JR is a 3 year old boy, who was brought to

the clinic by the mother because of stiffness

when crying and tip toe walking. History
revealed that patient was born via NSD, full
term, to a 35 year old mother G1P1 (1001),
with regular pre natal check-up with
obstetrician. She had history of UTI during
her last trimester but no bleeding. During
the actual delivery, it was noted that the
cord was coiled on the neck 3 times. APGAR
score was 5 and birth weight was 2.5kg
On patients developmental history, mother
noted:
 Baby started to roll over at 6 months
 Sat with support at 12 months
 Pulls himself up to stand by 18 months

Currently, he can walk without assistance. He

can make simple sounds and continues to
drool
• Ambulatory with scissoring gait
• Poor balance
• Maintains high guard of upper extremities
• (+) Cortical thumb
• With good health control
• (+) drooling
• Good sitting balance
• (+) Tightness of both Achilles
• (+) Clonus
Cerebral Palsy
 Maternal history of urinary tract infection
(UTI) during the last trimester
- Intrauterine exposure to maternal
infection such as UTI is associated with a
significant increase in the risk of cerebral
palsy in normal birth weight infants
 Cord coil and apgar score of 5
 The baby may have experienced hypoxia due to the
cord coiled on the neck which may have been severe
to enough to exceed the adaptive capacity of the
fetus which in turn may have caused neurologic
damage.
 Tip toe walking
- An affected child often walks on tip toes
because of the increased tone
 Ambulatory with scissoring gait
- Scissoring gait is due to spasticity of hip
adductors
 (+) Clonus
- Clonus may be demonstrated in the lower
extremity by sudden dorsiflexion of the foot with
knee partially flexed
- Five to ten beats in a newborn is normal
unless it is asymmetric
- Spasticity results from lesion involving the
upper motor neuron tracts and may be unilateral
or bilateral
Delay in Developmental milestones
- patients with cerebral palsy often are not at par with
normal children their age and often retains their primitive
reflexes
 Gross motor function

- J.R. started to roll over at 6 months (Normal: 2 – 4.5 months)

- Sat with support at 12 months (Normal: 7 months)

- Pulls himself up to stand by 18 months (Normal: 10 – 14
months)
- Can walk but needs assistance at 3 years old (Normal: 1 year
old)
 Speech and Language
- Can make simple sounds at 3 years old (Normal: 1.5 – 3 months)
• is a disorder of posture and movement that
occurs secondary to damage to the immature
brain before, during , or after birth.
• it is called a static encephalopathy because
it represents a problem with brain structure
or function.
 Once an area of the brain is damaged, the
damage does not spread to other areas of
the brain, as occurs in a progressive
neurologic disorder such as a brain tumor.
 However, because the brain is connected
to many different areas of the nervous
system, the lack of function of the
originally damaged areas may interfere
with the ability of these other areas to
function properly.
 CP is characterized by decreased
functional abilities, delayed motor
development, and impaired muscle tone
and movement patterns.
 When damage occurs before birth or
during the birth process, it is considered
congenital cerebral palsy.
 If the brain is damaged after birth, up to
3 years of age, it is considered to be
acquired.
 Due to cortex/pyramidal tract lesion
 Characterized by
 Spasciticity
 hyperreflexia
 Clonus
 Babinski reflex
Topographical Classification: Diplegia
Characteristics:
 Bilateral spasticity of legs greater than in
arms
 First indication: infant drags legs upon
crawling rather than using four limbed
movement
 Physical exams reveals spasticity in legs with
brisk reflex, bilateral Babinski sign.
 Scissoring posture of lower extremities when
suspended by axillae
 Scissoring gait (hips flexed and adducted,
knees flexed with valgus, and ankles in
equinus)
 Delayed walking
 Feet in equinovarus position and walks on
tiptoes
 Scissoringgait
 Poor balance
 Maintains high guard of upper extremities
 (+) Tightness of both Achilles tendon
 Ankle clonus
 All fingers flexed with thumb under second
to fifth fingers
 Infants with corticospinal tract damage
caused by hypoxic-ischemic insult
 Defined as velocity dependent resistance to
passive range of motion experienced by the
examiner as increased muscle tone, caused
by an increase in stretch reflex activity
 Arises from injury to pyramidal tracts
secondary to loss of inhibitory control on
lower motor neurons
Grade Description
0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a
catch and release or by minimal resistance at the
end of ROM when part is moved in flex or ext
1+ Slight increase in muscle tone, manifested by a
catch, followed by minimal resistance throughout
the remainder (less than ½ ) of ROM
2 More marked increase in muscle tone though most
of the ROM, but affected part is easily moved
3 Considerable increase in muscle tone, passive
movement difficult
4 Affected part rigid in flexion or extension
 Oral Medications
 Benzodiazepenes (GABA-A receptors)
 Baclofen (GABA-B receptors)
 Tizanidine (alpha-adrenergic receptors)
 Dantrolene (calcium influx)

Side effects: drowsiness, dizziness, and

weakness
 Starting Maximum Relative
Medication Common Effects
Dose Dose Contraindications

Sedation, rare
Baclofen 5–10 mg tid 20 mg qid Cognitive impairment
hepatotoxicity

History of
Diazepam 2 mg bid 10 mg qid Sedation benzodiazepine or
other substance abuse

Sedation,
Tizanidine 2 mg Tid 12 mg tid hypotension, Cognitive impairment
hepatotoxicity

Weakness,
hepatotoxicity,
Dantrolene 25 mg daily 10 mg qid Liver disease
occasional
sedation

FDA approved only up to 80 mg/day, but many clinicians exceed this in

patients who tolerate this medication well but do not respond to lower doses.
 Intramuscular botulinum toxin type A
 onset at 24–72 hours after the injection
 provides local relief of spasticity for 3 to 4
months
 larger muscles require higher doses
 Intrathecal baclofen pump
 for intractable bilateral lower extremity
spasticity
 delivers the medication directly into the spinal
fluid via a catheter
 Orthopedic surgery
 after failure of more conservative measures
 e.g. tendon lengthening, tenotomy, or joint
fusion
 To prevent contracture
 To temporarily reduce increased muscle
tone
 stretching exercises
 passive range of motion movements
 Toreduce the impact of spasticity on
function

 Splinting a spastic limb

 pre-fabricated
 low temperature thermoplastic
 plaster or fiberglass casts
 Physiotherapy
 Occupational therapy
 Bracing
 Assistivedevices
 Adaptive technology
 Sports and recreation

http://www.global-help.org/publications/books/help_cphelp32management.pdf
http://www.cerebral-palsy-help.com/injuries/ninds.html
 Help child grow up to be a productive,
independent individual
 Provide education
 Achieve independent mobility
 Encourage use of standers
 Bring child to an erect position regardless of
prognosis for walking

http://www.global-help.org/publications/books/help_cphelp32management.pdf
http://www.cerebral-palsy-help.com/injuries/ninds.html
 Improve mobility
 Teach child to use his remaining potential
 Teach child functional movement
 Gain muscle strength
 Prevent deformity
 Decrease spasticity
 Improve joint alignment
 Position for sitting, transfers

http://www.global-help.org/publications/books/help_cphelp32management.pdf
http://www.cerebral-palsy-help.com/injuries/ninds.html
 Educate the parents
 To set reasonable expectations
 Do the exercises at home
 Teach daily living skills
 Have the child participate in daily living
activities
 Social integration
 Provide community and social support

http://www.global-help.org/publications/books/help_cphelp32management.pdf
http://www.cerebral-palsy-help.com/injuries/ninds.html
 Nearly all children with CP develop an
abnormality of physical form or function
 The need for assistive technology in this
patient should be according to all the
therapists involved with the child e.g.,
physiatrists, surgeon (if applicable), etc.

Braddom, Randall. Physical Medicine &

Rehabilitation
 In
this 3 y/o kid, who would have been
jumping, pedaling a tricycle & learning
nursery rhymes, an assistive device
aims to help him develop social and
cognitive well-being by making him
more interactive with his environment

Braddom, Randall. Physical Medicine &

Rehabilitation
 Frequentreevaluation of orthoses
because children quickly outgrow them
& can undergo skin breakdown if used
improperly

Braddom, Randall. Physical Medicine &

Rehabilitation
– Since this patient already developed
the ability to walk but with assistance, a
walker will help him move about his
immediate environment
– To improve gait, decrease contracture
& increase endurance

Baker, K.M. Rehabilitation Analysis of Walker-

Assisted Gait in Spastic Diplegic Cerebral Palsy
– Patient has a (+) cortical thumbing
– WHO use leads to excellent positioning
of small hands & even larger hands that
do not have significant tone or
malpositioning
– This can help with improving function so
that a child can hold pencils, crayons
and utensils better

Nelson, Maureen, M.D. Cerebral Palsy

Equipments.
http://www.disaboom.com/Health/Cerebral-
Palsy/Core-Knowledge/Cerebral-Palsy-
References:
 Behrman, R E et al. Nelson Textbook of Pediatrics 17th Edition.
Elsevier Science. Copyright 2004. pp. 1978, 2024 – 2025.
 http://www.originsofcerebralpalsy.com/09-asphyxia.html
 Frontera: Essentials of Physical Medicine and Rehabilitation,
1st ed. 2002 Hanley and Belfus
 Baker, K.M. Rehabilitation Analysis of Walker-Assisted
Gait in Spastic Diplegic Cerebral Palsy Children.
http://www.orec.org/resna2003.pdf
 Nelson, Maureen, M.D. Cerebral Palsy Equipments. h
ttp://www.disaboom.com/Health/Cerebral-Palsy/Core-Knowledge/Cere
 Braddom, Randall. Physical Medicine & Rehabilitation
 http://www.global-help.org/publications/books/help_cphelp32manage
 http://www.cerebral-palsy-help.com/injuries/ninds.html