Cerebral Palsy Third Yr

8/6/2019 Cerebral Palsy Third Yr

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CEREBRAL PALSY

By

Khushbooo Dureja

Lecturer, Dept. Of Physiotherapy

MSRMTH



DEFINITION � Disorder of Posture and Movement that occurs

during infancy or early childhood.

� Caused by non progressive damage to the brain

before, during or shortly after birth.

� Also called as static encephalopathy of brain but

the manifestations change as the child grows.



� Incidence: 1-2.5 cases per 1000 live births.

� Early damage to the brain causes disruption involuntary movements.

� Also known as Littles Disease.



ETIOLOGY



CLASSIFICATION OF CP A) According to the type of abnormal tone

B) Anatomical classification









Mechanism Of Movement Problems� Abnormal muscle tone, disturbance of balance

mechanisms, muscle weakness and loss of

selective motor control lead to an inability tostretch muscles.

� Muscle weakness, spasticity,and contractures

also result in abnormal skeletal forces.

� The distal biarticular muscles are more affected

because selective motor control is worse distally.





PROBLEMS IN HYPOTONIC CP



Features in Hypotonic CP Hypermobility at joints and ligament laxity

Prone for hip and shoulder dislocation or

subluxation

Tightness of postural muscles like Lattisimus,

pectorals, upper cervical muscles.

Reduced strength and force production in

muscles

Wide movement transitions



PROBLEMS IN SPASTIC CP



Features in Spastic Diplegia Abnormal sitting/ standing postures

� W- sitting

� Crouch knee standing

Tightness/ contractures/ Deformities-Hip/ Knee/ Ankle

Inability to walk without support,

Scissoring, crouch knee gait

Some difficulty in hand function Visual problems



Muscle shortening

Joint contractures

Restricted movement activities

Altered and restarted bone growth

Scoliosis

Reduced strength

Altered muscle development





Problems of athetoid children� Sudden tonal variations

� Involuntary movements

� Poor postural control

� Poor coordination

� Tactile hypersensitivity � Auditory deficits



ASSESSMENT IN CP � History taking:

Prenatal History

Perinatal History

Postnatal History

Medical ± Surgical

History Immunization History

Developmental History

Family History

Socio-Economic History



Observation

� General appearance and activity level

� Signs of distress

� Posture of neck and extremities� Obvious deformities

� Gait evaluation



Palpation� Neck : for sternocledomastoid, trapezius

� Extremities for bone continuity, pain and end feel



Examination� ROM: Active and Passive

� MMT: Group and Individual

� Tightness: Special tests

� Limb length



Evaluation Of Hip� Ortolani¶s Test(reduction test)

± With the baby relaxed in the supine position,

the hips and knees are flexed to 90*, theexaminer grasp the baby¶s thigh with middle

finger over the greater trochanter and lifts the

thigh an simultaneously gently abducting thethigh, thus reducing the dislocation and a

³clunk´ will be observed



� Barlow¶s Test - provocative test (dislocation) also

called Reverse Ortolani¶s test.

� The baby¶s thigh is grasped with the middle

finger along the baby¶s thigh adducted and with

a gentle downward pressure.� Dislocation is palpable as the femoral head slips

out of the acetabulum.



� Thomas Test:Flexion of the opposite Lower

extremity and check for

lumbar lordosis.

Raising of affected extremity into flexion confirms

tightness of hip flexors.



� Duncan Elys Test for Rectus femoris tightness

� Tredlenbergs Sign for hip abductors

� Femoral anteversion and retroversion: ROM of

hip internal and external rotation in prone.

� Femoral anteversion ranges from 30-40 degrees

at birth and decreases progressively to about 10-15 degrees at skeletal maturity



Foot Progression AngleObserve child walking

and running.

Estimate the foot progression angle (FPA):

angular difference

between the axis of the

foot and the line of progression



Thigh Foot Axis ( Tibial Torsion)- Assess angle between

femur axis and foot axis

� Femur axis: Line along

length of femur

� Foot axis: Line from heel

through third web space



Lower Extremity Rotational Profile at Various

Ages� Normal alignment progresses from 10-15 degrees of varus at

birth to maximum valgus angulation of 10-15 degrees at 3-4

years of age



Evaluation of AnkleMetatarsus Adductus Calcaneal Valgus



Grading Severity of Forefoot Adductus

� Project a line that bisects the heel. Normally it falls on the 2nd toe� Mild: falls through the 3rd toe

� Moderate: falls between toes 3-4

� Severe: falls between toes 4-5



� Rearfoot Evaluation:

Talar head palpation

Curves below lateral and medial malleolus

Calcaneal eversion or

inversion

� Forefoot Evaluation:

Prominence of TNJ

Congruence of medial arch

Forefoot abduction or

adduction



Evaluation Of Tone� Modified Ashworth Score

� Modified Tardieus Score

� Ameil Tisson evaluation of passive tone



Gait Analysis� Observational gait analysis

� Foot print gait analysis

� Instrumented gait analysis



ORTHOPEDIC PROCEDURES IN

CEREBRAL PALSY



AIMS FOR SURGERY � Maintain ROM

� Restore Muscle balance

� Improve angular and rotational deformities

� Decrease energy expenditure

� Improve function and cosmetics



Classification systems for functioning in CP :

Level GMFCS ( Mobility)

MACS ( Handling objects)

I Walks without limitations Handles objects easily &

successfully

II Walks with limitations Handles most objects but with

somewhat reduced quality and/or spread of achievement

III Walks using a hand held mobility

devices

Handles objects with difficulty;

needs help to prepare &/or

modify activities

IV Self mobility with limitations; may use powered mobility

Handles a limited selection of easily managed objects in

adapted situations

V Transported in a manual

wheelchair

Does not handle objects & has

severely limited ability to

perform even simple actions.



Upper Extremity ProceduresGOALS

1. Improve function of helping hand that act as

stabilizer for manipulation of objects by normal

hand.

2. Improve gross function

3. Improve appearance.



� Goldner ( 1976) classified paralytic deformities:

a) Minimal involvement: pinch, grasp, release

present, lack dexterity & speed : No surgery

b) Thumb in Palm, wrist moderately flexed: patternof tenodesis, Surgery indicated

c) Thumb in palm, wrist and finger flexed

completely: Surgery for hygiene and appearance.





� For Thumb in Palm:

� Adductor policis spasticity: Tenotomy through

web space incision + release of origin of I dorsal

interosseus m/s.� For severe cases:

� Matev procedure: palmar incision used and strip

origin of Ad Policis & detach origin of FPB &distal 2/3 of APB.

� Z plasty in cases of contracture of thumb.



� Weakness of thumb extensors and abductors:

- Rerouting of EPL through

- Brachioradialis

- FCR

- FDS

� Wrist flexion deformity:

- Lengthening of FCR

- FCU transfer



Lower Extremity Procedures� For the Hip:

Common Problems:

1) Adduction Deformity

2) Flexion Deformity

3) Internal Rotation Deformity

4) Hip Subluxation



Operative Options for Adduction

Deformity Adductor longus myotomy & Anterior

branch obturator neurectomy

Adv:

a) Easier and shorter operationb) Short Immobilization period

c) Quicker recovery

d) Can perform other procedures at the

same time

Dis Adv:a) Weakens Adduction: If Add Brevis and

magnus preserved this is not

significant

Adductor origin transfer to Ischium

Adv:

a) Preserves Add strength for pelvic stability during stance

b) May correct IR deformity

Dis Adv:a) Longer operation

b) Require longer Immobilization



Operative Options for Hip Flexion

Deformity 1) Ober Yount Fasciotomy of IT Band and fascia

of hip

2) Soutter or Campbell muscle slide

operation:origin of Sartorius, RF and TFL

detached

3) Rectus Femoris Tenotomy

4) Myotomy of Ant fibers of gluteus medius

5) Iliopsoas tenotomy,lengthening or recession



Operative Options for Hip IR

deformity 1) Posterior transposition of origin of TFL

2) Adductor Myotomy

3) Gluteus medius and minimus transfer to origin

of vastus intermedius

4) Neurectomy of superior gluteal Nerve

5) Semitendinosus transfer to antero lat femur

6) Iliopsoas recession

7) Derotation subtrochateric osteotomy



Operative options for Hip

Dislocation� Salter Osteotomy: best done before 10-11 yrs of

age.

� Comprises of

a) Adductor Myotomy

b) Varus derotation subtrochanteric Osteotomy

c) Iliac Osteotomy



Operative options for Knee Flexion

Deformity � Proximal release of Hams origin by Sharard and

Drumond et al

� Posterior Capsulotomy of knee Jt: In c/o

contracture

� Hams Lengthening



Operative Procedures Ard Ankle





THANK YOU

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Cerebral Palsy Third Yr