Cerebral Palsy

definition
Persistent disorder of movement and posture appearing early in life that due to a
developmental, nonprogressive disorder of the brain.

Incidence
45000 → 46% white – 46% black → socioeconomic – low → met the criteria for
CP
- 12% → acquired.
-
Prevalence of cp
- 5.2 : 1000 → CP.
- 4.6 : 1000 → when acquired cases of CP are excluded.
- 2.6 : 1000 → excluding mildly affected children
-
aetiology
the series of disorders of the central nervous system known as cp may occus as a
developmental defect, or as result of an insult ,or trauma to the foetal or infants
brain the possible causative factors have grouped under three headings
prenatanl, perinatal and post natal

1-Prenatal (in utero):

there may be a failure in development or maldevelopment of the brain. It may be
due to the mother having viral infection as rubella, exposing to radiation or trauma
or drug use. Vascular insufficiency may occur during fetal life. Genetic
abnormalities leading to malformations of the brain during fetal life appear to
account for a smaller percentage.

2- Perinatal
: Injury during birth may cause damage to the brain particularly when there is a
breech or forceps delivery. Injury may result in asphyxia and consequent brain
damage (Preterm and low birth weight babies are especially at risk for injury at
birth because of immature development of some systems). More than one third of
CP children weighted less than 2500g at birth.

3- Post natal factors:

Generally the upper age limit for the use of term CP is approximately 3 years. The
causative factors are: infections as meningitis, encephalitis, measles, anoxia from
suffocation and post epilepsy, cerebrovascular accidents and malnutrition.
 classification
The most commonly accepted classification of cp that is based on clinical signs
1- spastic type includes hemiplegia, diaplegia and quadriplegia about 70 % of
the total.
2- Dyskinetic type form of cp includes athetosis ,dystonia .chorea about 10 – 20
%
3- More rarae types of cp include ataxia, rigidity and atonia (ataxia forms
about 5 – 10 %)
4- Mixed neurological signs involve spastic athetosis and spastic ataxia. It is
common, this refers to when aperson is diagnosed with more than one of the
types of cp described above

Topographical classification : describe what is seen clinically

according to the part of the body involved:
1- quadriplegia : involvement of four limbs
2- double hemiplegia : the upper limbs are more affected than the lower limbs
3- diaplegia : involvement of four limbs with the lower limbs more
affected than the upper limbs
4- paraplegia : involvement of both lower limbs, rare
5- triplegia : involvement of three limbs
6- hemiplegia : one side of the body is affected
7- monoplegia : one limb is affected

pathology
MOTOR DISORDERS IN CP
Primitive reflex
1- Serve as protective mechanisms and a means for the newborn to obtain
nourishment.
2- Become integrated into voluntary movements, usually around 6 to 8 months of
life.
3- Near the end of the first year of life, the gains seen in muscle strength,
control, and tone give the child postural control and body stability.

Postural reflexes or reactions

1- allow the infant to adjust the body's position, keep it aligned, maintain
balance, and prevent falling.
2- Postural reflexes fall into three main categories: Protecting, righting, and
equilibrium reactions
a- Protective reactions:- are movements of the limbs as
the head or trunk is lowered toward the floor As the child falls forward,
backward, or sideways while sitting , he will extend his arms to protect himself.

b- Righting reactions:- are responses of the head and

trunk to the loss of balance or postural shifts. The head can also be used to bring
the body back into alignment when moved or tilted forward, backward, or to the
side.
c- Equilibrium reactions:- *are responses of the total
body to shifts in body alignment or loss of balance.
* occur when the child is in any body position: sitting,
standing, or on hands and knees.

1. Disorders of postural fixation:

Defective postural fixation, as seen in inability to maintain the head or trunk
erect, is the most important and obvious defect in all cases of cerebral palsy
except the mildest cases of hemiplegia

2. Failure of suppression of primitive, and brain stem reflexes:

Brain stem reflexes act upon the distribution of postural tone. These reflexes are
the tonic labyrinthine reflex and the tonic neck reflexes, positive-supporting
reactions. Persistence of primitive reflexes are grasp and moro reflex.

3. Disorders of tone:
In the abnormal state, tone can be diminished (hypotonic) or increased
(hypertonic), or fluctuated.

4. Paralysis and disorders of the pattern of voluntary movements:

Weakness is common to all forms of cerebral palsy, even those characterized by
involuntary movements. The weakness of severe cerebral palsy is at first
generalized, involving the neck and the trunk as well as the limbs. The paresis
comprises a number of features. The initiation of a movement is slow. Discrete
movement is impossible e.g. extension of the wrist is associated with extension of
all fingers, while attempts at flexion result in flexion of all the segments of the
limb or involve both limbs simultaneously in a crude symmetrical movement; in
the lower limb, flexion at the hip can only occur with flexion at the knee. Even in
the mild cases 'mirror movements' are often seen in the unaffected hand when
an effort is made to use the affected one in a case of hemiplegia. Thus the
essential features of the paresis of cerebral palsy are slowness of initiation,
simultaneous contraction giving a crude and ineffective pattern and lack of
fractation of movements.

5. Involuntary movements:
Involuntary movements form the principal feature of athetosis with early
hypotonia and impairment of postural fixation of the trunk. They are also often
present in less marked form in other types of cerebral palsy because of the
diffuse nature of the lesion. Almost any kind of "unwanted" movement, form
tremor to rapid choreic or slow dystonic movements, can occur in cerebral palsy,
but the violent and irregular movements are confined to athetosis. The irregular
arrhythmic movements affect almost all muscles, including the respiratory, but
are most evident in face, tongue, neck and arms. In infancy they appear first in
 the fingers and toes. They are absent when attention is deeply held, diminished
by fatigue and fever. They are increased by emotion stress, insecurity, startle or
the desire to perform a voluntary act. Frequently, cases of athetosis show over-
activity of the tonic neck and labyrinthine reflexes. Athetosis is caused by
disorders of basal ganglia. The common cause of disorders of basal ganglia is
jaundice or anoxia.

6. Failure of development of cortical reactions (Postural

reactions):
Many of the phenomena of cerebral palsy are the result of disinhibition of
primitive reflexes or of failure of higher centers to gain control of, or assimilate
basic movement patterns. These are termed positive or release phenomena and
include hypertonic, involuntary movements and overactivity of primitive brain
stem reflexes. In contrast, in negative phenomena, e.g. paresis and inco-
ordination, there is absence of function due to disorder of the neural pathway
necessary for these functions and, in addition, failure to develop certain
reactions, which require cortical functions.

Clinical signs of cerebral palsy:

1. Feeding difficulties, inability to suck or swallow, lack of interest and very slow
feeding.
2. Abnormalities of gaze, failure to fix when feeding and delayed smiling.
3. Abnormalities of tone, reduced or increased.
4. Abnormalities of behavior-irritability, anxiety, lack of interest in sounds or
visual cues, and sleep disturbance.
5. Delayed postural development, lying ability (persistent asymmetry) head, and
trunk balance reactions.
6. Development of asymmetry of movement or tone.
7. Delayed motor development.

Physical problems of cerebral palsied children:

A) Physical problems of the child with spasticity:
1- Low tone in trunk musculature.
2-Spasticity in extremity musculature, the degree of it varies according to child’s
general condition, emotional state, temperature and health, it also depends on
correct positioning and the degree of support of the child.
3-Severe degree of co-contraction of the involved parts, especially around
proximal joints.
4- Maintains extremities in mid-range.
5- Stereotypical (patterned) movement.
6. Slow movement.
7. Associated reactions present.
8. Incomplete righting reflexes, equilibrium reactions and protective responses.
9. Some muscles appear weak due to reciprocal inhibition by their spastic
antagonists e.g. dorsiflexors of the ankle by spastic triceps surae.
10. True weakness may develop in some muscles from long standing disuse.
11- At risk for orthopedic deformities secondary to muscle and joint tightness.
e.g. flexion deformity at knee, equinus at ankle contractures and skeletal
deformity may develop due to an imbalance of muscle activity, lack of active
functional movement, prolonged positioning with muscles held at one length and
the effect of these on growth.
12- Fearful of movement.

B) Physical problems of the child with athetosis:

1- Involuntary movements.
2- Fluctuating level of muscle tone (hypotonia-hypertonia), started with early
hypotonia.
3- Muscle spasms.
4- Inability to hold segment at various points within the range of motion.
5- Impairment of postural fixation of the trunk.
6. Asymmetry in both posture and movement.
7. Head, trunk and upper extremities usually more involved than lower
extremities.
8. Movement of head affects trunk and limbs.
9. Over activity of tonic neck and labyrinthine reflexes.
10. Incomplete righting reflexes, equilibrium reactions and protective responses.

C) Problems of the child with ataxia:

1. Usually hypotonic, but some have increased tone.
2. Poor co-contraction and sustained holding of postures.
3. Incoordination.
4. Dysmetria.
5. Righting reflexes, equilibrium reactions and protective responses are present
but poorly coordinated.
6. Difficult balance and lurching staggering gait.

D) Problems of the child with hypotonia :-

1-Extensive hypotonia for all body, it may persist but it is often transient,
subsequently being reclassified as spasticity, athetosis or ataxia.
2-Loss of head, trunk control and kicking movements.
3-The child may have respiratory problems.
4-Dysphagia and drooling are common.
5-Developmental delay.

Associated neurological disorders in cp :

1- Vision problems:
Strabismus is present in 20% to 60% of children with CP. The highest incidence
is in the diplegic and quadriplegic children. Esotropia; deviation of eyes toward
the midline is more prevalent than extropia. Homonymous hemianopsia occurs
in 25% of children with hemiplegia. Nystagmus is most common in children with
ataxia.

2-Mental retardation:
It is more common in cerebral palsied children. About 40 to 60% of them have
some degree of retardation, with the highest proportion of severe deficits seen in
quadriplegic, rigid and atonic children.

3- Communication disorders:
Communication disorders may be present in children with CP. These disorders
may be secondary to poor oral motor control of speech, central language
dysfunction, hearing impairment or cognitive deficits.

4-Dysphagia:
The dysphagic problems in CP may lead to inadequate fluid and caloric intake,
which results in protein-calorie malnutrition and associated problems.
The development of eating and drinking behaviors may be impeded by
the presence of one or more of the following difficulties in cerebral
palsied children:
1. Poor trunk and head control.
2. Poor grasp.
3. Poor coordination.
4. Persistence of infantile reflexes as extensor thrust and asymmetrical tonic
neck reflex.
5. Altered reflexes involving oral musculature.
6. Hypersensitivity, with lack of awareness of the presence of food in the mouth.
7. Drooling.
8. Abnormal or limited movements of the tongue, jaw, lips and soft palate.
9. Respiration.

5- Drooling:
It is a problem for a large number of cerebral palsied children. It interferes with
eating, speech, self-image and social activities. It may also cause soreness of skin,
infections and aspiration.

6- Seizures or Epilepsy
Fifty percent of cerebral palsy children have seizures. During a seizure, the
normal, orderly pattern of electrical activity in the brain is disrupted by
uncontrolled bursts of electricity. In cerebral palsy children with epilepsy, this
disruption may be spread throughout the brain and cause varied symptoms all
over the body as in tonic- clonic seizures – or may be confined to just one part of
the brain and cause more specific symptoms as in partial seizures.
Tonic- clonic seizures generally cause patients to cry out and are followed by loss
of consciousness, twitching of legs and arms, convulsive body movements and
loss of bladder control.
Partial seizures are classified as simple or complex. In simple partial seizures,
the individual has localized symptoms as muscle twitches, numbness, or tingling.
In complex partial seizures, the individual may hallucinate, stagger, perform
automatic and purposeless movements, or experience impaired consciousness or
confusion.

7- Growth problems:
A syndrome called failure to “thrive” is common in children with moderate to
severe cerebral palsy, especially those with qudriparasis. Failure to thrive is a
general term, physicians use to describe children who seem to lag behind in
growth and development despite having enough food.
In babies, the lag usually takes the form of too little weight gain. In young
children, it can appear as abnormal shortness. In teenagers; it may appear as a
combination of shortness and lack of sexual development.
Failure to thrive probably has several causes, including, in particular, poor
nutrition and damage to the brain centers controlling growth and development.
In addition, the muscles and limbs affected by cerebral palsy tend to be smaller
than normal.

8-Abnormal sensation and perception:

Some children with cerebral palsy have impaired ability to feel simple sensations
like touch and pain. They may also have stereognosis, or difficulty perceiving
and identifying objects using the sense of touch.

Neurological Organization for Cerebral Palsy Management

1- Each child must retrace much of what long evolutionary history in
developing and organizing his own nervous system to the fullest.
2- Developing more ancient and more primitive section of the brain to more
recent and more complex areas.

3-Children must retrace this progression from the primitive reflex levels of
muscular function to The uniquely human functions of speech and cognition
4- The poorly use brain is a poorly organized brain.
5- Treatment is based on recapitulation

What is motor control

motor control is the ability to regulate or direct the mechanisms essential to
movement.

What are the factors that interacts to generate movement ?

1- Individual
2- Task
3- Environment
 Movement without mobility

Re-experience Crawling

Creeping

Walking holding
Problem
on

Walking alone
Patterning
Temple Fay

Motor Learning process

I- Cognitive phase
II- Intermediate phase
III- Autonomous phase
 Light reflex

Re-experience Convergence

Problem Normal proprioception

Frequency
Intensity
Duration

Dose USE change the development and organization of the brain ?

Motor
Sensory

Motor plane
Summary of techniques
1- Roods approach (sensory approach )
1-The normalization of tone through correct sensory input.
2-Seneorimotor control is developmentally based on progress him sequentially to
higher and higher levels of sensorimotor control.
3- Movement is purposeful.

2- Temple fay
Stage 1: prone lying
Stage 2: homolateral stage
Stage3: contalateral stage
Stage4: on knees and hands
Stage5: walking patterns

3- The bobath technique

Reflex inhibiting patterns
Facilitation of righting and equilibrium reactions
Conductive education program

4- Eirene collis (neuro motor development )

- The mental capacity.
- Early treatment.
- Management of CP child throughout the day.
- Strict developmental seqyence.
-
5- Gillette technique : (muscle education / braces)
This technique based on how to gain good skeletal alignment for cerebral palsied
children.

6- Phol technique : (muscle education / braces )

This technique based on three principles:
1- General relaxation.
2- Muscle consciousness.
3- The activities.

7- Deaver technique (muscle education / braces )

- This technique based on extensive use of braces.
• Major aims of hs treatment system are:
• Maximal use of the hands.
• Usable speech.
• Ability to travel.
• Normal or near- normal appearance.
•
8- Schwartz technique (muscle education – braces)
Technique based on simplifying the external environment and providing motivation.

9- Phelps technique (muscle education – braces)

- Massage
- Passive motion
- Active assisted motion
- Active motion
- Resisted motion
- Conditioned motion
- Confused motion
- Combined motion
- Relaxation techniques
- Movement from relaxation
- Rest period
- Reciprocation
- Balance training
- Reach and grasp and release
- Skills of daily living as feeding
- Braces and calipers
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