BASIC TERMS Cell: cell is structural and functional of body
Cell tissues organ system Neuron=nerve=brain=nervous system Neuron:
structural and functional unit of nervous system Tone: ability to
muscle contract Spasticity: increased tone, tight muscle(one group)
Rigidity :both group Reflex: involuntary action, no conscious
control Posture: A position of the body or of body parts
NERVOUS SYSTEM
what is cerebral palsy? Cerebral palsy is defined as Disorder
of movement and posture Non progressive Lesion in immature
brain(fetal or infant brain) Features: 1.epilepsy. 2. involuntary
movement 3. abnormal sensation & cognition 4- abnormal vision ,
hearing & speech. 5- mental retardation. 6. abnormal movement /
behavior.
LITTLE'S DISEASE 150 years ago described by Dr. Little an
orthopedic surgeon known as Littles Disease Lesion results in
paralysis, weakness, incoordination or abnormal movement
Possible Indicators of Cerebral Palsy After two months: 1. poor
head control 2. stiffness in the legs that cross or scissors when
picked- up 3. pushing away, arching pack 4. failure to smile by 3
months After six months: 1. Continued difficulty controlling head
when picked up 2. Floppy or limp posture. 3. Feeding difficulties -
persistent gagging or choking
possible indicators of cerebral palsy After 10 months: 1. Crawl
by pushing off with one hand and leg while dragging opposite hand
and leg. 2. Inability to sit unsupported After 12 months: 1.
Inability to crawl. 2. Inability to stand without support. After 24
months: 1. Inability to walk. 2. Inability to push toys with
wheels.
CAUSES.CONT. Brain injury can occur in the following periods:
a. Prenatal b. Perinatal c. Postnatal PRENATAL PERIOD- where in
most causes of CP occur. Intrauterine stroke Genetic malformations
The most common currently understood causes are related to brain
injury occurring in children born prematurely.
ETIOLOGY: POSTNATAL CEREBRAL INJURY AND CP Major causes: CNS
infections Vascular causes Head injury Other Causes: Anoxia
Ischemia Inflammation
CP: Epidemiology One of the most common disabling conditions
affecting children. 1-2.3/1,000 live births Diagnosis is not made
at any specific age Can resolve in up to 50% of children diagnosed
prior to 2 years of age Or the brain insult might not occur until
later in childhood.
RISK FACTORS ASSOCIATED WITH CEREBRAL PALSY GENERAL Gestational
age < 32 weeks Birth weight 2/3 of patients with Quadriplegia
(undernourished) 27% of patients malnourished Treatment:
Gastrostomy Gastrojejunostomy tube
CHRONIC CONSTIPATION Neuromuscular control of the bowel
Exaggerated by immobility and abnormal diet and fluid intake
Treatment: Increase activity Increase fluid and fiber intake
medications
Other problem: Gastroesophageal reflux: Urinary Symptoms: 1/3
of patients frequency, incontinence or difficulty urinating.
Cognitive Impairments: 30% of patients- mental retardation Risk is
directly proportional to severity of motor disability. 20-30% -
have specific learning disabilities Seizure Disorders 1/3 of
children with CP Hemiplegic> Quadri > Diplegic Reflects a
greater extent of cortical brain injury Treatment: Antiseizure
techniques
Other problem(cont.) Osteoporosis Secondary to the following
factors: Feeding difficulties deficient Ca and Vit D Decreased
weight bearing/ Immobilization Muscle stresses Antiseizure meds
Weight percentile/ Low triceps skinfold Treatment: Ca and Vit D
supplementation Bisphosphonates (Pamindronate)
FUNCTIONAL PROGNOSIS
Functional Prognosis Children typically develop motor skills
craniocaudally. The age at which these skills are developed help to
predict the eventual outcome.
PROGNOSIS for AMBULATION Hemiplegics/ Ataxic pxs Achievement of
all motor skills by age of 8. Independent sitting before 2 years
Persistence of fewer than 3 of the primitive reflexes at age 18
months. Quadriplegics Did not attain independent sitting by age 4.
Persistence of primitive reflexes beyond 18 months GOOD Prognosis
POOR Prognosis
Interventions
Intervention Philosophies & strategies Neurodevelopmental
Therapy ( NDT) Moving through normal movement patterns to
experience normal movement Major components : reflex-inhibiting
posture, inhibition of abnormal reflexes, normalization of muscle
tone, and adherence to normal developmental sequence of motor
progression
NDT Inhibiting abnormal movement patterns. Facilitating normal
movement patterns. No strong evidence that supports the
effectiveness of NDT for children with CP with respect to
normalizing muscle tone , increasing rate of attaining motor
skills, and improving functional motor skills Butler C, Darrah J:
Effects of Neurodevelopmental treatment (NDT) for cerebral palsy:
An AACPDM evidence report. Dev Med Child Neurol 2001 ; 43: 778 -
790
AlWasl Hospital - Rehabilitation Section
Sensory Integration Therapy Principle: a neurobiological
process organizes sensation from ones own body and from environment
and makes it possible to use the body effectively within
environment Emphasis on importance of three body centered sensory
systems : tactile , proprioceptive & vestibular
SI Therapy
Constrained - Induced Movement Therapy Constraining
non-affected arm to encourage performance of therapeutic task with
the affected arm, which children normally tend to disregard.
Systematic review has found the effectiveness of CIMT for children
with hemiplegic CP.
Serial casting Serial casting may serve to reduce spasticity in
muscles by decreasing the strength of abnormally strong tonic foot
reflexes.(Bertoli 1996). Serial casting in the CP population has
been shown to improve ROM.( Brouwer 2000) Casting provides
stability and prolonged stretch of a muscle which is immobilized in
a lengthened position(Mosley 1997). At least 6 hrs of prolonged
stretch is needed for effectiveness(Tardieu 1987).
Botox + serial casting Botox reduces spasticity and improves
ambulatory status.(Flett 1999) When used in combination with serial
casting it has shown to help maintain and improve muscle length and
passive ROM.(Kay 2004) Without conservative interventions such as
serial casting, (with & without botox injection) more expensive
procedures may be necessary. (Flett 1999)
Body Weight Supported Treadmill Training Uses theories of motor
learning & importance of early task specific training Theory :
activate spinal & supraspinal pattern generators for gait
Strengthening Progressive resisted exercise improves muscle
performance & functional outcomes in CP children Research had
supported effectiveness on increasing force production in CP Dodd
et.al. systematic review of strengthening for individuals with
cerebral palsy . Arch Phys Med Reh,83:1157-1164, 2002
Intervention Philosophies & strategies NMES Multiple
studies have demonstrated the effectiveness of NMES, Reduce
spasticity. Increase ROM & strength. Increase force production.
Promote initial learning of selective motor control.
Orthotic devices , splints , cast Goals : Maintenance or
increase ROM Protection or stabilization of a joint Promotion of
joint alignment Promotion of function
Ankle Foot Orthosis Compared with barefoot gait, AFOs enhanced
gait function in diplegic subjects. Benefits resulted from
elimination of premature PF and improved progression of foot
contact during stance.
Assistive Technology & Adaptive Equipment Optimizes
alignment, posture & function. Inhibits spasticity patterns.
Facilitates more normal movement.
Speech & Language Therapy Oralmotor function using
strengthening / Intraoral stimulation verbal ( PROMPT) &
non-verbal communication skills ( PECS ) auditory training for HI
audiometry screening swallowing function
Intervention Philosophies & strategies Psychological
Assessment & Management Social support
Cerebral palsy and posture
Posture is the extent to which the body is maintained in
alignment with a variety of positions.
81 Feet flat on floor or footrest Knees at 90 o Head is upright
Ideal Posture Table at elbow height Pelvis in neutral 90 degree
RULE
Normal postural tone Normal patterns of movement Success in
normal patterns of movement repetitions Normal functional Skills
achievements
CP? Abnormal postural tone Abnormal patterns of movement
Success in abnormal patterns of movement/ stereotyped repetition
Deformity/ less functional skills acheivments
1. Head and neck 2. Shoulders and shoulder girdle 3. spine 4.
Hips and pelvis Key Points of Control
Sitting
Positioning is key for normalization of tone.
Use of Adaptive Equipment for Positioning
Is it a right posture of child?
So what is correct way?
How to sit in washroom?
Corrective sitting: erect head erect neck back supported and
erect foot suppotrted
Focus on backalways
Change positions frequently
How to grip a child?
standing
What to correct?
Child is shifting to side
Standing with head down and round back affecting the
spine.
Locked standing back locked hip locked knee locked ankle
locked
Identify what wrong here?
Reflexes and cerebral palsy
Reflex action:
Stimulus / Response S: Palm stimulated R: 4 fingers (not thumb)
close Duration 5 months gestation - 4 months postpartum Concerns No
palmer grasp may indicate neurological problems (spasticity) Other
One of the most noticeable reflexes May lead to voluntary reaching
/ grasping May predict handedness in adulthood Primitive Reflexes ~
Palmar Grasp
Stimulus / Response S: touch of lips R: sucking action Duration
In utero - 3 months postpartum Concerns No reflex problematic for
nutrition Other Often in conjunction with searching reflex
Primitive Reflexes ~ Sucking
Stimulus / Response S: Suddenly but gently lower babys head S:
Hit surface beside baby R: Arms and legs extend Duration Prenatal
4-6 months postpartum Concerns May signify CNS dysfunction if
lacking May signify sensory motor problem if persists May delay
sitting & head control if persists May indicate injury to one
side of brain if asymmetical Other Reaction time increases with age
Preceeds startle refle Primitive Reflexes ~ Moro
Positive supporting
Stimulus / Response S: Prone/supine position, turn head to one
side R: Limbs flex on one side, extend on other side Duration After
birth 3 months Concerns Facilitates bilateral body awareness
Facilitates hand-eye coordination Other Also called bow and arrow
or fencers position Primitive Reflexes ~ Asymmetric Tonic Neck
Stimulus / Response S: Baby sitting up and tip forward R: Neck
and arms flex, legs extend S: Baby sitting up and tip backward R:
Neck and arms extend, legs flex Duration After birth 3 months
Concerns Persistence may impede many motor skills and cause spinal
flexion deformities Primitive Reflexes ~ Symmetric Tonic Neck
Fine motor
Major normal milestones (average age) Gross Motor Fine motor
& vision Hearing & language Social 6 weeks Head level with
body in ventral suspension Fixes & follows Stills to sound
smiles 3 months Head at 90deg in ventral suspension Holds object
placed in hand Turns to sound at ear level Laughs & squeals
Hand regard 6months No head lag. Sits w support. Up on forearms
when prone Reach w palmar grasp. Transfers between hands Babbles
Works for toy May finger feed 9 months Crawls Sits steadily &
pivots Pincer grasp, index finger approach, bangs 2 cubes 2
syllable babble. Distraction hearing test possible Waves bye-bye
Pat-a-cake Indicates wants
Major normal milestones (2) Gross motor Fine motor & vision
Hearing & language Social 12 months Pull to stand, cruise,
stand alone. Walks alone (13m) Puts block in cup. Casting 1-2 words
Imitates activities, plays ball, object permanence 18 months Walks
well & runs Tower of 2-4 cubes. Scribbles 6-12 words Uses
spoon, helps in house, symbolic play 24 months Kicks ball. Climbs
stairs 2 ft /step Tower of 6-7 cubes. Circular scribble Joins 2-3
words 5-6 body parts Identifies 2 pictures Removes a garment 36
months Throws overarm, stairs 1 ft/step, stands briefly on 1 ft
Tower of 6 cubes, 3 brick bridge, copies circle, cuts w scissors
Sentences, names 4 pictures Eats w fork & spoon. Puts on
clothing. Names friend
Palmar grasp: A palmer grasp appears once the grasp reflex has
disappeared, at around 4 months. The whole fist is first used in
this grasp- the palm covers the object and the fingers then curl
around the object intentionally. The child is able to let go of the
object when they want to.
Drawing and Writing Palmar grasp (power grip) < 3 years of
age Fingers and thumb wrap object Movement guided by shoulder and
arm Figure
Pincer grasp: A pincer grasp occurs next as the fingers become
more controlled. The pincer grasp is useful for picking up small
objects and uses the index finger (the first finger) and the thumb
together in a pinching motion.
Tripod grasp: A tripod grasp follows where a thick crayon or
piece of food is held with the fingers in a tripod style with two
fingers and the thumb.
Pencil grasp: Finally, a pencil grasp develops. This enables
the child to have greater control over their drawing or writing
implement.
149 Development of Pencil/Crayon Grasp Least Mature Grasp Most
Mature Grasp
Hand Strength The following activities promote development of
strength in the small muscles of the hand and the muscles of the
forearm. Adequate hand strength is essential for maintaining grasp
(eg holding pencil and drawing/writing for long periods) and
manipulating objects with our fingers. Activity ideas: Scissor
activities Squeezing clothes pegs Painting with spray bottles
Squeezing tubes Hammering Using pop beads and other interlocking
toys kneading dough Using tweezers/tongs to pick up
objects/materials Play musical instruments Using stapler and hole
punch in craft activities Tearing and crumpling paper Squeezing
sponges Screw/unscrew jars
Using water pistol Using wind up toys Putting buttons into an
opening of tennis ball Playdough activities: Rotate a small ball of
plasticine with finger tips; roll plasticine into a sausage shape
using fingers, not palm; Hold up playdough sausage and pinch
between index finger and thumb without breaking sausage; Pinch
playdough into a peak using three fingers; Cutting playdough with
scissors; Interweave a large rubber band between fingers and
stretch fingers. Pick up beads between fingers and drop one by
one.
Finger isolation The term finger isolation refers to the
ability to use certain fingers in isolation from the rest of the
hand/fingers. It is an important skill for children to develop as
it increases and improves their ability to control their pencil
when writing and drawing. Activity ideas: Draw in wet sand with
finger (eg index finger) Finger painting Finger puppets Music
keyboard Push button activities Using eye-dropper for painting
Picking up coins & cards Sprinkling rice ,sand etc Card games
Spray bottles Intrinsic colouring-in Playdough activities Using
stickers as part of activity (peel off backing & place
down)
29/07/2014 153 Midline Crossing Midline - A line between the
eyes, separating the body into left and right sides. Midline
crossing the ability to use one side or part of the body (hand,
foot or eye) in the space of the other side or part. Problems with:
Using cutlery, scissors, reading, handwriting and copying from the
board.
29/07/2014 154 Bilateral Integration The ability to use both
sides of the body together in a smooth, simultaneous, and
coordinated manner. If a child has problems crossing the midline,
coordinating the two sides together will be problematic.
155 Seating Position
156 7 Steps to Fine Motor Success 1. Stability of trunk,
shoulder and elbow 2. Wrist extension 3. Grasp (pincer and tripod)
& release 4. Arches of the hand/separation of 2 sides of the
hand 5. Finger isolation 6. Thumb opposition and web space 7. In
hand manipulation Stability before mobility
157 Start with Position Check how child is positioning
him/herself for the activity. Do they have adequate support? When
postural control is affected, arm movement and fine motor control
are often impacted. May see: Rounded back, resting head on hand,
resting trunk forward on desk, constant repositioning, leaning on
walls, friends or teachers.
158 Positioning Strategies At the table: (sometimes easier said
than done!) Feet flat on the floor, hips/knees bent at 90 Table
height, about 2 inches above the level of the elbows Placing items
on a slanted surface or working in vertical may encourage more
upright posture.
159 Positioning Strategies On the floor: Cross legged sitting
more stable than long sitting or side sitting Back supported
against a wall may be best for some children Mats/carpet pieces to
provide some cueing as to boundaries
160 Fine Motor Pre-requisites Good general trunk tone and
strength for good position and alignment. Adequate shoulder, arm
and wrist strength in order to stabilize and use the fingers.
Bilateral coordination between the helping hand and the doing
hand.
POSTURE AND OUR BODY
Some exercises that keep your postural muscle tone up.