RECUPERARE IN

PARALIZIA CEREBRALA
LA COPIL (I.M.C.)
Curs anul III DSDU
Dr. Florin Filip
An universitar 2018/ 2019
 Definitie (1)

- Deficit neurologic definit prin:

- Caracter persistent si constant (neevolutiv)
- Afectare multipla (miscari, postura si tonus muscular)
- Leziune care afecteaza SNC imatur (intrauterin, nou- nascut sau sugar)

- Se exclud leziunile progresive si cele traumatice ale MS

- Se includ afectiuni non- progresive congenitale sau genetice

 Definitie (2)

- La IMC se pot asocia o serie de anomalii de dezvoltare:

- Retard mental (60%)
- Epilepsie (33%)
- Defecte vizuale, auditive (surditate- 10% din pacienti) si de
vorbire
- Strabism (50%)
- Disfunctii cognitive
- Probleme senzitivo- senzoriale
- Probleme emotionale si de comportament
 Etiopatogenie

- Legat de existenta unui travaliu complicat si de lunga durata

- Sunt implicate procese vasculare si tisulare care genereaza leziuni
neuronale:
- Hipoxie = scaderea aportului de O2 la tesuturi
- Ischemie = scaderea fluxului sanguin la un tesut/ organ
- Asfixia = tulburarea schimbului de gaze sanguine fat - mama
- Fiziopatologia leziunii neuronale:
- Leziune ischemica focala/ multifocala
- Leukomalacie periventriculara
- Necroza neuronala selectiva
 Clasificarea IMC

TOPOGRAFIC FIZIOPATOLOGIC

• MONOPLEGIE • SPASTICA
• HEMIPLEGIE • EXTRAPIRAMIDALA
• DIPLEGIE • ATAXICA
• QUADRIPLEGIE • COMBINATA
• HEMIPLEGIE DUBLA • ATONICA
• TRIPLEGIE
 Clasificarea IMC

Site of brain injury Pathological

• Cortical • Periventricular leucomalacia

• Sub – cortical –spastic diplegia
• Periventricular • Stroke in utero - hemiplegia
• Basal ganglia • Multifocal encephalomalacia
• Cerebellum -quadriplegia
• Brain stem • Cerebellar - ataxic
• Basal ganglia, thalmus,
putamen - dyskinetic
 Etiological
Prenatal Perinatal Postnatal
• I, iron def.,poor –nut. • Birth asphyxia •CNS infections
• Inf, UTI, high fever • Premature / LBW •Head injuries
• Chorioamniotis • IUGR •Seizures
•Hypoxic
• HTN, DM • Hyperbilirubenemia damage
• Teratogens • IVH •Hyperpyrexia
• Poor ANC • Sepsis, pneumonia, damage
• LOW SES meningitis
• Twins • Develop.
• Fetal vasculopathy malformation
 Severitatea IMC

• Motor development quotient :

• = motor age / chronological age × 100
 > 70 : disfunctie minima, fara defect semnificativ
 50-70 : defect neurologic/ motor mediu
 < 50 : defect sever (IMC tipica)
 Diagnostic precoce al IMC
• Crestere lenta a craniului
• Control deficitar al capului
• Ocular- control deficitar, lipsa
fixarii mainilor
• Audiologic- lipsa raspunului
la stimulare
• Iritabilitate, convulsii, calitate
redusa a somnului sau
suptului
• Iritabilitate/ sensibilitate la
lumina
• Cortical thumb beyond 8
weeks
• Handedness before 2 yrs
• Paucity of limb movements
• Scissoring of lower limbs
• Toe walking
• Abnormal tone
• Persistence of primitive
reflexes or failure to
acquire postural reflexes
• Stereotypic abnormal
movements
• Lack of alertness
 Differential diagnosis
• In the early infancy when the child is in
hypotonic phase, neuromuscular conditions like
myopathies may cause diagnostic confusion.

• Children with mental retardation may have

hypotonia but do not have abnormal motor
patterns or postures
 Orthopedic Problems
• Hip subluxation, scoliosis, equinus deformity, and
contractures of hamstring muscles and tendoachilles.

• Reduced bone density and propensity to fractures with

trivial trauma is common

• Equinus deformity is the most common

musculoskeletal abnormality in patients with CP.

• It is due to fixed or spastic contracture of

gastrocnemius and causes the typical tip toe or toe
heel gait in children with CP.
• The hemiplegic type of CP has the best prognosis for
walking with 95% walking by 3 years compared to
40% of other groups.

• Age of sitting is a good guide to prognosticate about

walking. A child who is able to sit unsupported at 2
years will eventually be able to walk.

• On the contrary, a child whose sitting is delayed

beyond 3 years has remote prospects for functional
outdoor walking
• Management - The pediatrician's initial
role consists of making a correct
diagnosis,determining the etiology, and
identification of the type, extent and
severity of the neuromotor deficit as well
as of associated problems
 ii) Comprehensive assessment
a multidisciplinary team comprising of a neuro-developmental
pediatrician as the team-leader,
• physiotherapist,
• occupational therapist,
• clinical psychologist,
• speech pathologist,
• orthopedic surgeon,
• otorhinolaryngologist,
• ophthalmologist,
• teacher,
• play therapist and
• social worker is required,
preferably under one roof.
 Physiotherapy (P.T.) -
• P.T. especially when started early in life, is
helpful in promoting normal motor development,
and preventing deformity and contractures.
• In the young child it aims at reducing abnormal
patterns of movement and posture and
promoting the normal ones so as to enable the
child to gain maximal functional independence.
• A number of techniques have been used for this
purpose. The neurodevelopmental Bobath
technique is commonly used.
• It consists of guiding the child through
normal sequences of motor development,
• inhibition of primitive and abnormal
reflexes,
• re-inforcement of normal postural reflexes
and
• facilitation of normal movements.
 Occupational Therapy
• The role of P.T. and O.T. are so closely linked that
they could infact be considered together.
• The occupational therapist is usually better trained
to advise on activites of daily living like feeding,
bathing, dressing, toilet training etc, and the
equipment needed to facilitate these.
• Co-ordination and sensory-perceptual integration
can be taught and multisensorial stimulation
provided through peg board, blocks and other toys
of different colours, textures, sizes and shapes, and
producing different sounds
Play Therapy: It is the use of a natural activity
with a young child, to help him consolidate the
levels of development that he has reached and
encourage him to move on, to the next level.

• Parents are taught to break down each activity

into its simplest components and make the child
practice it in a real life situation. It then is not
considered as an 'exercise' but becomes a way
of life.
Assistive and adaptive devices :
• Various simple modifications like angled
spoons, two handled cups etc can be
made to help the child.
• Old stools and boxes can be adapted to
provide support during sitting
• Parallel bars can be constructed with logs
of wood to help gait training.
• Standing frames and prone boards are a
useful intermediate stage in mobilization.
• A number of high technology devices like
programmed wheel chairs, electronic
feeding devices, various access systems,
computerized speech systems and
cochlear implants are available
• Splints, Casts and Calipers: Specially
designed shoes, ankle-foot orthoses
(AFO) and calipers
• AFOs, are particularly useful in children
with spastic diplegia who have dynamic
spasticity with tendo- achilles (TA)
tightening.
 Management of Spasticity:
• Proper P.T. given regularly considerably
reduces spasticity and improves function.
• (i) Drugs:
• Baclofen - acts at the level of spinal cord
neurons and enhances GABA activity.
• It is commonly used in a starting dose of 1.25 -
2.5 mg BD orally and increased gradually upto a
maximum of 30 mgm/day, monitored by a
clinical response.
• It is not recommended in children with seizures
as it may provoke them. (
• ii) Diazepam- a small dose given half an hour
before PT is effective in some cases especially
where anxiety increases spasticity. Its
disadvantage is that it may cause unacceptable
drowsiness.
• (iii) Tizanidine an alpha 2 adrenergic agent and
• (iv) Dantrolene sodium which acts on calcium
channels have also been used, but experience
with them is limited.
• Baclofen has also been used intrathecally
using implantable infusion pumps.
• It may be helpful in cases of severe
spasticity or disabling total body dystonia
• Botulinum Toxin: (BTA): is derived from
Claustridium botulinum.

• It causes muscle relaxation by blocking the release of

acetylcholinesterase, with loss of motor end plates.
• As affected nerve roots sprout to form new junctions,
the relaxing effect reverses over 3-6 months.
• It is more often used in children with spastic diplegia.
• Surgery: Surgery is useful in some children with
spasticity, especially where mainly the lower limbs
are involved.

• Tendon lengthening and transfer and arthrodesis are

some of the procedures commonly performed.
• Generally multilevel surgery is required and is done
after 8 years of age.
• Simultaneous availability of intensive physiotherapy
is essential.
• Dorsal rhizotomy which involves selective
resection of posterior nerve roots from L 2_ to S 2

• It may be helpful in children with severe lower limb

spasticity, with sufficient trunk control and some
form of forward locomotion.

• Its advantage must be weighed carefully against

the sensory losses that may occur after the
procedure.
• Relief of athetosis and dystonia - is difficult
occasionally levo-dopa for severe
athetosis and carbamezepine for dystonia
may be helpful.

• Thalamotomy for athetoid CP, stereotactic

dentatomy and chronic cerebellar
stimulation via implanted electrode .
• Parent Counselling : This is one of the
most important aspects because parents
are pivotal in the management of their
child.
• It is an ongoing process, as the parents
need to be counseled periodically at
various stages of their child's
development.
 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

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 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

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AlWasl Hospital - Rehabilitation Section
 Intervention Philosophies &
strategies

Sensory Integration Therapy

Principle: a neurobiological process organizes sensation from
one’s 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
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 SI Therapy

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 Intervention Philosophies &
strategies
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.
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 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).
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 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
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injection) more expensive procedures may
 Intervention Philosophies &
strategies

Body Weight Supported Treadmill Training

Uses theories of motor learning &

importance of early task –specific
training

Theory : activate spinal & supraspinal

pattern generators for gait

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 Intervention Philosophies &
strategies

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

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 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.

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 Intervention Philosophies &
strategies

Orthotic devices , splints , cast

Goals :
• Maintenance or increase ROM
• Protection or stabilization of a joint
• Promotion of joint alignment
• Promotion of function

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AlWasl Hospital - Rehabilitation Section
 Ankle Foot Orthosis

• Compared with barefoot gait, AFO’s

enhanced gait function in diplegic subjects.
Benefits resulted from elimination of
premature PF and improved progression of
foot contact during stance.

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 Principii/ strategii de tratament
Tehnologie/ echipamente adaptative:
• Optimizeaza alinierea, echilibrul, postura si nivelul
functional
• Inhiba pattern- ul spastic
• Faciliteaza mobilitatea normala
 Adjunct therapies
• Hippotherapy.

• Aquathearpy.

• suits.

• Theratogs.

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 Intervention Philosophies &
strategies
Speech & Language Therapy
Oralmotor function using strengthening /
Intraoral stimulation
 verbal ( PROMPT) & non-verbal
communication skills ( AAC & PECS , macatone)
auditory training for HI
audiometry screening
 swallowing function
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 Intervention Philosophies &
strategies

Psychological Assessment & Management

Social support

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Section
 % of patients who did not attend PT Mx

31%
Attended PT
m anagem ent
69% Not attended PT
m anagem ent

Out of 32 patients received botox 69% attended PT &

31% did not attend

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 % of patients included in PT Mx

9%

Attended PT Mx
Dropped out

91%

Out of 22 patients, 91% fully attended PT Mx .

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 % of patients who improved in ROM post botox
3-6 weeks & 3-6 months.

80%

70%

60%

50%
post 3-6 weeks
%

40%

30%
post 3-6 months
20% 68% 56%
10 %

0%

post 3-6 w eeks post 3-6 months

post 3-6 weeks & months

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 Benefits of communication
• Case selection.

• Goal setting.

• Educating parents/caregiver in active participation

• Compliance

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