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Cerebral Palsy

Cerebral Palsy is an umbrella term that includes the disorders of motor function caused due to a non progressive
damage to the developing brain.
Etiologies
Prenatal:
1.Consanguinity
2.Trauma
3.Malnutrition
4.Infection
5.Stress- physical and mental
Antenatal
1.Placenta previa
2.Abruptio placentae
3.Breech presentation
4.Rh incompatibility
5.Prolonged second stage of labour
6.Birth asphyxia
Post natal:
1.Infection
2.Epilepsy
3.Jaundice (Kernicterus)
4.Trauma

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Typical Classification:
1.Spastic
2.Athetoid
3.Dystonic
4.Ataxic
5.Hypotonic

Topographical classification
1.Monoparesis/ plegia
2.Hemiparesis / plegia
3.Double hemiparesis / plegia
4.Diplegia
5.Triplegia
6.Quadriparesis / plegia

Features of Different types of Cerebral Palsy

Spastic Diplegia
At birth: Movements seen predominantly in Upper limbs
Stereotypical movements in lower limbs
Common attitude in supine: Anterior pelvic tilt, internal rotation at the hip, knee extension/ mid flexion, equinus
at ankles
Turning: Log rolling seen
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Gait:
1. Scissoring
2.Crouching
3. Equinus

Crouching gait : increase in energy expenditure

Possible reasons for crouching
Hamstring shortening
Imbalance between Quadriceps and hamstrings
To re-position the Center of Gravity
Lengthening at the proximal end of the hamstrings causing knee flexion ( coupled with anterior
pelvic tilt)

Equinus:
Equinus
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Pseudo-equinus
Equinus with Talo-navicular break

Absent heel strike

2nd rocker of foot compromised: no decelration control
Malrotated lever arm and flexible lever arm ( 2nd order lever absent) in push off
Decreased force production in push off

Secondary Complications: Inadequate bone modeling

Persisent Anteversion
Coxa-valga
Decreased acetabular depth
Tightness:
•Sarcomeres in series: speed of contraction
•Sarcomeres in parallel: cross sectional area: force of contraction
•Loss of sarcomeres in parallel in atropy, followed by loss of sarcomeres in series
•Replaced by Extracellular Matrix
•Tensile forces are not distributed evenly: leading to muscle injury and hyperreflexia

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HEMIPLEGIA
Assess the movements in Supine:
decreased on one side
Turning to one side preferred
Preferred use of one upper limb
Supine to sit transition from the unaffected side
Sitting posture :
1.Assymetrical weight bearing
2.Pelvis and scapular positions altered
3.Positioning of the affected upper limb– internal rotation, adduction, elbow flexion, pronation, ulanr deviation,
finger flexion
Standing:
1.Weight bearing- assymetrical
2.Pelvic retraction and hiking
3.Lower limb position: internal rotation, adduction, knee extension, plantar flexion, inversion
Gait:
1.Absent heel strike
2.Loading response – absent
3.Inverted pendular motion not seen in mid stance
4.Ground reaction force placed anteriorly pushes knee into hyperextension
5.Decreased weight shift to the affected side
6.Absent push off
Spastic Quadriparesis

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Constraints:
Muscle weakness
Spasticity
Altered alignment
Altered line of action of muscles
Altered sensitivities and arousal
Resulting in inappropriate interaction between different systems
Muscle weakness
Capital flexors
Serratus anterior
Core muscles
Hip extensors, abductors
Back extensors
Quadriceps
Dorsiflexors
Spasticity
Back and neck extensors
Biceps
Latissimus dorsi
Pectorals
Adductors of hips
Hamstrings/ Quadriceps/ both
Plantar flexors
…. Shortening may be seen in Hip flexors and Rectus abdominus
Altered line of action
• Rectus abdominus
• Diaphragm
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• Other muscles of lower extremities

Altered Alignment
Foreams
Hips… Bigelow’s ligament
Pelvis
Rib cage
Femur

Altered sensitivity
Tactile defensiveness
Proprioceptive seeking
Vestibular

Interaction between
Oromotor
Respiratory
Gross motor

Sensory integration
The ability to take in information through our senses and effectively utilize the information to respond to the
demands of our environment.
Sensory processing
Integrating the information from the various sensory modalities
Forming a concept based on the information
Ideation of the motor activity

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Planning the activity

Execution of the activity

Sensory processing involves

1. Modulation
2. Synthesis
Leading to behaviour indicating modulation and praxis

Theories of motor control related to sensory integration

Closed loop theory: associated with error correction and refining the movement based on the ongoing feedback
Feedback: Knowledge of performance
Knowledge of results
Open loop theory: Based on feedforward
Basic frame of reference---- projected movement----- efference copy sent to the perceptual cortex---- internal
feedback goes back to the supplementary motor area

Praxis disorders
General dyspraxia, which is characterized by dysfunction in discrimination of somatosensory and vestibular inputs
with performance problems in motor planning and sequencing.
Somatodyspraxia, which is characterized primarily by decreased tactile discrimination and motor planning
problems, is conceptualized as a specific problem in the motor planning component of praxis and is manifested in
difficulties performing actions such as imitating gestures as well as performing various motor tasks.
Bilateral integration and sequencing dysfunction, which is characterized by primary deficits in vestibular,
proprioceptive, and visual integration deficits.
Deficits in this area are reflected in problem with timing, motor coordination, execution, and completing projected
action sequences.

Sensory Modulation

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At a Physiological level means to regulate or adjust to a certain level in order to adapt to the circumstances
At a behavioral level it means to respond in a way to match the demands of the environment

Over-responsiveness
Low neurological thresholds
It takes very little to activate them
Strong negative response
Avoidance-withdrawal
Activation of sympathetic system
Habituate very slowly to stimuli

Under-responsive
High neurological thresholds
Require a lot of stimulation to get activated
Seek strong sensations
Prone to dangers
Stress and Modulation
Many theories exist
Anxiety resulting from stress can amplify tactile defensiveness
Stress relies on comparison with the past experience based on functions of hippocampus.
Relevance of the current sensory experience to the organism’s survival plays a role.

General adaptive response:

Alarm reaction: adrenaline- nor-adrenaline
Phase of resistance: ACTH- Cortisol
Phase of exhaustion
Because there are chronic stress conditions
Here the organism gets used to expecting noxious stimulus in every situation and there is an increased arousal tone

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Increased tone of defensiveness

Thus expecting pain actually decreases modulation of pain

Tactile defensiveness
2 main tactile systems
1.Anterolateral system
2.Dorsal column- medial longitudinal fasciculus

Defensiveness is an imbalance between discriminative interpretation and need for defense

Avoidance of certain textures
Avoid contact with others
Pull away from anticipated touch
Aversive response to non-noxious stimulation
May respond with aggression
Stress induced Analgesia may not work in these cases

Gravitational insecurity and Aversion to movement

Proprioception modulates the vestibular system
Within the vestibular system --- otolithic organs are known to modulate semicircular canals
Aversion could be related to:
1.Poor modulation by the otolithic system
2.Sensory conflict between visual and vestibular inputs
3.Overload of the vestibular system
4.Disruptive body schema

Over-responsive to movement

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Avoid moving out of certain positions

May be coupled with decreased proprioceptive feedback- sensory seeking behaviour may be seen.

Assessment of Children with Cerebral Palsy

• History:
-- Pre natal, Perinatal, post natal
-- Family history
-- Immunisation
-- Milestone
-- Investigations: MRI, EEG, BERA, VEP
-- Treatments previously taken
-- Any assessment done by related professionals ( psychologists, OTists)

• Higher functions: Arousal, Attention, Orientation, Memory

• Sensory functions: Reasons for the same
• Reflexes
• Tone: Ashworth scale, Tardieu’s scale.
•
Tardieu’s scale
• Angle of muscle reaction (y)
• Quality of muscle reaction (x)
•
Velocity of stretch:
• V1: As slow as possible (minimizing stretch reflex)
• V2: Speed of the limb segment falling under gravity
• V3: As fast as possible (faster than the rate of the natural drop of the limb segment under gravity)
The resulting joint angles are defined as:
• R1 (the angle of catch following a fast velocity stretch - during either V2 or V3); and

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• R2 (passive range of motion following a slow velocity stretch - V1) (Mackey, Watt, Lobb & Stott, 2004).
• As V1 is used to measure the passive range of motion (PROM), only V2 and V3 are used to rate spasticity.
• Quality of muscle reaction (X):
• Grade Description
• 0 No resistance throughout the course of the passive movement.
• 1 Slight resistance throughout the course of the passive
• 2 Clear catch at a precise angle, interrupting the passive movement, followed by a release.
• 3 Fatigable clonus (<10 seconds when maintaining pressure) occurring at a precise angle.
• 4 Infatigable clonus (>>10 seconds when maintaining pressure) occurring at a precise angle.
• 5 Joint is immoveable.
• Voluntary control: if possible
• Posture, attitude at rest
• Tightness
• Deformity: Equinus, supination, pronation of midfoot, Rotational hip deformity, Knee flexion, Kyphosis,
scoliosis,
• Range of motion
• Posture and Balance
• Functional mobility

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• Hand function
• Oromotor function
• Visual and Auditory functions
• Other relevant functions
• Timing sequencing of muscle activation
• Strategy level assessment:
Postural stability,
Equilibrium, protective reactions,
Reach, grasp,
Eye hand coordination,
In hand manipulations,
Visual regard,
Visual guidance,
Temporo spatial parameters of gait
Specific alterations in gait.
Gait Alterations
• Assess gait based on phases:
-- Stance: heel strike, foot flat, midstance, heel of, toe off
-- Acceleration, Mid Swing, Deceleration
Pay attention to all the body segments including UL, Ribcage, Pelvis and LL.
• Impairments that alter gait: weakness,
tightness,
spasticity,
altered pattern of activation,
Sensory modulation deficits
Tests and Scales for Cerebral Palsy
--Gross Motor Function Measures
--Pediatric Evaluation of disability index ( PEDI)
-- School Function assessment
handwriting related tests

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-- Evaluation of sensory processing ( Sensory Integration and Praxis test - SIPT)

-- Paediatric balance scale
-- QUEST
-- Jebsens Taylor hand function measure
-- Social maturity scale
-- FMS: Functional Mobility score: mobility at home (5m), school ( 50m), the community ( 500 m) …. Maximum score
of 6 based on whether the ambulation is independent, with an assistive device,or with wheelchair

Management of Cerebral Palsy

Older schools of Therapy

• Phelps: Passive movements followed by active assisted movements followed by active movements
• Temple Fay: Treatment along the phylogenetic process of evolution
• Erine collis: Move from one milestone to the other
 Brunnstorm: Building up synergies and then breaking them
 Roods: Sensory stimulus to bring about a motor response
 Proprioceptive Neuromuscular facilitation:
-- Muscles work in certain synergies to the best of their potentials.
-- One muscle can be used to activate another
-- Verbal commands, manual contact, resistance used to facilitate the movement

Recently used concepts

• NDT: derives from Bobath school of therapy
• Motor learning
• Sensory Integration
• Functional Rehabilitation

Neuro developmental Therapy

• Principles of Bobath

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-- Shunting
-- Key points
-- Reflex inhibitory patterns

Motor Learning
• Definitions : Learning
Motor Learning
Performance
Recovery of function
• Neuroplasticity involves:
1. Unmasking of silent synapses
2. Collateral synaptogenesis
3. Regenerative synaptogenesis

Forms of Learning
1. Non associative: Habituation
Sensitization

2. Associative: a) Classical Conditioning

Operant Conditioning

b) Procedural Learning
Declarative Learning

Physiological Basis
Habituation: Short term :- decreasing the EPSP
Long term :- Decreasing number of synapses, activity of existing synapses.

Sensitization : Short term :- Increasing EPSP

Long term :- Increasing number of synapses, activity of existing synapses.

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Classical conditioning:
conditioned stimulus should be before unconditioned stimulus.
eg: verbal command before weight shift
Operant conditioning :
Response generated in the environment reinforces or discourages behavior.
(reinforcers and punishers)

Declarative Learning: requires perceptual cortex ( primary and association), medial temporal lobe, hippocampus,
frontal cortex (cingulate gyrus)
Procedural Learning : Cerebellum, premotor cortex and motor cortex
• Closed loop theory and open loop
( schema theory)
Practical applications of Motor Learning
Feedback: intrinsic and extrinsic
Knowledge of result (KR)
Knowledge of
performance (KP)
Practice:
Constant v/s variable
Random v/s blocked
Whole v/s part
Transfer
Mental practice
Guidance v/s discovery learning
Sensory Integration
• Identification of abnormality
• Sensory Modulation/ praxis
• Create optimal sensory enviornment
• Subject the child to reasonable challenges
• Give feedback with caution

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• Use functional activities.

Salient aspects of a treatment session:
• Correct the alignment of the body parts through elongation
• Manage pain
• Activate and strengthen the weak muscles
• Normalize tone
• Create an optimal sensory environment
• Bring about activation with appropriate timing and sequencing.
• Individual muscle strengthening by way of:
Function electrical stimulation
Theraband exercises ( with attention to proximal stability)
• To activate the muscles of the affected extremity,
Constrained induced therapy may be used.
Alignment
• Should be actively achieved as far as possible
• Where ever not possible provide orthotic assistance.

Chair for CP and Standing Frame

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• In addition to various interventions as part of the rehabilitation program, and surgical interventions, Orthotic
management has a major role to play in Management of Cerebral Palsy.

• The dysfunction may be resulting from one/all of the following:

i. Abnormal tone
ii. Lack of power generation
iii. Compromised agonist-antagonist muscle balance
iv. Abnormal timing of muscle activation
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v. Abnormal biomechanical alignment.

vi. Altered soft tissue characteristics.

Phases of gait
• Stance phase: Initial contact
Loading Response
Mid stance
Terminal Stance
Pre Swing
• Swing Phase: Initial Swing
Mid swing
Terminal Swing
• Stance: Stability
Progression
• Swing: Foot clearance
Acceleration
Deceleration: Preparation for stance
Impairments in Cerebral Palsy Affecting Gait
• Weakness: Tibialis anterior
Plantar Flexors
Hip Flexors
Hip Extensors
Hip Abductors
• Spasticity : Plantar Flexors
Hip Adductors
Hamstrings
Quadriceps
Common Gait Alterations
 Diplegic Gait:
Scissoring Gait: Adductors pulling the pelvis down on opposite side

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Crouched Gait
Ankle Foot: Equinus
Medial Weight Bearing
 Hemiplegic Gait: weight bearing on unaffected side with Affected limb in Adduction, Internal rotation,
Knee extension, Plantar flexion.
Orthotic Management
• Considerations for Ankle and Foot Orthoses:
Rockers involved in stance phase normal gait: 1. First (heel) Rocker
2. Second ( Ankle) Rocker
3. Third (toe) Rocker.
Biomechanical Principles of AFO
Ankle joint: Lateral malleolus situated below and slightly posterior to medial malleolus,
Hence: Movements happen in more than one plane– Dorsiflexion associated with pronation, abduction and
hind foot valgus.
Plantar flexion with supination,Adduction and hind foot varus.
This is to be considered for Placing the mechanical axis of an AFO.
Types of ankle & Foot Orthoses
• Infra malleolar
• Supra malleolar & Dynamic AFO
• Static AFOs: Solid Ankle AFO
Anterior floor reaction AFO
Patellar tendon Bearing AFO
• Dynamic AFOs:
Posterior Leaf Spring AFO
Conventional dorsiflexion assist AFO
Articulating AFO
Infra malleolar :
• grabs the calcaneus, holds the midfoot for subtalar orientation
• used for dynamic control coronal plane movements of subtalar joints.

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• not effective for saggital plane problems.

Supramalleolar AFOs
• One variant: Inframalleolar exended mediolaterally: to improve proximal lever arm
• Dynamic AFO: with mechanical ankle joint
Attempts to control reflexes by supporting the triplanar motion, but this effect is not supported by
evidence.
Static AFOs
• Solid Ankle AFO: Provides maximum immobilisation at the ankle
Anterior border placed at midlines of the medial and lateral malleolus
Proximal border is 11/2 inches below the apex of the fibular head.
Foot plate is usually extends under the toes to avoid toe grasp.
Ankle is neutral at 90 degrees.
• Uses: Incorporates force systems for 4 movements.
1) prevents plantar flexion: allowing heel strike in initial contact, thus preventing knee
hyperextension.
2) Prevents valgus
3) Prevents Varus
4) In late stance: Prevents dorsiflexion, thus preventing knee flexion.
Limitations: Deleterious effects on all three rockers of stance.
Anterior Floor Reaction AFO
• Designed to harness the GRF as a source of sagital plane stabilty
• Anterior to the proximal leg: extention of the material present, through which the GRF pushes the knee in
extension.
• Ankle is placed in 5degrees plantar flexion
• When progress of leg over the foot is attemted the knee is pushed back.
• Used: when Quadriceps cannot control knee in extension.
• Inappropriate in cases of genu recurvatum.
Patellar Tendon Bearing AFO
• To avoid loading of Ankle Foot
• The weight in directed to patellar tendon

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• From the patellar tendon: 2 uprights present mediolaterally direct the weight to the ground.
• Prerequisites:
--- good sensory function
--- Knee anatomy should be normal.
Dynamic AFOs
• Posterior Leaf Spring AFO:Mediolateral trim lines placed posteriorly
• Flexible orthosis
• 1st rocker: Substitutes eccentric activity of dorsiflexors
• 2nd rocker: allows dorsiflexion for tibial advancement over the foot in midstance.
• Swing: supports the foot in swing.
• Cannot be used in cases of Moderate/severe spasticity.
Convention dorsiflexion assist AFO:
Spring present posterior channel
It supports the foot in swing, early stance.
With good plantar flexors, spring can be pressed in terminal stance
Recoils back into dorsiflexion in swing.
Cannot be used in cases of moderate/ severe spasticity.
Articulating AFO
• Mechanical axes present:
• Patient should have true dorsiflexion without a compromise of midfoot and forefoot.
• Patient should have active knee extension
• Uses: Supprts foot during swing and initial contact if Plantar flexion is locked.
Allows 2nd rocker dorsiflexion.
Posterior strap may be given to change the amount of dorsiflexion and plantar flexion made available
Knee Ankle Foot Orthosis
• To protect the joint ROM
• When antigravity knee extension is not available: for stance and gait ( Push knee).
• To prevent hyperextension: ( Anterior knee guard).
• Post operatively, Knee immobilisers can be used
Hip Knee Ankle Foot Orthosis

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• Generally used in non ambulatory children

• To protect and improve range of hip, to prevent subluxation
• To improve Sitting posture
Hip Abduction Brace
Used in cases of adductor spasticity.
This helps correct the alignment, improves weight bearing
Thus Orthotic management if selectively done is an ajunctant but important part of rehabilitaton program for
Cerebral Palsy.
Oro Motor Management
• Feeding
• Speech
History and assessment
• Type of feeds
• Duration of feeding
• Utensils used
• Signs of hypersensitivity
• Abnormal postures, patterns
• Regurgitation, digestion
• sequence of motor patterns
• History and assessment of speech
Oro motor management
• Posture while feeding
• Sensory modulation:
-- Tactile and proprioceptive desensitisation
-- Stimulation to increase awareness
• Increase flexibility
• Improve basic posture
• Breathing control and alignment
• Increase challenges and level of training by:
-- offering varied foodstuffs

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-- making the child control drooling in varied positions

-- make the child pronounce different vowels for different durations
-- make the child recite nursery rhymes etc in different postures and during weight shifts.
Equipments that can be used
• Vestibular ball
• Wedge
• Bolster
• Tilt board
• Swings
• Tunnels
• Pools with balls
Choice of equipments
• For alignment: wedge, bolsters
• To make the surface dynamic– to increase the challenge : vestibular ball
• To facilitate easy weight shifts
• To provide inclination – to decrease the challenge: wedge, vestibular ball
• To desensitize, soothe the child.
• Make the activities purposeful; especially for older children
• Involve them in play, writing, feeding etc
• Couple NDT, SI with functional rehabilitation
Play therapy
• Age appropriate play epochs:
---- Sensorimotor 0-2 years
---- Parallel play/ echo play, Simple constructional play, Associative play (2-4 years)
---- Co-operative play/ Realistic role play/ complex constructional play (4-7 years)
---- Imaginative role play/ rule based play .. Pre-game epoch (7-12 years)
---- Game epoch and application( post 12 years)
Coordinate with
• Speech therapist
• Occupational therapist

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• Special educator
• Orthotists
• Behavioral therapists, Psychologists
• Eventually after training for individual functions:
• It is essential to enable the child to deal with the physical and psycho-social stresses with maximal
independence.
• With the synergized efforts of a multidisciplinary team,
• child should be enrolled into a normal or special school depending on the ability to cope.
• --- Vocational Guidance and training
• --- Placements

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