, which makes dissociated
movements of the hips impossible. He
moves forward by lifting and pulling
both arms towards himself, with legs
straight. The effort increases hip and leg
extension.
• Dislikes prone position because of poor
head control, trunk and pelvic instability.
They usually push themselves forward in
supine.
• Moving backward and forwards in a
sitting position when they have learned
to keep their legs flexed, back straight,
supporting themselves on their arms,
can be an effective way of locomotion.
Hemiplegics – will propel themselves in an
asymmetrical pattern as they are unable to
weight bear on their affected side
5.Bunny-hopping
Pushing backwards, weight taken on extended arms, pushing
with his bottom back and straightens his leg.
• Pushing forwards, weight taken on extended arms, moving his
trunk forwards, with bent legs pushing his bottom forward as
he straightens his legs.
Child with spasticity sits and moves with his bottom between
his legs, with legs flexed and internally rotated at the hips,
usually taking more weight on one leg than the other.
• This increases spasticity on hip and knee flexors and increases
possibility of developing deformities. It will also impede the
child’s development of balance reactions in sitting and will
make it harder for the child to move away from the sitting
position.
Basic principle of handling
• Aim :
is to stop any unwanted activity
Establish more normal postural tone
Facilitate more postural reaction
Guide voluntary movement
Leading activities participation by the child himself
Key point of control
Mainly proximal
• i.e the head, neck and spine
• Other parts, shoulder and the pelvis girdle
Importance of play
provides non-threatening environment
Acts as a motivator
Opportunity to practice skill
Therapeutic tool
Child feels relaxed and comfortable
Main functional activity
Assessment process
Appropriate context
Play will motivate the child:
To be more attentive
• To participate
• To move
Children learn through play…
To move
Perseverance
Visual attention/eye hand regards
How to cope with frustration
Social skills
Perceptual and cognitive skills
Communication and language skills
Gross and fine motor skills
To have FUN
Impairment restrict development of play
Movement
• Sensory processing
• Perceptual deficits
• Environmental interactions-access
• Cognition
• Motivation
Types of play
Sensorimotor/exploratory
• Social
• Gross motor play
• Relational/functional
• Constructive play
• Symbolic/pretend
• Rough and tumble
• Games with rules
Stages of play
Choice of play activity during therapy
Consider the child’s age
Consider the sensory stimuli
Level of excitement
Demand/difficulty
Type of toys
Physical support/cognitive support
Aspects to consider when selecting toys:
Choose toys that make use of children’s abilities and
capabilities
Locally available materials (imagination)
Find out what their interests are
Variety of textures
Modify toys
TREATMENT
General principles
Analyze the predominant pattern of spasticity
• Prepare child before main activity
• Apply inhibitory/ facilitatory techniques before main activity
• Avoid functional activities which increases flexion
Treatment
Focus on observable signs and symptoms in behaviour and
movement
• Early treatment using active facilitation and righting reactions
to influence the movement patterns
• Involve caregiver as much as possible
• Aim is to assist child and family to reach full potential.
• Advise the caregivers not to do everything for the child.
Goal setting
Organize your findings
Set your goals with the parents/caregivers
Short term and long term goals
Make sure you are taking environmental facilitators and barriers
in consideration as well
General principles
Let the child enjoy movement and activities
• Communicate with the child
• Use variety of toys and objects
• GO SLOWLY
• AVOID quick movements
• Create opportunities to explore environment
• Create opportunity to learn new skills
• Give enough positive feedback for attempts
Prevent deformities
Proper positioning
• Correct handling of the child
Moderate spasticity
Reduce tone
• Facilitate sequence of movement
• Facilitate wide range of movement in tone influencing
patterns
• NDT
Severe spasticity
Analyze the predominant pattern of spasticity
• Prepare child before main activity
• Apply inhibitory/fascilitatory techniques before main activity
• Avoid functional activities which increases flexion
Athetosis
Stabilising of posture through controlled stimulation and small
range of movement
• Weight bearing and compression to facilitate co-contraction
and reduce involuntary movements
• Work for symmetry and midline orientation
• Facilitation of head and trunk control
• Facilitation of arm reach and grasp
Treatment guidelines…
(functional)
• Athetoid
sitting; pelvic strap attached to chair at joint between seat
and seat-back, close to the pelvis. Provide good lateral
support. Use chest strap if necessary but avoid foot straps
except for short periods.
- Position in chair with feet clear off floor until can maintain
foot contact without triggering flexor withdrawal or extensor
thrust. Food in chair or other well supported position,
ensuring that the head retraction is controlled.
Treatment guidelines ataxia
• Control postural tone by weight-bearing and joint
compression
• Place and hold child in position to facilitate co-contraction
• Work for rotation around body axis
• Facilitate balance and protective reactions
• Use mobile weight-bearing and graded movements to change
from one position to the other
Treatment guidelines hypotonia
Flaccidity/ Hypotonia
• Work for sustained co-contraction
• Have the child work against gravity
• Use weight-bearing through all the limbs and in all positions
• Use sensory stimulation and joint compression
• Use vocalisation and laughter to build up tone
• Treat slowly – give time to respond
NB! Low tone in young children can change to abnormally high
tone or fluctuating tone
Treatment…
Spastic
- Inhibit flexor pattern at shoulder
- Stimulate shoulder girdle stability via weight bearing,
movement and or compression - May be necessary to w/b on extended arms initially, before
can manage the less global pattern of w/b on forearms. - May be necessary to w/b laterally before forward
- May be necessary to de-sensitise palms before can w/b on
open hands.
Treatment guidelines HEMIPLEGICS
Treat them assymetrical in order to develop symmetry
• All activities done should be structured on the hemi side.
• Play on puppy prone to be encouraged
• Children to be assisted to come to sitting over the hemi side
and to side sit on the hemi hip
• Weight bearing on the extended arm can be assisted via use
of gaiter splint, provided flexor spasticity in the elbow is not
too strong
Treatment guidelines Spastic quads and severe diplegics
Teach mother to position child in supine
• Prone over the wedge, make sure arm are forward
• Sitting: pelvic strap as for athetoids, lateral support and chest
strap if necessary, abduction block between the legs.
• Inhibit via rotation
Conditions associated with CP
Hearing problems
• Problems with vision
• Epilepsy
• Intellectual challenges
• Speech and language problems
• Perceptual difficulties
• Failure to thrive (undernutrition)
• Bowel and bladder
Obesity
• Constipation
• Gastro-oesophageal reflux
• Recurrent chest infection
• Chronic lung disease
• Dental health
• Osteoporosis
• Emotional problems
Approaches
Developmental Approach
• Sensory integration
• Motor Learning Approach
• NDT Approach
• Holistic approach
• Educative Approach
• Model of creative ability
• Humanistic approach
• Client-centred approach
• Behavioural modification approach
Treatment strategies
Habilitation
• Compensatory/ adaptation
• Remediation
Specific principles
Handling- physical and psychological
• Presentation
• Structural
• Grading –up-grading or down grading
• Nb: always include precaution
Challenges working with CP
Acceptance and hope
• Adequate resources
• Ongoing training programme
• Good management
• Trained professionals
