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  1. 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.
  2. definition • By definition, the impairment known as cerebral palsy (CP) describes damage to the immature brain resulting in problems with balance, coordination, and movement
  3. 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
  4. Other names • Birth asphyxia • Neonatal encephalopathy • HIE • Traumatic brain injury • stroke
  5. Causes PRENATAL NATAL |together are called perinatal |ie 1 month after the delivery | POSTNATAL|
  6. 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 -
  7. 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
  8. ---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
  9. CLASSIFICATION • Cerebral palsy is classified according to the site of involvement as • QUADRIPLEGIA • DIPLEGIA • TRIPLEGIA • HEMIPLEGIA • MONOPLEGIA
  10. According to the type of CP • Spasic • Ataxic • Athetiod • Hypotonic • mixed
  11. 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
  12. 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
  13. • . 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.
  14. 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.
  15. • 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.
  16. • Flexed knees and hips to varying degrees, and moderate to severe adduction (stemming from tight adductor muscles and comparatively weak abductor muscles), are present.
  17. • 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. 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.
  26. 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.
  27.  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.
  28. . 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.
  29.  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
  30. 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
  31.  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
  32.  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
  33. 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_ Save
  34. 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 .
  35. 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
  36. 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.
  37. 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.
  38. 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.
  39. 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.