CEREBRAL PALSY
DEFINITION
Cerebral palsy is defined as a non-
progressive static disorder of the central
nervous system due to an injury to the
immature brain causing disorder of
movement and posture.

definition
• By definition, the impairment known as
cerebral palsy (CP) describes damage to
the immature brain resulting in problems
with balance, coordination, and movement

CHARACTERISTICS
• NONPROGRESSIVE---This implies that the
injury is sustained in the early development of
life and does not progress
• There is change in the tone and posture of the
muscle both at rest voluntary activity
• Disorders of cerebral palsy are most often
associated with disorders of speech ,sensory
perception

Other names
• Birth asphyxia
• Neonatal encephalopathy
• HIE
• Traumatic brain injury
• stroke

Causes
PRENATAL
NATAL |together are called perinatal
|ie 1 month after the delivery
|
POSTNATAL|

PRENATAL
from the conception to the time of birth
-Maternal diseases like TORCHES----Toxoplasmosis,
rubella ,CMV Virus infection,Herpes simplex v irus
infections ,
Maternal diseases like diabetes , PET , jaundice ,
heart disease,
severe asthma anemia
--- poor prenatal care
- Rh incompatibility between the parent
- abdominal injuries smoking ,drinking during the
pregnanacy
-

Intranatal causes
----Birth asphyxia
----Drugs causing anoxia to the brain
----Injury to the head causing internal bleeding
----Uterine bleeding from the placenta or uterus
itself
---Forceps delivery
---Poor position of the infant after the breech
---Cord around the neck

---Abnormalities in the baby like microcephly
Macrocephali
---Head injury occuring after the birth
----Infections occuring o the nervous system like
meningitis,encephalitis.TB,etc
----Hydrocephalus
Poisoning, murder attempts, vascular anomalies of the brain

CLASSIFICATION
• Cerebral palsy is classified according to the
site of involvement as
• QUADRIPLEGIA
• DIPLEGIA
• TRIPLEGIA
• HEMIPLEGIA
• MONOPLEGIA

According to the type of CP
• Spasic
• Ataxic
• Athetiod
• Hypotonic
• mixed

Commonest type is spastic cerebral
palsy
• Spastic
• Spastic cerebral palsy is by far the most
common type of overall cerebral palsy,
occurring in 70% to 80% of all cases.
Moreover, spastic CP accompanies any of the
other types of CP in 30% of all cases.
• People with this type of CP are hypertonic

TYPES OF CEREBRAL PALSY
• Spastic hemiplegia is one side being affected.
• Generally, injury to muscle-nerves controlled
by the brain's left side will cause a right body
deficit, and vice versa

• . Typically, people that have spastic
hemiplegia are the most ambulatory of all the
forms, although they generally have dynamic
equinus on the affected side and are primarily
prescribed ankle-foot orthoses to prevent said
equinus.

types
• Spastic diplegia is the lower extremities
affected, with little to no upper-body
spasticity. The most common form of the
spastic forms, most people with spastic
diplegia are fully ambulatory, but are "tight"
and have a scissors gait.

• The intelligence of a person with spastic
diplegia is unaffected by the condition. Over
time, the effects of the spasticity sometimes
produce hip problems and dislocations . In
three-quarters of spastic diplegics,strabismus
(crossed eyes) can be present as well.

• Flexed knees and hips to varying degrees, and
moderate to severe adduction (stemming
from tight adductor muscles and
comparatively weak abductor muscles), are
present.

• Gait analysis is often done in early life on a
semi-regular basis, and assistive devices are
often provided like walkers, crutches or canes;
any ankle-foot orthotics provided usually go
on both legs rather than just one. In addition,
these individuals are often nearsighted.short
sight

CLINICAL FEATURES
• DELAYED MILESTONES OF DEVELOPMENT
• HYPER TONICITY
• INCREASED TENDON REFLEXES
• ABNORMAL POSTURES
• SPASTICITY
• SLOW IN MOTOR DEVELOPMENT
• ABNORMAL PRIMITIVE REFLEXES
• ABNORMAL MOVEMENTS AS IN ATHETOID
CEREBRAL PALSY

ASSOCIATED ABNORMALITIES
There may be multiple problems
Visual impairment
Speech impairment
Hearing affection
Epilepsy
Abnormality in balance and posture
Lack of sensation in one half of the body
Spinal deformities
Contractures in the joints of the upper and lower limbs
MENTAL RETARDATION is most often associated with
cerebral plasy

AIMS OF REHABILITATION
• To make the child independent in all activities
of daily living ADL
To develop independent locomotion and
independent mobility with the help of wheel
chairs ,orthoses
To prevent contractures by giving exercises
In the event of contractures plan various
surgeries to correct them and then fit with the
caliper

Normal developemental milestones
Social smile-----45 days
Head steadiness----3 months
Head righting---3months
Turning over ---5months
Sitting with support-----6 months
Sitting without support-----8-9 months
Standing with support---10 months
Standing without support---11 months
Walking with support---12 months
Walking without support---1yr and 2 months

Common deformities in CP
• Scissoring—due to adductor muscle spasm
• Hip flexion adduction and internal rotation
• Knee flexion or hyper extention
• Ankle and foot--plantar flexion or equinus
• Invertion ,forefoot addction.valgus and collapsed
arches
• Shoulder flexion adduction and internal rotation
• Elbow –flexion and pronation
• Wrist and fingers flexed

Orthosis
• Commonest ----diplegia
• Depending on the level of involvement we can
give hip kneeankle foot orthosis,KAFO,AFO,OR
EVEN ANKLE BOOTS IF ONLY THE FOOT
DEFORMITY IS THERE

OCCUPATIONAL THERAPY AND
PHYSIOTHERAPY
• Various therapeutic approaches are there to
treat this conditions
• Neurodevelopemental patterning
• Proprioceptive neuromuscular facilitation
• Progressive movement pattern
• Reflex inhibition techniques of Berta Bobath
• Margaret roods technique of sensory stimulation

Treatment Strategy
Medication
Botulinum toxin A (Botox) injections into muscles that are either
spastic or have contractures, the aim being to relieve the disability
and pain produced by the inappropriately contracting muscle.

Surgery usually involves one or a
combination of:
Surgery and orthoses
Loosening tight muscles and releasing
fixed joints, most often performed on the
hips, knees, hamstrings, and ankles.
 In rare cases, this surgery may be used
for people with stiffness of their elbows,
wrists, hands, and fingers.

 The insertion of a baclofen pump usually during
the stages while a patient is a young adult. This is
usually placed in the left abdomen.
 It is a pump that is connected to the spinal cord,
whereby it sends bits of Baclofen alleviating the
continuous muscle flexion.
 Baclofen is a muscle relaxant and is often given
PO "per os" (Latin for "by mouth") to patients to
help counter the effects of spasticity.

. Typically, people that have spastic hemiplegia
are the most ambulatory of all the forms,
although they generally have dynamic equinus
on the affected side and are primarily
prescribed ankle-foot orthoses to prevent said
equinus.

 Straightening abnormal twists of the leg bones,
i.e. femur (termed femoral anteversion or
antetorsion) and tibia (tibial torsion).
 This is a secondary complication caused by the
spastic muscles generating abnormal forces on
the bones, and often results in intoeing (pigeon-
toed gait).
 The surgery is called derotation osteotomy, in
which the bone is broken (cut) and then set in the
correct alignment

Treatment Strategy
Cutting nerves on the limbs most affected by
movements and spasms.
This procedure, called a rhizotomy, "rhizo" meaning root and "tomy"
meaning "a cutting of" from the Greek suffix 'tomia' reduces spasms and
allows more flexibility and control of the affected limbs and joint

 Early nutritional support: In one cohort study of 490
premature infants discharged from the NICU, the rate
of growth during hospital stay was related to
neurological function at 18 and 22 months of age.
 The study found a significant decrease in the incidence
of cerebral palsy in the group of premature infants with
the highest growth velocity. This study suggests that
adequate nutrition and growth play a protective role in
the development of cerebral palsy
 Hyperbaric oxygen therapy (HBOT), in which
pressurized oxygen is inhaled

 Orthotic devices such as ankle-foot orthoses
(AFOs) are often prescribed to minimise gait
irregularities.
 AFOs have been found to improve several
measures of ambulation, including reducing
energy expenditure and increasing speed and
stride length.
 Cooling high-risk full-term babies shortly after
birth may significantly reduce disability or death

Orthotic Management of Children with Cerebral Palsy
Christopher Morris, MSc, SR Orth
In conjunction with other medical, surgical, and therapeutic interventions, orthoses continue to play an important role in the physical management o
•To correct and/or prevent deformity
•To provide a base of support
•To facilitate training in skills
•To improve the efficiency of gait
2002_04_
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The impact of skeletal growth during childhood can compound the primary
problem if muscles fail to lengthen in proportion to their adjacent long bones.
Therefore, although CP is by definition a static neurological lesion, the phenotype
has also been labeled with the secondary impairment of a 'progressive
neuromuscular deformity.
Children with CP are often limited in their activities because of primary and
secondary impairments. A valid and reliable means of measuring functional
limitations in children with CP is now possible using the Gross Motor Function
Classification System (GMFCS) for children up to 12 years old.
The GMFCS enables clinicians to describe the severity of a child's functional
limitations in one of five levels.
Children in Level I are only mildly affected and can achieve most the activities of
their age-matched healthy counterparts, with only modest qualitative differences .
Children in Level V are the most limited in their activities and have little ability to
control their head and trunk posture to counter the effects of the motor impairment
and gravity .

To Correct and/or Prevent Deformity
Mobile joint deformities caused by gravity or unbalanced muscle forces can be
corrected passively and the position maintained using orthoses.
Fixed deformities caused by relative shortening of muscles and soft tissues and
structural deformities of abnormal bone shape cannot be passively corrected and
must be accommodated in orthoses.
Ensuring that muscles spend more than 6 hours during each 24-hour period in an
elongated position may help to prevent or reduce the rate of progressive
contractures.
However, stretching muscles using active forces for shorter periods may perhaps be
more effective than maintaining a static position to increase muscle length and hence
the available range of motion at joints.
Treatment goals

To Provide a Base of Support
Stability in any position of lying, sitting, or standing requires consideration of both
intrinsic and extrinsic factors.
Intrinsic stability involves controlling the position of the center of mass within the body.
Extrinsic stability involves maintaining the center of mass within the supporting area.
Hip abduction orthoses may improve stability and sitting balance by increasing the size
of the support area, either in combination with a spinal orthosis or by encouraging
independent control for the position of the center of mass of the trunk.
Similarly, standing frames use hip-knee-ankle-foot-orthoses to control body position and
wide bases of support to provide upright postural stability.

Normal functional development can be impeded by impairments of coordination and
movement.
Orthoses can maintain optimum biomechanical alignment of body segments encased
within the orthosis.
• These effects may enable children to overcome activity limitations by focusing training on
unrestricted parts of their bodies over which they have better control.
• Common training targets include encouraging head control by providing trunk stability
• using wrist orthoses to facilitate manual dexterity when grasping objects.
•For lower limb orthoses, the effects also include influencing external movements acting
around proximal joints by altering the line of action of the ground reaction force during
standing and walking.
• There may be some motor learning effect when children repeat movements through the
altered sensations provided by the orthosis.

TO IMPROVE THE EFFICIENCY OF GAIT
Children who are able to achieve upright locomotion must be encouraged to optimize
their ability to achieve an efficient gait.
Gage has described the prerequisites of normal gait:
1. Stability of the supporting leg during stance phase:
-Requiring an appropriate foot-floor contact area,
-Minimizing the external moments acting on the knee,
-Creating adequate hip abduction power to prevent the pelvis dropping on the
unsupported side.
2 Clearance of the foot from the ground during swing phase:
- requiring adequate hip and knee flexion and
-ankle dorsiflexion of the swinging limb.
-Appropriate prepositioning of the limb at the end of swing phase
- created by knee extension and ankle dorsiflexion.

Achieving an adequate step length: by hip
extension of the stance limb and unrestricted
advancement of the swinging limb.
Conservation of energy expenditure through
reduced excursion of the center of mass of the
body.
Lower limb orthoses may improve gait
efficiency by restoring these prerequisites
through the manipulation of forces acting on
the body. Orthoses may reduce energy
expenditure further by decreasing the need for
compensatory gait deviations to achieve
locomotion.