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
