Rehabilitation Programs for Cerebral Palsy

IO2 Module 5
Rehabilitation Programs
CP-CARE - 2016-1-TR01-KA202-035094
(01.12.2016 – 30.11.2019)

Unit 1 – Neurodevelopmental
treatment/NDT

Concept and basis of neurodevelopment treatment
 It is a concept, not a technique
 It adapts to advance in Neuroscience
 Interdisciplinary approach
 It is based on the Normal Postural Control Mechanism
(N.P.C.M)
 Commonly referred to as Bobath approach in many European
countries.

Evolution and
Quality of
Movement
Organization of
the SNC
Normal Postural
Tone
Reciprocal
Innervation
Patterns of
movement and
normal
coordination
Sensory
Perception
NORMAL MOVEMENT

Normal Postural Tone
Movement
Continuous and
automatic
organization and
adaptation of the
tone
Before, during
and after it
Degree of Tension
• High enough to
counteract the
Force of gravity
• Sufficiently low to
allow movement
Tone Distribution
• Variation in the
course of
development
• Proximal stability
• Selective distal
movement
Adaptability
• Response to
stimuli
- Touch
- Vision / hearing
- Pressure
- Vestibular
- Stress emotion
…
Go to:
Module 4
Unit 5

Reciprocal Innervation
 Allows all degrees of coordinated interaction between different
muscle groups
MUSCLE COACTIVATION
 Prerequisite for automatic and voluntary activity
 Proximal Synergistic Stability-Distal Selective Motion
 Automatic adaptation
 Control of Agonists and Antagonists
 Depending on the needs of each moment: + co-contraction or
+ mobility

Patterns of movement and normal coordination
 Protection reactions that act against gravity
 They are a series of dynamic postural reactions that act together
to maintain balance (balance) and postural adjustment before,
during and after the movement.
 The development of coordination in the child goes step by step
with the development of the postural reactions when the child
learns to be active against gravity and to move effectively.
 They are divided into three types of reactions:
Straightening reactions
Supporting Reactions
Balance Reactions

Righting/Straightening reactions
 This group of reactions maintains the position of the head in
space, the alignment of the head and neck in relation to the trunk
and trunk with the extremities and vice versa
Head and Trunk Control
Alignment
Rotation of the body axis
Orientation and postural adjustment through vision

Supporting and protecting Reactions
 They arise when the straightening and equilibrium reactions
are insufficient
 They constitute a bond between the reactions of equilibrium
and straightening in the development of the child.
 They may be
◦ Previous
◦ Medium
◦ Subsequent

Balance Reactions
 Automatic Postural Reactions to maintain or regain Balance
◦ When the body moves in the space
◦ When the support base moves
 Objective
◦ Keep the center of gravity in the support base
◦ Any change of the center of precise gravity of postural
adjustments
Balance
Reactions
Automatic Inmediate Efficient

Applications of the program in CP
It affects the immature brain, interfering
with the maturation of the CNS
CNS injury causes variable disorders of
the Normal Postural Control Mechanism
Abnormal Postural Tone
Abnormal reciprocal innervation
Abnormal Movement Coordination

Disorders of the Abnormal Postural Control Mechanism
Abnormal Postural
Tone
Too High
Too Low
Fluctuating
No control against
gravity
Abnormal reciprocal
innervation
Overfixing
Instability
Lack of graduation
Stability/mobility
interferes
Abnormal Motion
Coordination
Lack of variety
Lack of
organization
Lack of selectivity
Abnormal
functional activity

Abnormal
Movement
Coordination
Repetitions of
abnormal
posture and
movement
patterns with
abnormal
postural tone
Learning and
use of
abnormal
movement
Risk of
development
of
contractures
and
deformities as
a secondary
problem

Assessment
 Observation from his spontaneous activity, continuing in the
different positions, according to his possibilities
Skills
What?
How?
Why?
Correlation:
Postural
patterns and
movement
What
can be
done
with a
little
help?
POTENTIAL

Results of the program. Effects on CP
 Muscle Tone Preparation
◦ Patterns of tone inhibition for
reducing hypertonia
◦ Proprioceptive and tactile
stimulation for increasing tone
 Facilitation
◦ For posture and movement
patterns more normal
Modification
of the Tone
Facilitation
Functional
activity

Muscle Tone Preparation
Sensory and perception of movement
Provide a
good
feeling of
movement
Repetition of
normal
posture
patterns with
normal
postural tone
Learning
base of the
closest
movement
to normal

Adaptation to activity, elongation, movement skill
Tone Reduction (spasticity/hypertonia)
Patterns of normal movement to modify abnormal patterns
Tone Influence Patterns (TIP)
Muscle Tone Preparation

Techniques to increase muscle tone of the trunk
 Load more presure
 Tapping
 Placing
 They are techniques of
propioceptive and tactile
stimulation that cause an
increase of postural tone.
 Neoprene and corset

Get automatic or more voluntary active reactions as a response
to postural adjustment and movement
Organize the starting position keeping the sensory information
towards a specific movement pattern
Made from "key control points"
Automatic postural adjustment reactions are facilitated with a
functional objective
Movement Facilitation Go to: Module 4 Unit 4
Module 2 unit 2

Results of the program. Contrasted effectiveness of
treatment in CP
Marked improvement of gross motor function
Significant improvement of gross motor control after 15
treatment weeks
Studies reported that motor function quickly improve in the
first years of life, not after 7 years
Therapy at older ages prevents the gross motor function
deterioration
Other studies showed that NDT treatment after 4 weeks
improved the Gross Motor Function.

References
 Pujante Guirado, JA. Tratamiento Neuroevolutivo de Bobath. En: Programas de
Rehabilitación para pacientes con Parálisis Cerebral. C Suarez-Serrano y A Gomez-
Conesa, editores. Madrid: Asociación Española de Fisioterapeutas. 2018, 10-18.
 Tsorlakis N, Evaggelinou C, Grouios G, Tsorbatzoudis C. Effect of intensive
neurodevelopmental treatment in gross motor function of children with cerebral
palsy. Dev Med Child Neurol 2004;46:740-5.
 Bobath K. Base neurofisiológica para el tratamiento de la parálisis cerebral. 2ª ed.
Madrid: Editorial médica Panamericana; 1982.
 Colver A, Fairhurst Ch, O D Pharoah P. Cerebral palsy Lancet 2014; 383:1240-9.
 Butler C, Darrah J: Effects of neurodevelopmental treatment (NDT) for cerebral
palsy: an AACPDM evidence report. Dev Med Child Neurol, 2001, 43: 778–790.
 International Bobath Instructors Training Association (IBITA). Theoretical
assumptions of clinical practice. IBITA annual general meeting, Sept 2006. Available
at: www.ibita.org.
 Lee KH, Park JW, Lee HJ, Nam KY, Park TJ, Kim HJ, Kwon BS. Efficacy of Intensive
Neurodevelopmental Treatment for Children With Developmental Delay, With or
Without Cerebral Palsy. Ann Rehabil Med, 2017;41(1):90-96.
 Knox V, Evans AL: Evaluation of the functional effects of a course of Bobath therapy
in children with cerebral palsy: a preliminary study. Dev Med Child Neurol, 2002, 44:
447–460.

Vojta Method
 Concept and basis of the method
 Applicability of Votja method
 Effects of the Votja method

Concept and basis of the Vojta method
 The Vojta’s Principle of Reflex Locomotion is a form of
kinesitherapy that activates the preorganized circuits of the
Central Nervous System (genetically inherited) triggering
motor programs with locomotion components

Concept and basis of the Vojta method
It focuses on activating in a reflex way the basic principles of
human locomotion and the global and different motor patterns of
the locomotor development of the first year of life
Sensory
Information
Positions of
Defined Items
Reflex Locomotion
Reflex Creeping Reflex Flip
Locomotion forward Lateral locomotion

Neuromuscular activated circuits
by the physiotherapist require a
specific initial starting position.
The application of appropriate
proprioceptive stimuli.
A final position.

 The physiotherapist makes a selective pressure in certain areas
of the body and the patient is lying on his back, face down or
sideways.
 Maintaining the starting position + the combination of the stimuli
+ the resistance to the turning movement of the head = the
analogous components to locomotion are triggered through two
global patterns keys, one from the ventral decubitus and the
other from the dorsal.

The base position is the ventral
decubitus (face down), with the
head resting on the plane and
turned to the side. In the newborn
child the response can be triggered
from a single area, but in older
children and adults it is necessary to
combine several zones at the same
time.
Reflex Creeping
The reflex creep is a motor activity that includes the 3 essential
components of locomotion:
 Postural control.
 Straightening of the body against gravity.
 Movements of the arms and legs.

The objectives of the Reflex Creeping are:
 Activation of the muscular mechanisms necessary for
grasping, straightening and walking, as well as for the
movements of the arms and legs.
 Activation of the respiratory, abdominal and pelvic floor
musculature, as well as that of the bladder and rectal
sphincters.
 Swallowing movements.
 Movements of the eyes.

Reflex Flip
Reflex flip begins from the dorsal
decubitus, passes through the lateral and
ends in the crawling. In the normal child,
part of this motor activity is observed
around 6 months and another part towards
8-9 months. With Vojta therapy all this can
be triggered already in the neonatal period.
The first phase begins in dorsal decubitus.
The second phase of reflex flip is
performed from the lateral decubitus
position.

 Extension of the column.
 Flexion of hips, knees and ankles
 Maintained elevation of the legs
against gravity, outside the support
base on the trunk.
 Preparing the arms for later support.
 Lateral movements of the eyes.
 Appearance of swallowing
movements.
 Breathing becomes deeper.
 Coordinated and differentiated
contraction of the abdominal muscles.
First phase of Reflex Flip Second phase of Reflex Flip
 The opposite movements of
extension and flexion between
the upper and lower extremities.
The support is increased in the
shoulder below, moving towards
the hand, and also in the
hemipelvis below, moving
towards the leg.
 The extension of the column
during the entire flip process.
 The straightening of the head in
the lateral decubitus, against
gravity.
REACTIONS

Applicability of Votja method
Vojta therapy can be applied at any age, although with
different objectives.
Vojta therapy can prevent pathological motor patterns
from developing in infants.
It can improve their maturation and growth process in
young children, in school-age children or in young
people.
Being able to activate old healthy motor patterns with
therapy has the objective of avoiding functional pains
and limitations or improving strength in adults.

Vojta therapy can be applied as a basic physiotherapy
treatment in any motor disorder:
 In the alterations of the central coordination in infants.
 In motor alterations secondary to brain injuries (cerebral
palsy).
 In peripheral paralysis (spina bifida, plexus paresis, or
others).
 In different muscular diseases.
 In diseases or functional limitations of the spine, e.g. in
scoliosis.
 In orthopedic injuries of the shoulders and arms, of the hip
and legs especially in the growth.
 As a coadjuvant treatment in hip disorders (dysplasia or
dislocation).
 In problems of breathing, swallowing, and chewing.

Vojta therapy should not be applied:
 Acute or inflammation infections.
 Some special diseases, for example crystal bones.
 Certain heart or muscle diseases.
 Immediately after the vaccines.

Effects of the Votja method
The effect is the facilitation and the therapeutic
activation of those innate muscular functions, which
are used unconsciously in daily life, especially those
that maintain the spine, but also those that direct
the movements of the arms and legs, hands and
arms. feet, and face.
All this also improves communication and the patient's
contact with the environment.

Vojta therapy acts on the patient in different areas of the body:
The skeletal muscles :
 The column extends and rotates in each of its segments,
improving its functional mobility.
 The head can move with greater freedom.
 Centering of the joints occurs, especially of the hips and
shoulders. This reduces abnormal postures.
 The hands and feet can be used more accurately, and more
widely, for support and grasping.

Orofacial area:
 Suction, swallowing and
chewing are facilitated.
 The eyes move more
differently, and more
independently of the
head.
 Increase the tone of the
voice.
 Language is facilitated
and speech is more
intelligible.
Breathing / Breath:
 The rib cage widens.
 The breathing becomes
deeper and more constant.
Vegetative nervous system :
 The skin is better irrigated.
 Improves the rhythm of
sleep and wakefulness.
 The regulation of bladder and
intestinal functions is
activated.

Perception:
 Improve balance reactions.
 Improves spatial orientation.
 Improve sensations of cold, heat, increase or decrease in
sensitivity.
 There is a clearer perception of the body.
 Improves tactile recognition of the shape and structure of
objects (stereognosia).
 It increases the ability to concentrate.
Psychological health:
 The patient is more balanced, more cheerful and with
better emotional control.

The effectiveness of the
treatment depends, in addition
to the underlying disease, on
the intensity of the exercises,
the frequency and the accuracy
with which they are applied.
Teaching of the technique to the
parents must be done
immediately so that the
treatment can be initiated at
home and the appropriate
intensity maintained.

Feldenkrais method
• Concept and basis of the method
• Effects of Feldenkrais Method

Concept and basis of the Feldenkrais method
The Feldenkrais method of self-consciousness by
movement (ACM) and functional integration (IF) proposes
a global approach to the human being.
It is a form of education to improve the disturbances of
human functioning, which emphasizes on learning, rather
than the notion of treatment or cure.
Through the ACM and IF, the Feldenkrais method aims to
improve mental and physical functioning.

This method leads to the creation of new motor
schemes, modifying the usual responses of the
body against gravity, with the search for more
efficient ways from the point of view of mobility
and energy expenditure.
It consists of using touch (in individual session of
IF) and movement (in group session of ACM) so
that the student focuses on the proprioceptive
process rather than on the external result.

 During the IF, the trainer uses his hands and
performs stimulations (light touches, to guide
the patient through various movement patterns).
 In the ACM the teacher verbally directs the
participants through various movements
(breaking complex movements into smaller
sequences and varying the order and types of
movement).
 It can be done in a live class or at home with
audio tapes.
 The objectives are:
◦ to improve flexibility, posture, mental state and
comfort

Effects of Feldenkrais method
 The main effect of the method is the improvement of the
function and the image of itself, which the broader and more
complete, the more the number and the variety of its
possibilities of action increases.
 However, there are very few studies on the Feldenkrais
method and there is no evidence about its effectiveness with
people with cerebral palsy.

Pëto method
• Concept and basis of the method
• Effects of Pëto Method

Concept and basis of the Petö method
 The approach, called Conductive Education (CE), was
developed by Petö in Hungary during the 1940s.
 Sutton describes CE as a pedagogical approach that deals with
all aspects of development (motor, cognitive, communication,
psychosocial, and activities of daily life) in any student with a
neurological disorder, including in those diagnoses cerebral
palsy and spina bifida.
 The main objective of the CE is to achieve ortho-function,
defined as the ability to function in all activities of life without
the use of assistive devices.

Concept and basis of the Petö method
 The active participation of the child in the program
and within a group becomes a key element.
 One of the hallmarks of CE is the use of drivers to
facilitate learning in a small group with an emphasis
on the stimulation of motor skills.

Effects of Pëto Method
 CE treatment improves the coordination of hand functions and
activities of daily life (ADL) in children with CP.
 In the absence of evidence to support or not support CE
treatment, it is recommend that parents of people with CP
should consider other aspects, such as cost, accessibility, time
and the effect of the intervention on the family dynamics.
 CE's focus on education, function and ADL can be tailored to
the needs of many families.

References
 Fernández Rego, FJ. Métodos Vojta, Feldenkrais y Peto. En: Programas de Rehabilitación
para pacientes con Parálisis Cerebral. C Suarez-Serrano y A Gomez-Conesa, editores.
Madrid: Asociación Española de Fisioterapeutas. 2018, 19-27.
 Vojta V. Alteraciones motoras cerebrales infantiles. Diagnóstico y tratamiento precoz.
2da. ed. Madrid: Ediciones Morata; 2005.
 Vojta V, Peters A. El principio Vojta: Juegos musculares en la locomoción refleja y en la
ontogénesis motora. Madrid: Springer-Verlag Ibérica; 1995.
 Vojta V, Schweizer E. El descubrimiento de la motricidad ideal. Madrid: Ediciones Morata;
2011.
 Bauer H, Appaji G, Mundt D. Vojta Neurophysiologic Therapy. Indian J Pediatr. 1992; 59:
37-51.
 Kanda T, Pidcock FS, Hayakawa K, Yamori Y, Shikata Y. Motor outcome differences
between two groups of children with spastic diplegia who received different intensities of
early onset physiotherapy followed for 5 years. Brain Dev. 2004; 26: 118-26.
 Buchanan PA, Ulrich BD. The Feldenkrais Method®: A Dynamic Approach to Changing
Motor Behavior, Res Q Exerc Sport. 2001; 72(4): 315-323.
 Ives JC, Shelley GA. The Feldenkrais Method® in rehabilitation: a review. WORK. 1998;
11: 75-90.
 Oppenheim WL. Complementary and alternative methods in cerebral palsy. Dev Med
Child Neurol. 2009; 51(4): 122-129.

 Liptak GS. Complementary and alternative therapies for cerebral palsy. Ment Retard
Dev D R. 2005; 11: 156-163.
 Anttila H, Suoranta J, Malmivaara A, Mäkelä M, Autti-Rämö I: Effectiveness of
physiotherapy and conductive education interventions in children with cerebral palsy: a
focused review. Am J Phys Med Rehabil 2008; 87(6):478–501.
 Reddihough DS, King J, Coleman G, Catanase T. Efficacy of programmes based on
Conductive Education for young children with cerebral palsy. Dev Med Child Neurol.
1998; 40: 763-770.
 Stiller C, Marcoux BC, Olson RE. The Effect of Conductive Education, Intensive
Therapy, and Special Education Services on Motor Skills in Children with Cerebral Palsy.
Phys Occup Ther Pediatr. 2003; 23 (3): 31-50.
 Darrah J, Watkins B, Chen L, Bonin C; AACPDM. Conductive education intervention for
children with cerebral palsy: an AACPDM evidence report. Dev Med Child Neurol. 2004;
46 (3):187-203.
Blank R, von Kries R, Hesse S, von Voss H. Conductive Education for Children With
Cerebral Palsy: Effects on Hand Motor Functions Relevant to Activities of Daily Living.
Arch Phys Med Rehabil. 2008; 89 (2): 251–259.

Unit 3 - Pre- and Postoperative
rehabilitation principles

Conceptual basis of pre- and postoperative
programmes
Rehabilitation in Cerebral Palsy (CP) consists mainly of:
 Improving mobility
 Preventing deformity
 Helping learning or maintaining the necessary skills in daily life
 Providing education and training to families about the problems
and needs of patients and facilitate them access to school,
sports, recreational and social activities
Go to: Module 2 Unit 8

 Problems in CP
PRIMARY PROBLEMS
Alterations in the tone and strength of
different muscles
Weakness
Balance problems
Difficulty using a muscle in
isolation
SECONDARY PROBLEMS
Deformities in the bones of the extremities
Shortening of different muscles and
tendons
Rigidity
Alterations in movements
Difficulty sitting, standing
and walking

The joints of the body
that intervene in a
movement are related
to each other, so that
the alteration in a joint
can affect the function
of other joints
Multilevel surgeries
(MLS) are usually used
in patients with CP

MLS concept
It consists in the realization at the same time of several
types of surgery that affect soft and bony parts and in
several joints at the same time. It is mainly performed on the
lower limbs (foot, knee and hip).
It prevents patients with CP from having to undergo surgery
of a muscle or a bone each year with its corresponding period
of immobilization with plaster and rehabilitation

DIAGNOSIS GMFM LEVEL
OBJECTIVES PATIENT,
CAREGIVERS,
MULTIDISCIPLINARY TEAM
DEGREE OF SEVERITY
Type and
Number of
Surgeries
Go to: Module 0
Unit 4

Application of the programmes of pre- and
postoperative rehabilitation
Preoperative phase Postoperative phase
The rehabilitation of surgery in
patients with CP should be
started in the Preoperative
Considerations:
• In relation to families and
caregivers
• In relation to patient
• In relation to preoperative
Immediately
Hospital discharge
3 weeks
4-6 weeks
7-12 weeks
13-24 weeks
6 to 12 months

 Preoperative Phase
In relation to families and caregivers:
• Information and participation in the decision of type of
surgery and goals
• Knowledge of the functional objectives of surgery and
collaboration throughout the process
• Motivation of the family, mood or stress factors that may
influence rehabilitation
• Economic and geographical situation that may influence
access to some type of treatment

In relation to patient:
• Age. The optimal age for the MLS is 6 to 8 years; surgery for
dislocation of hips is performed at younger ages.
In the child, the decision to receive surgery depends on the
parents. In adolescents and adults with CP, their own decisions
regarding the type of surgery and rehabilitation must be taken
into account.
• Mental level. Assess personality and behavioral aspects
that may influence rehabilitation.
• Preoperative evaluation. Functional assessment using the
Gross Motor Function Measure (GMFM)
The objectives of surgery and rehabilitation will be different if the
child walks independently, can not walk without aids or does not
have a walking prognosis.

Treatment objectives according to the GMFM
Levels I- III
a) Improve the efficiency
of walking
b) Improve the quality of
the gait
Levels IV-V
a) Prevent or reduce pain.
b) Facilitate care activities
c) Preserve or improve
health.
d) Improve the quality of
life.

In relation to the preoperative:
• Analyze preoperative skills for walking
• Handling and use of wheelchairs
• Transfers
• Functional assessment of gross motor skills through the GMFM
• Independence in the activities of daily life (ADL)
• Determine accessibility at home, school or work, and in
transportation
• Use of orthesis or technical aids
• Goals expected by the patient, family, caregivers and health
personnel
• Evaluation, planning and access to Postoperative rehabilitation

 Postoperative Phase
Immediately:
 Anesthesia and analgesia
 Monitor the presence of pain, pressure ulcers by tight
plasters, compression of a nerve and muscle spasms, and
intestinal transit
 Management of spasticity to reduce pain and favor early
rehabilitation
 Positioning generally in supine or prone position, without
pillows under the hips or knees, avoiding rotations
 Passive mobilizations, to avoid rigidity in hips and knees

The hospital stay varies from one day to weeks.
Goals:
 Make active or assisted transfers from bed to chair.
 Iniciate the weight load as tolerated
 Ensure mobility in a wheelchair
 Value technical aids at home
 Communicate with the professionals in patient's environment,
to report on aspects of the surgeries performed and the
rehabilitation program to be carried out at home

3 first weeks
• Evaluate spasticity
• Weight load 2nd-3rd day (soft parts), 1-2 weeks (bony
parts)
• Passive mobilizations: hip flexors and knees
• Transfers
• Tone and muscle strength: abdominals, gluteus, quadriceps
and upper extremities.
• Respiratory physiotherapy

3 to 6 weeks
• Assessment of the alignment of the lower extremities.
Replacement of casts by ankle and foot orthesis.
• Weight load in supine plane
• Passive and active mobilizations
• Muscle strengthening: Separator and extensor muscles of
the hip, knee and ankle.
• Gait. Evaluation in parallel, walker and crutches.
• Hydrotherapy

7 to 12 weeks
• Active mobilizations of the main joints
• Muscle strengthening: resistance exercises and bicycle
• Gait. Walker, crutches and automated walking devices.
• Hydrotherapy. Play and load exercises.

13 to 24 weeks
• Evaluation of walking pattern and decrease in the intensity
of Physiotherapy.
• Strengthening programs.
• Stretching of the main muscles.
• Active exercises according to the characteristics of the
patient

6 to 12 months
• Avoid tiredness and fatigue in Rehabilitation
• Strengthening with adapted equipment in gyms and sports
centers
• Assessment of the gait if the use of orthesis
• Work independence at home, school or in the workplace

> 12 months
• The osteosynthesis material (metal plates and pins) is
removed from the bones (femur and tibia).
• Evaluation of the gait in a laboratory through gait anylisis
(e.g. Vicon)

 Rehabilitation phase of discharge
The same frequency of treatment as in pre-surgery
phase
 Continue the assessment of spasticity
 Encourage participation in sports and
recreational activities
 Assess the patient's environment, avoiding
barriers and promoting accessibility
 Promote healthy living habits.

 Technical Aids
Supine
Plane
Paralels Walker Ankle
and foot
orthesis

Effects of pre- and postoperative rehabilitation
(with and without orthopaedic devices)
 The majority of patients will require adapted equipment, technical
aids and new orthesis from the beginning of rehabilitation at
hospital
 The need for technical aids depends on the gross motor, age,
cognitive level, mobility and prognosis of the patient's progress
prior to surgery
 After MLS, most will require a wheelchair that allows to raise of
lower limbs
 After the standing and start of the gait, the step of using two
crutches to one will depend on the strength, balance and safety
of the patient
 From 3 to 6 months of surgery, supra-malleolar orthesis or
articulated orthesis can be used.
 School and work environments must allow the gait with technical
aids in a safe environment

Rehabilitation in Upper Extremity Surgery
The preoperative for the upper extremities is similar to that in MLS.
The participation of the patient and the family or caregivers is required
to determine their role in activities such as hygiene, balance, sitting and
walking.
The objectives of the surgery are:
 to decrease or improve the symptoms,
 to improve the manual function and the aesthetic aspect of the upper
extremity.
• It is also used in severe contractures to facilitate cleanliness, clothing
and transport.
• The postoperative period includes limb protection, pain control and
inflammation, initiation of mobility and function. In forearm surgery,
the limb is immobilized in supination with the elbow to the greatest
extent possible and mobilizations start from the first day except for
this joint.

References
 Montero Mendoza, S. Principios de la Rehabilitación Pre y Post quirúrgica. En:
Programas de Rehabilitación para pacientes con Parálisis Cerebral. C Suarez-Serrano y
A Gomez-Conesa, editores. Madrid: Asociación Española de Fisioterapeutas. 2018, 28-
38.
 Berker AN, Yalçin MS. Cerebral palsy: orthopedic aspects and rehabilitation. Pediatr
Clin North Am. 2008;55(5):1209-1225.
 Trabacca A, Vespino T, Di Liddo A, Russo L. Multidisciplinary rehabilitation for patients
with cerebral palsy: improving long-term care. J Multidiscip Healthc. 2016;9:455-62.
 Thomason P, Graham KH. Rehabilitation of children with cerebral palsy after single-
event multilevel surgery. In: Iansek R, Morris M, editors. Rehabilitation in Movement
Disorders. Cambridge University Press; 2013, p. 203-2016.
 Morante RM, Arigón BE, De la Maza AU. Guía de manejo de rehabilitación en cirugía
multinivel. Rehabil integral. 2009;4(1):31-40.
 McGinley JL, Dobson F, Ganeshalingam R, Shore BJ, Rutz E, Graham HK. Single-event
multilevel surgery for children with cerebral palsy: a systematic review. Dev Med Child
Neurol. 2012; 54(2):117-28.
 Sharan D. Orthopedic surgery in cerebral palsy: Instructional course lecture. Indian J
Orthop. 2017;51(3):240-55.
Castelli E, Fazzi E, SIMFER-SINPIA Intersociety Commission. Recommendations for the
rehabilitation of children with cerebral palsy. Eur J Phys Rehabil Med. 2016;52(5):691-
703.

Unit 4 - Oral motor rehabilitation

Indications of oral motor rehabilitation in CP
 CP can affect to the oral motor skills which leads to:
• A delay in speech
• An increase in drooling
• That can trigger physical problems and has an
important effect on social development
• Difficulties in performing sucking, swallowing and
chewing.
• Delay in growth and development
• Caused by a state of nutrition and reduced
hydration and use long periods of time to feed
that tend to be stressful.
• Risk of aspiration when performing oral feeding,
with possible pulmonary consequences.

 Constant adoption of defective spastic positions  atrophy
of certain muscle groups as the face area.
 CP can interrupt the development of the specific neuronal
circuit known as the "Central Pattern Generator" (CPG),
which often leads to deficit feeding skills.
 The development of this neuronal circuit depends partially
on sensory impulses  Early sensory experiences are
important for correct feeding skills.
BECAUSE:
Although children with a severe and generalized motor
deficit are more likely to have deficits in swallowing, than
those with less alterations; it has been seen that
oropharyngeal dysphagia (Swallowing disorders) is
prevalent even in children with middle CP.

Objectives of rehabilitation in CP
Combining physiotherapy
and rehabilitation with oral
motor therapy can have a
beneficial effect on levels of
functional independence.
The fundamental
objective of therapy is to
regulate the proper
functioning of the
orofacial area

Orofacial Regulation Therapy
 It is important to consider the sensory responses
when planning interventions, not just the motor
aspects.
 It is believed that non-nutritious oral opportunities
facilitate oral feeding skills.

 Currently stimulation of oral structures (SOS) is
used along with non-nutritive suction (NNS) to
promote a normal oral motor development, and
an improvement in oral abilities in babies.
 In 1998, Castillo Morales described Orofacial
Regulatory Therapy (ORT), to treat functional
orofacial alterations, taking into account the
overall posture of the body.

 At this point, it is important to remember that to develop
the correct complete oral feeding, it is necessary that the
child is able to regulate and coordinate, not only the
orofacial structures, but also the breathing.
 Therefore, it is important to take into account the results of
some studies on the effectiveness of physiotherapy
with the Vojta method, in the improvement of the
respiratory pattern, since it can improve the coordination
between suction, swallowing and breathing, necessary to
promote the full scope of oral feeding as quickly as possible

Oral Motor Interventions. Conceptual basis
 The child must be treated in its entirety, always
including the muscles of the face, the orofacial
zone and the respiratory aspect.
 It is essential to take into account three
elements:
◦ Structure and functioning of the
temporomandibular joint (TMJ)
◦ Control of the head and the TMJ following the
Brodie scheme (modified by Castillo-Morales)
◦ Manual techniques used in therapy (contact,
pressure, sliding, traction and vibration)

 Joint control
◦ the middle finger is
placed on the floor of
the mouth,
◦ the index finger is
placed laterally along
the body of the jaw
◦ and the thumb on the
chin, below the mento-
labial groove

 Head control:
◦ An open hand is placed in
the occipital region of the
baby and rhythmic and
intermittent movements are
made in the cranial
direction.
◦ The other hand is placed on
the sternum and an
intermittent pressure is
made in the back-to-caudal
direction.
◦ We use this principle of
motor calm with great
success also in younger
children and adults,
adapting it to the different
needs of the patient

 Preparatory measures:
◦ We always start the intervention solving the
existing compensations and controlling the tone
Mobilization of the orbicular
muscle of the eye
A global vibration on the
whole face.

Results of Oral motor rehabilitation in clients
with CP.
 Oral feeding interventions for children with cerebral palsy can
promote oral motor function, but these interventions have not
been shown to be effective in promoting the efficiency of diet
or weight gain.
 Some authors did not identify any study that examined the
effects of oral motor stimulation (OMS) on children's lung
health and observed mixed findings in all the results selected
in their review.
 Three valid studies (meta-analysis) were found and neither do
they reach enlightening conclusions.

 A significant improvement was found in FFA and BSID-II
scales by combining the components based on the and
adaptive components for 12 weeks.
 Significant improvements in the KCPS and BPFAS scales, by
performing oral motor training one day a week for 6 months.
 Studies show improvement in the position of the tongue,
opening of the mouth and lip tone when using the moral
Castillo method.
 After doing oral motor stimulation between 12 and 24
sessions, a significant improvement was revealed in feeding;
showing that sensorimotor stimulation is useful for the
treatment of feeding problems.

References
 Torró Ferrero, G. Rehabilitación Motora Oral. En: Programas de
Rehabilitación para pacientes con Parálisis Cerebral. C Suarez-Serrano y A
Gomez-Conesa, editores. Madrid: Asociación Española de Fisioterapeutas.
2018, 39-47.
 Castillo-Morales R. Die Orofaziale Regulationstherapie. Pflaum; 1998
 Vojta V. Alteraciones Motoras Cerebrales Infantiles: Diagnóstico Y
Tratamiento Precoz. Ediciones Morata; 2005.
 Snider L, Majnemer A, Darsaklis V. Feeding Interventions for Children With
Cerebral Palsy: A Review of the Evidence. Phys Occup Ther Pediatr.
2011;31(1):58-77. doi:10.3109/01942638.2010.523397.
 ARVEDSON J, CLARK H, LAZARUS C, SCHOOLING T, FRYMARK T. The effects
of oral-motor exercises on swallowing in children: an evidence-based
systematic review. Dev Med Child Neurol. 2010;52(11):1000-1013.
doi:10.1111/j.1469-8749.2010.03707.x.
 Morgan a T, Dodrill P, Ward EC. Interventions for oropharyngeal dysphagia
in children with neurological impairment. Cochrane Database Syst Rev.
2012;10(11):CD009456. doi:10.1002/14651858.CD009456.pub2.

 Serel Arslan S, Demir N, Karaduman AA. Effect of a new treatment
protocol called Functional Chewing Training on chewing function in
children with cerebral palsy: a double-blind randomised controlled
trial. J Oral Rehabil. 2017;44(1):43-50. doi:10.1111/joor.12459.
 Baghbadorani MK, Soleymani Z, Dadgar H, Salehi M. Acta Medica
Iranica. Vol 52. Univ; 2014.
 Sığan SN, Uzunhan TA, Aydınlı N, Eraslan E, Ekici B, Calışkan M.
Effects of oral motor therapy in children with cerebral palsy. Ann
Indian Acad Neurol. 2013;16(3):342-346. doi:10.4103/0972-
2327.116923.
 Limbrock GJ, Fischer-Brandies H, Avalle C. Castillo-Morales’
orofacial therapy: treatment of 67 children with Down syndrome.
Dev Med Child Neurol. 1991;33(4):296-303. doi:10.1111/j.1469-
8749.1991.tb14880.x.
 Clawson EP, Kuchinski KS, Bach R. Use of behavioral interventions
and parent education to address feeding difficulties in young
children with spastic diplegic cerebral palsy. NeuroRehabilitation.
2007;22(5):397-406

Unit 5 - Rehabilitation in swallowing
disorders

Swallowing disorders in Cerebral Palsy
 Swallowing is a complex
neuromuscular process,
whereby food from the mouth
passes through the pharynx
and esophagus to the stomach.
 The swallowing includes four
phases (preoral, oral,
pharyngeal and esophageal), its
alteration being known as
dysphagia.

 Dysfunction of the preoral phase.
 Lack of lip seal
 Involuntary movements of the jaw
 Increased contact time between the lips and the spoon.
 Reflection of tonic bite.
 Multiple attempts to swallow.
 Increase of oral transit time.
 Motor dysfunction of the tongue.
 Mechanical alterations by elevated palatal arch (ogival).
 Delay in the triggering of the swallow reflex.
 Exaggeration of the gag reflex
 Hypersensitivity of the oral cavity.
 Prolongation of swallowing apnea in the oropharyngeal phase
In CP the most frequent swallowing problems are:

Oropharyngeal dysphagia in clients with CP
 Neurogenic dysphagia is a swallowing or feeding disorder
caused by a disease or neurological trauma. Neurological
dysfunctions can affect the muscular action responsible for the
transport of the food bolus from the oral cavity to the
esophagus.
 The greater the oral motor dysfunction, the greater the time
spent in swallowing. This, added to the child's energy
expenditure and the low amount of food, can contribute to the
stagnation of growth and harm global development.

The signs and symptoms associated with dysphagia
are:
 Aspiration and respiratory disorders
 Sialorrhea
 Reflex of delayed laryngeal elevation
 Mastication with open mouth
 Changes of voice (voice humid)
 Persistence of primitive oral reflexes and pathological reflexes
 Alterations of growth and nutritional status
 Constipation
 Gastroesophageal reflux disease
 Dental alterations
 Alterations of orofacial sensory integration

Management of the FSD
Manage
of the
FSD
From an integral
perspective
Specific program of
feeding and
swallowing functions
Gravity of the
problem
Comorbidities that
present themselves
The family must be
a main protagonist
Treatment
priorities
are
established
based on:
Basis of the treatment of Oropharyngeal
dysphagia in CP

Objectives of the management of the FSD
Quality of life
Sensorimotor facilitation of feeding
Techniques with the environment

Improvement in the patient's quality of life
Encourage
sufficient
intake to
cover
nutritional
and hydration
needs
Indicate and monitor
the safest, most
efficient and best
tolerated feeding
method
Minimize the
risk of
pulmonary
complications

Facilitation of the sensorimotor sequence of the
development of feeding
Create spaces and instances for oral motor learning
Allow the gradual transit of nutrition via non-oral
nutrition to the mouth or in a mixed form, according to
the patient's remaining capacities.
Supervise needs for adaptation of the feeding routes
along the stages of the life cycle
Facilitate functional performance in the feeding routine
according to the potential
Prevent future feeding problems with positive feeding
experiences

Consensus of techniques in feeding management
with the environment
Positive social affective
bond through the
process and the feeding
routine
Determine optimal
feeding methods or
techniques to
maximize safety
Develop observation
skills
Dietary preferences

Therapeutic tools available in the FSDs in clients with CP
 Positioning techniques and adapted furniture.
 Feeding techniques and oral sensorimotor management.
 Adapted textures.
 Utensils adapted.
 Nutritional management
 Treatment of general and orofacial sensory integration.

 Respiratory physiotherapy and indications in bronchopulmonary
diseases.
 Surgical alternatives: antireflux operations, GTT (gastrotomy),
etc.
 Pharmacological management: muscle tone, extrapyramidal
movements, sialorrhea, GERD (gastroesophageal reflux disease),
constipation, respiratory morbidity, etc.
 Dental therapy
 Educational aspects for the caregiver and family.
 Coordination with support networks and social participation
(e.g. school).
Therapeutic tools available in the FSDs in clients with CP

• Postural Management
• Positioning strategies
• Modification of consistencies and volumes of food
Other treatment alternatives for the FSD in clients with CP
 They are based on SECC parameters (safety, efficiency,
competence and comfort):

Postural Management
Objectives:
 Protect the airway
 Facilitate the sequence of global motor
development
Pelvic stability is essential for an orderly
posture that facilitates oroesophageal
transit of swallowing
 It can be supplemented with orthotic
support devices, adapted furniture,
restraint systems to the chair, etc.
 A lower trunk control  greater need
for support

Positioning strategies
It includes:
 Cervical control: Elongated neck with neutral head flexion (in
midline, symmetrical and stable).
 Control of trunk and pelvis: Shoulders descended and
symmetrical; symmetrical trunk stretching; symmetrical and
stable position of the pelvis; stability and trunk inclination.
 Limb control: Feet symmetrical and supported; limbs
contained.
Go to: Module 1 Unit 1-2

Modification of consistencies and volumes of food:
 Improves the safety and efficiency of swallowing.
 Achieves more common consistencies of food (such as nectar,
honey or puree).
 Allows to alter the taste or temperature.
 Consider possible preferences and incorporate dietary
nutritional needs.

Different methods in swallowing disorders
 Neuro-developmental treatment (NDT): It is based on two
principles: the inhibition or suppression of abnormal tonic reflex
activity responsible for hypertonia patterns and the facilitation of
normal reactions and postural control and balance.
 Castillo Morales: It is based on the importance of the function
and not only on the movement itself, relating each part of the
oral complex and converting it into a dynamic system through
coordinated activities.
 Oral sensorimotor therapy: Speech therapy includes orofacial
sensory motor exercises aimed at directly and indirectly
improving the strength, mobility and sensitivity of the structures
involved in the process of suction, swallowing and chewing.

Results of rehabilitation in swallowing disorders
in Cerebral Palsy
 Effects of the Oropharyngeal dysphagia treatment on
clients with CP
 Effects of the swallowing treatment on clients with CP
•Although the different methods of treatment have given favourable results in certain
types of CP, these results can not be generalized with respect to a specific method
•Great heterogeneity in the structural and functional characteristics.
•There is no gold standard treatment.
•The effectiveness of the different treatments is a function of the patient's own
characteristics and environmental and environmental factors.
•The postural management of the client with CP, as well as the modification of
consistencies and volumes, of the food are the basis to obtain favorable results

References
 Torró Ferrero G, Fernández Rego FJ. Rehabilitación en los trastornos de la
deglución. En: Programas de Rehabilitación para pacientes con Parálisis
Cerebral. C Suarez-Serrano y A Gomez-Conesa, editores. Madrid:
Asociación Española de Fisioterapeutas. 2018, 48-58.
 J L Bacco R, F Araya C, E Flores G, N Peña J. Trastornos de la alimentación
y deglución en niños y jóvenes portadores de parálisis cerebral: abordaje
multidisciplinario. Rev Médica Clínica Las Condes. 2014;25(2):330-342.
doi:10.1016/S0716-8640(14)70044-6.
 H Cámpora L, A Falduti L. Evaluación y tratamiento de las alteraciones de la
deglución. Rev Am Med Respir Rev Am Med Resp. 2012;12(3):98-107.
 Chen MY, Peele VN, Donati D, Ott DJ, Donofrio PD, Gelfand DW. Clinical and
videofluoroscopic evaluation of swallowing in 41 patients with neurologic
disease. Gastrointest Radiol. 1992;17(2):95-98.
 Clavé P, Arreola V, Velasco M, et al. Diagnóstico y tratamiento de la disfagia
orofaríngea funcional. Aspectos de interés para el cirujano digestivo.
Cirugía Española. 2007;82(2):62-76. doi:10.1016/S0009-739X(07)71672-X
 Bobath K. Base neurofisiológica para el tratamiento de la parálisis cerebral.
2ª ed. Panamericana: Buenos Aires. 1982

 Castillo Morales R, Brondo JJ, Oviedo G, Haberstock B. Terapia de
Regulaçao Orofacial : Conceito RCM. Memnon; 1999..
 Haberfellner H. ISMAR: An autotherapeutic device assisting patients from
drooling to articulated speech. Pediatr Rehabil. 2005;8(4):248-262.
doi:10.1080/13638490400023954.
 Hirata GC, Santos RS. Reabilitation of oropharyngeal dysphagia in
children with cerebral palsy: A systematic review of the speech therapy
approach. Int Arch Otorhinolaryngol. 2012;16(3):396-399.
doi:10.7162/S1809-97772012000300016.

◦ Ergotherapy is a functional approach to motor learning and skill
learning.
 Training for ADL
◦ Ergotherapy should help us to acquire new complex motor skills for
activities of daily living (ADL)
 ADL as therapy
◦ Ergotherapy should use ADL to acquire new motor skills.
 ADL Centred approach
◦ Functional orientation to activities of daily living
Conceptual basis of Ergotherapy in Cerebral
Palsy

Indications and contexts of application.
• Ergotherapy should be developed in home based program,
parents should be supported from:
◦ Community services
◦ Early attention
◦ School
◦ Resources centres for special education
• Training is necessary for parents and caregivers, to identify
barriers and facilitators in ADL.
Positioning
Walking
Reaching objects
Handling objects

 Lying position
◦1st year most important
◦Sensory stimulation for head orientation
◦Personal support for rolling
 Sitting position
◦ Probably most used position
◦ Back and head alignment
◦ Pelvis and hip support
◦ Feet supported
◦ Arms free
 Standing position
◦ Hip development
◦ Multisystem effect
◦ Legs apart
◦ Goal is development not always self standing
◦ For every child
◦ Parents involvement very important
Positioning
Personal support
From lying to sitting
Keep sitting
Objects superior level
Manual stimuli
Visual stimuli
Go to: Module 1 Unit 2
Module 2 Unit 1
Module 3 Unit 3

 Walking as an exercise
 Walking as way to move
 Walking with support products is possible
 Goal is development not always self walking
 Parents important effort
Walking Go to: Module 3 Unit 3,5

 Qualitative more complex
 Cognitive and voluntary movements
 Sensitive integration necessary
 Goal is development not always self walking
 Guided movement are recommended
 Constraint induce movement could be indicated
Reaching and handling objects
Go to: Module 3 Unit 4,8

Results of the program. Effects on ADL and
social integration
 Facilitate development
 Attendance to school and Improve
school activities
 Improve feeding
 Overcome mental barriers
 Facilitate inclusion and participation
 Improve health status and self care
Positioning
Walking
Reaching objects
Handling objects

References
 Rodríguez Lozano R. Conceptual Basis of Ergotherapy in Cerebral Palsy. En: Programas de Rehabilitación
para pacientes con Parálisis Cerebral. C Suarez-Serrano y A Gomez-Conesa, editores. Madrid: Asociación
Española de Fisioterapeutas. 2018, 59-70.
 Kevberg GL, Ostensjo S, Elkjaer S, Kjeken I, Jahnsen RB. Hand Function in Young Children with Cerebral
Palsy: Current Practice and Parent-Reported Benefits. Phys Occup Ther Pediatr. 2017 May;37(2):222–37.
 Beckung E, Carlsson G, Carlsdotter S, Uvebrant P. The natural history of gross motor development in
children with cerebral palsy aged 1 to 15 years. Dev Med Child Neurol [Internet]. 2007 Oct [cited 2018 Jan
21];49(10):751–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17880644
 Richards CL, Malouin F. Cerebral palsy. In: Handbook of clinical neurology [Internet]. 2013 [cited 2018 Jan
21]. p. 183–95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23622163
 Pelc K, Daniel I, Wenderickx B, Dan B, Primebrain group. Multicentre prospective randomised single-blind
controlled study protocol of the effect of an additional parent-administered sensorimotor stimulation on
neurological development of preterm infants: Primebrain. BMJ Open [Internet]. 2017 Dec 3 [cited 2018 Jan
21];7(12):e018084. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29203503
 Porter D, Michael S, Kirkwood C. Is there a relationship between preferred posture and positioning in early
life and the direction of subsequent asymmetrical postural deformity in non ambulant people with cerebral
palsy? Child Care Health Dev [Internet]. 2008 Sep [cited 2018 Jan 21];34(5):635–41. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18796054
 Boxum AG, La Bastide-Van Gemert S, Dijkstra L-J, Hamer EG, Hielkema T, Reinders-Messelink HA, et al.
Development of the quality of reaching in infants with cerebral palsy: a kinematic study. Dev Med Child
Neurol. 2017 Nov;59(11):1164–73.
 Miller L, Ziviani J, Ware RS, Boyd RN. Does Context Matter? Mastery Motivation and Therapy Engagement of
Children with Cerebral Palsy. Phys Occup Ther Pediatr. 2016;36(2):155–70.
 Lundh S, Nasic S, Riad J. Fatigue, quality of life and walking ability in adults with cerebral palsy. Gait
Posture. 2017 Dec;61:1–6.

 Domagalska-Szopa M, Szopa A. Postural orientation and standing postural
alignment in ambulant children with bilateral cerebral palsy. Clin Biomech
(Bristol, Avon). 2017 Nov;49:22–7.
 Park M-O. Effects of gross motor function and manual function levels on
performance-based ADL motor skills of children with spastic cerebral palsy. J
Phys Ther Sci [Inte
 Chen C, Lin K, Kang L, Wu C, Chen H, Hsieh Y. Potential predictors of functional
outcomes after home-based constraint-induced therapy for children with
cerebral palsy. Am J Occup Ther. 2014;68(2):159–66.
 Kruijsen-Terpstra AJA, Verschuren O, Ketelaar M, Riedijk L, Gorter JW,
Jongmans MJ, et al. Parents’ experiences and needs regarding physical and
occupational therapy for their young children with cerebral palsy. Res Dev
Disabil. 2016;53–54:314–22.
 Case-Smith J, Frolek Clark GJ, Schlabach TL. Systematic review of
interventions used in occupational therapy to promote motor performance for
children ages birth-5 years. Am J Occup Ther. 2013;67(4):413–24.
 Imms C, Wallen M, Elliott C, Hoare B, Randall M, Greaves S, et al. Minimising
impairment: Protocol for a multicentre randomised controlled trial of upper
limb orthoses for children with cerebral palsy. BMC Pediatr. 2016 May;16:70.

What is Sensory Integration (SI)?
• Theory developed by Jean Ayres in the 1960s.
• Defined as the neurological process responsible
for the organization of the different sensory
inputs for their own use.
• According to the theory of Ayres, the SI is the
basis for motor, cognitive, communicative and
emotional development. (Ayres, 2006; Ayres,
2008)

Through sensory
integration, the various
parts of the nervous system
work together so that the
person can interact with
their environment
effectively.

7 sensory channels are
defined:
• View
• Ear
• Taste
• Smell
• Touch
• Propioception
• Vestibular
Greater weight
for development

Physical and psychological benefits
An updated review of the
term cerebral palsy
contemplates sensory
information as a central
component of these
neuromotor alterations.

The postural and movement deficiencies
observed in clients with cerebral palsy are, at
least in part, a consequence of the existing
sensory alterations.
As a consequence of the limitations of
movement, the clients have less exercises
and experiences

This lack of interaction with the environment can
affect the cognitive, social, language and even
emotional development of clients with cerebral
palsy.

The SI can
positively influence
the motor
development of
clients with cerebral
palsy, but also in
their cognitive,
language, social and
emotional
development.

Indications and applications of the SI
programs
• Whenever there is any difficulty of sensory
integration
• It is up to the therapist to evaluate this
situation
In the case of clients with cerebral palsy,
sensory integration programs should always
be applied in conjunction with other
individualized interventions.

• Somatosensory stimulation (tactile,
proprioception):

• Visual, auditory, gustatory and olfactory
stimulation:

Each intervention
must be
designed
according to the
needs of each
client and it is
very important
to provide
sensory
experiences that
represent a
challenge for the
client.

Results of the SI programs
◦ Effects on cerebral palsy:
 It favors the development of the motor area
 It improves the level of activity and participation in
the activities of daily life.
 It improves postural control, mobility as well as
emotional well-being.

◦ Effectiveness of the SI in cerebral palsy:
• They are more efficient than interventions
that take place only in the home.
• No differences have been observed
between its application individually or in groups
• They have shown the same effect as
neurodevelopmental therapy.

◦ Contexts of
application of the
SI:
• Early care
units
• Specialized
centers
• Schools
• Home

◦ Contexts of application of the SI:
• Multisensory stimulation rooms
https://www.youtube.com/watch?v=8GPwlopWXlk

References
 Casuso Holgado MJ. Integración sensorial. En: Programas de Rehabilitación para pacientes con
Parálisis Cerebral. C Suarez-Serrano y A Gomez-Conesa, editores. Madrid: Asociación Española de
Fisioterapeutas. 2018, 71-80.
 An, S.-J. L. (2015). The effects of vestibular stimulation on a child with hypotonic cerebral palsy.
Journal of Physical Therapy Science, 27, 1279–82. doi:10.1589/jpts.27.1279
 Ayres, J. (2006). La integracion sensorial y el niño. (MAD, Ed.) (1a Ed., p. 226). Alcalá de Guadaira
(Sevilla).
 Ayres, J. (2008). La integración sensorial en los niños. Desafios senoriales ocultos. (TEA, Ed.) (25
anivers). Madrid.
 Bumin, G. (2001). Eectiveness of two different sensory- integration programmes for children with
spastic diplegic cerebral palsy. Disabiltity and Rehabilitation, 23(9), 394–399.
 Pavão, S. L., & Rocha, N. A. C. F. (2017). Sensory processing disorders in children with cerebral palsy.
Infant Behavior and Development, 46, 1–6. doi:10.1016/j.infbeh.2016.10.007.
 Rosenbaum, P., Paneth, N., Leviton, A., Goldstein, M., Bax, M., Damiano, D., Jacobsson, B. (2007). A
report: The definition and classification of cerebral palsy April 2006. Developmental Medicine and Child
Neurology, 49(April), 8–14. doi:10.1111/j.1469-8749.2007.tb12610.x
 Shamsoddini, A. (2010). Comparison between the effect of neurodevelopmental treatment and sensory
integration therapy on gross motor function in children with cerebral palsy. Iranian Journal of Child
Neurology, 4(June), 31–38.
 Shamsoddini, A. R., & Hollisaz, M. T. (2009). Effect of sensory integration therapy on gross motor
function in children with cerebral palsy. Iranian Journal of Child Neurology, 3(1), 43–48.
 Thickbroom, G. W., Byrnes, M. L., Archer, S. A., Nagarajan, L., & Mastaglia, F. L. (2001). Differences
in sensory and motor cortical organization following brain injury early in life. Annals of Neurology, 49,
320–327.

Unit 8 - Speech and language
therapy

SPEAKING
PROBLEMS
AFFECTING OF THE
COMMUNICATION
BOTH (SPEAKING,
COMMUNICATION)
Speech, language, and communication
disorders in Cerebral Palsy
70-80% of CP cases are affected, regardless of the type and
severity of the problem.

EXPRESSIVE LANGUAGE
•Variability in speech
•Limited syntactic
development
•Phonetic and
morphosyntactic problems
(by breathing and motor
problem)
COMPREHENSIVE
LANGUAGE
•Limited context
•Failures in lexical
processing
•Problems in the search
for semantic information
The affectation of both implies
an affectation the two main
dimensions of the language:
Representative
Dimension
Communicative
Dimension

Treatment
INTEGRATE:
INTERDISCIPLINARY TEAM + FAMILY + CLIENTS WITH CP
The objectives of language therapy are:
• Cognitive - linguistic: Aimed at improving linguistic
development.
• Social: They seek the integration, adaptation and
inclusion of learning in the social enviroment of the
person with PC
Physiotherapists,
Psychologists,
Speech therapists, among others

 Treatment: Development of communication
skills
◦ Treatment begins with Global Techniques so that the subject
becomes aware of the possibilities he/she has, continue with
functional techniques to end with the most analytical and own
language techniques.
GLOBAL
TECHNIQUES
FUNCTIONAL
TECHNIQUES
ANALYTICAL
TECHNIQUES
Postural Control Chewing Respiration
Phonation
Swallowing Resonance
Participatory
approach (DLA)
Articulation
Suction Language
Rhythm

 We can summarize the areas of intervention in:
◦ Motivation
◦ Feeding
◦ Work in the oral area (proprioceptive facilitation, reflexes
and oral functions, praxias, among others).
◦ Postural facilitation
◦ Phonation and voice (for example, with the Facilitated vocal
emission method (MEVF))
◦ Articulation
◦ Prosody (Refer to metric and accent of the words)
◦ Advice to the family

Treatment: Communicative functions
• When there is a low communicative intention:
• When oral language is possible, this content and its
intention will be worked on progressively, from the most basic
needs to the most complex ones.
• When there is an impossibility for speech:
DIFFICULT
PRAGMATICS
MEET NEEDS
OF THE
CLIENT
WITH CP
SEEKING
INTENTION:
PRAGMATIC USE
AUGMENTATIVE AND ALTERNATIVE
COMMUNICATION SYSTEMS - AAC

Treatment: Expressive language
Facilitated
Vocal
emission
VISUAL
STIMULI
PROSODY
EXERCISES
Through
EFFECTIVE
TO IMPROVE
EXPRESSION
IN CLIENTS
WITH CP
Superior
properties of
speech:
accent,
intonation
and rhythm
Visual support
to recognize
the work to be
done
Go to: Module 3
Unit 2

METHOD OF RELEASED VOCAL EMISSION
Example of exercise: in decubitus, sustained emission of
sounds / o /, / u /, / i /, / e /, / a / with visual support (a car
that advances while the child emits the sound). We progress
with changes in emission intensity.

 Structured set of codes, verbal
and non-verbal, expressed
through non-vocal channels
(gestures, signs, graphic
symbols), whether or not they
require physical support, which
through specific processes of
instruction serve to carry out
acts of communication per se
alone or in conjunction with
vocal codes (channels), or as
partial support to them
Treatment: Augmentative and alternative
communication (ACC) systems
Go to: Module
3 Unit 2

ICT supported Non-ICT solution
REQUIREMENTS: durable and portable devices, minimum
maintenance, extensive vocabulary and technology of easy access
and management and economic cost according to family
possibilities.
NEW
TECHNOLOGIES
• Communication improvement
• Increase socialization
• Reduce environmental barriers, in
personal relationships of clients with
CP

Results of Speech and language therapy in
Cerebral Palsy
Studies focused on the motor
aspect
Depending of the type of the
therapy the signs of evidence
should be checked
Participation and family
involvement

References
 Piñero Pinto E. Terapia del habla y del lenguaje. En: Programas de
Rehabilitación para pacientes con Parálisis Cerebral. C Suarez-Serrano y A
Gomez-Conesa, editores. Madrid: Asociación Española de Fisioterapeutas.
2018, 81-89.
 Barty E, Caynes K, Johnston LM. Development and reliability of the Functional
Communication Classification System for children with cerebral palsy.
Developmental Medicine & Child Neurology 2016, 58: 1036 – 1041.
 Lund S, Wendy Q, Weissling K, McKelvey ML, Dietz AR. Assessment with
children who need augmentative and alternative communication (ACC): clinical
decisions of AAC specialist. Special Education and Communication Disorders
Faculty Publications 2017. 150.
http://digitalcommons.unl.edu/specedfacpub/150
 Rasid NNBM, Nonis K. Exploring communication technology behaviour of
adolescents with cerebral palsy in singapore. International Journal of Special
Education 2015; 30: 17 – 38.
 Chorna O, Hamm E, Cummings C, Fetters A, Maitre NL. Speech and language
interventions for infants aged 0 to 2 years at high risk for cerebral palsy: a
systematic review. Dev Med Child Neurol 2017; 59 (4): 355 – 360.

Unit 9 - Physical activity and
recreation for clients

PHYSICAL ACTIVITY IN CP
Promote physical
activity
Avoid sedentary
isolated lifestyle
Two main
objectives
Concept and basis of physical activity in
clients with CP

30% less Physical Activity
(PA) than young people
without disabilities
An average of 28.6 weekly
hours of sedentary activities
in front of a television or
computer (twice the
recommended maximum
screen time)
Decrease in
muscle
strength
Decrease in
cardio
respiratory
resistance
2 main factors
that limit the
perfomance of
Physical
Activity in
clients with CP

ADAPTED PHYSICAL ACTIVITY (APA) ON THE CP
"All movement, physical activity and sport in which
special emphasis is placed on the interests and abilities of
people with limiting conditions, such as disability, health
problems or the elderly"
Areas of application of the APA
Therapeutic
APA
Recreational
APA
Educational
APA
Competitive
APA

Obtain an inclusive educational APA
Educational
APA

Young people with CP have fewer skills and
opportunities to explore their own
environments
Family, caregivers and therapists
must provide fun and creative ways
for care, and treatment
Achieve maximum
effort and
enthusiasm
Implementation of games
adapted to the age and
needs of young people
with CP
Based on therapeutic
exercises
Recreational
APA

Benefits of Physical Activity in CP
Improve the skeletal
muscle system
Improves weight
control
Improves the health
of the bone system
Improves
cardiorespiratory
function
Improves
psychosocial and
mental health
Reduces the risk of
secondary health
problems

Benefits of recreative therapeutic PA in CP
•Improve physical condition
•Improve balance
•Improve range of motion and flexibility
•Improve coordination
•Improve muscle strength
Physical
Mental
Emotional
•Improve social skills
•Improve self esteem

Physical Activity Programmes in CP
Facilitators and barriers in PA in young people with CP
PERSONAL FACILITATORS PERSONAL BARRIERS
Psychological factors
New experiences, belonging to the group and
/ or being accepted, etc.
Do not accept the degree of disability,
feeling of insecurity, etc.
Psysiological factors
Know the benefits of PA, improves pain,
relaxation, etc.
Fatigue, lack of energy, physical
limitations, pain, etc.

Facilitators and barriers in PA in young people with CP
ENVIRONMENTAL FACILITATORS ENVIRONMENTAL BARRIERS
Familiar factors
Believe in the benefits of PA, assertiveness
and perseverance, etc.
Investment of time and energy, believe
that PA is not important.
Oportunities for sports and PA
Encouraging schools, be aware of the
opportunities for PA, etc.
The activities of interest are not offered or
have no possibility of doing it, etc.
Practical feasibility
Accessibility to PA, use of adapted materials,
etc.
Not finding time to practise PA, economic
limitations, etc.
Factors of the social environment
Allows the child to establish relationships
between equals
Not being accepted by their peers or
parents

Anaerobic
activities
Aerobic
activities
Muscle
strengthening
exercises
Therapeutic
APA

e.g. Sprinting
Improve
muscular
endurance
Improve
anaerobic
power
Anaerobic
activities

AEROBIC EXERCISES
* 2-3 times a week (30 min)
* Moderate intensity 60-
75%
* Duration: 4-8 months
Cycle therapy
* Sessions 20-30 minutes
* 2 times a week
Aquatherapy
* 5-8 months duration
* 3 times a week
Functional activities such as walking and
running performed separately, or in
combination with muscle strengthening
exercises or anaerobic training
Aerobic
activities

Functional
Objective
INITIAL PHASES:
Low dosage
2 times a week, 2-4
weeks
Simple exercises,
involving a single
joint
AFTER THE
FAMILIARIZATION
PHASE:
Complex activities
involving several joints
Like step-ups and sit-
tostand exercises
From 1 to 4 sets of 6-15
repetitions
2-3 times a week
The training
program lasts at
least 12-16
weeks
Muscle
strengthening
exercises

Cardiorespiratory Endurance Training
Improve cardiorespiratory resistance
• Frequency: 2-3 times per week
• Intensity: 60% -75% of the maximum heart rate, or between 40% -
80% of the reserve heart rate, or between 50% -65% of the maximum
volume of oxygen
• 20 minutes session
• 8 consecutive weeks (if the training is 3 times a week) / 16 consecutive
weeks (if the training is 2 times a week)
Regular exercises are recommended, involving large muscle groups and
continuous and rhythmic nature
• Among them: running, step-ups, negotiating stairs, cycling, arm
ergometry exercise, propelling a wheelchair, swimming

Animal
Assisted
Therapy
Art
Therapy
Play
Therapy
Recreational
APA
Therapeutic
APA

Horse Assisted Therapy
Improves balance, gait,
gross motor skills, range of
motion, strength,
coordination and muscle
tone
Hippotherapy
• Objective:
Improve the
neurological
function of the
patient, the
sensory
processing and
the general
functional
capacity through
the movement of
a horse
Therapeutic
horseback riding
• It differs from
hippotherapy in
that it teaches
specific skills for
riding
Animal
Assisted
Therapy
Go to: Module 6
Unit 5

•Clients with CP develop
emotional, cognitive, social and
physical skills
ART THERAPY
• Improves expression skills, motor skills,
increases self-confidence and self-esteem in
young people with CP
Musical therapy
•At a physical level, it improves muscle tone,
balance, coordination, flexibility and general
physical health in young people with CP
Dance therapy
•Allows cllients with CP to explore their artistic
interests and express their ideas, thoughts,
frustrations and emotions in different ways
Visual art therapy
Art
Therapy

Play
Therapy
• Offers valuable and creative personal and
interpersonal benefits
• Promotes an important emotional,
psychological functioning
Play
Therapy
FLOOR TIME APPROACH: It is a play-based
treatment for children with developmental delay
and autism.

Boccia International Sports
Federation (BISFed)
International governing body for the
sport of boccia
ADAPTED AND PARALYMPIC SPORT ON CP
Cerebral Palsy International Sports
and Recreation
Association (CPISRA)
International governing body
for sports for athletes with CP

Football 7-a-side, boccia, and race
runner.
CPISRA also holds events for its
athletes in alpine
skiing, athletics, bowls, cycling, nor
dic skiing, powerlifting, swimming,
and table tennis
ADAPTED AND PARALYMPIC SPORT ON CP
Other adapted sports:
Table tennis adapted (for table
tennis)
Tennis in a wheelchair
Chess
Adapted cycling, among others.

STRATEGIES TO IMPROVE PA
PARTICIPATION IN CP
Some of the strategies are:
Design PA interventions that promote and develop personal and environmental
facilitators of physical activity
Design PA interventions that minimize the barriers that influence the performance
of physical activity
Know and look for preferences and interests to perform PA in young people with CP.
Know the culture and family attitudes when designing interventions
Involve friends and competent adults in PA. Ensure that children with CP perform
PA adequately and meaningfully at school

CONCLUSIONS PHYSICAL ACTIVITY AND
RECREATION FOR CLIENTS
Subjects with CP
have a lack of
physical
conditioning and /
or physical
limitation that
significantly affect
the performance
of PA
Recomendations:
Perform moderate-
vigorous PA daily
(60 minutes).
PA must be
adequate, pleasant
and involve a
variety of
activities.
Participate in
<2 hours / day
of non-
occupational
sedentary
activities, such
as watching
television, using
the computer
and / or playing
video games.
The professionals,
parents,
caregivers,
teachers, we must
know not only the
different PA
programs, but
also the
facilitators and
barriers of the PC,
and what are the
strategies to
improve the
regular
participation of PA
in PC

References
• Calvo Muñoz I. Physical activity and recreation for clients. En: Programas de Rehabilitación para
pacientes con Parálisis Cerebral. C Suarez-Serrano y A Gomez-Conesa, editores. Madrid: Asociación
Española de Fisioterapeutas. 2018, 90-100.
• Carlon SL, Taylor NF, Dodd KJ, Shields N. Differences in habitual physical activity levels of young
people with cerebral palsy and their typically developing peers: a systematic review. Disabil
Rehabil. 2013;35(8):647-55.
• DeFazio V, Heather R. PorterBarriers and Facilitators to Physical Activity for Youth With Cerebral
Palsy. Therapeutic Recreation Journal. 2016;4:327-34.
• Ryan JM, Cassidy EE, Noorduyn SG, O'Connell NE. Exercise interventions for cerebral palsy.
Cochrane Database Syst Rev. 2017 11;6:CD011660.
• Powrie B, Kolehmainen N, Turpin M, Ziviani J, Copley J. The meaning of leisure for children and
young people with physical disabilities: a systematic evidence synthesis. Dev
Med Child Neurol. 2015;57(11):993-1010. doi: 10.1111/dmcn.12788.
• Pickering DM, Horrocks L, Visser K, Todd G. Analysing mosaic data by a ‘Wheel of Participation’ to
explore physical activities and cycling with children and youth with cerebral palsy. International
Journal of Developmental Disabilities. 2015;61(1):41-8.
• Verschuren O, Peterson MD, Balemans AC, Hurvitz EA. Exercise and physical activity
recommendations for people with cerebral palsy. Dev Med Child Neurol. 2016;58(8):798-808.
• Lauruschkus K, Nordmark E, Hallström I. Parents' experiences of participation in physical activities
for children with cerebral palsy - protecting and pushing towards independence. Disabil
Rehabil. 2017;39(8):771-8.

Unit 10 - Play and Cerebral Palsy

Objectives of play in Cerebral Palsy
 The game favors the formation of synapses. The game is a
natural activity in every evolutionary process, which is produced
by:
The impulse that children
have towards movement and
exploration of the
environment
Need for affective
and social contact
Understanding
and use of the
environment in
which they live
Exposure to objects as
game tools
Experiment and
stimulation motor

 The game favors learning in all areas of development
Motor:
fine motor, gross
motor and
proprioception
Social: roles,
competence,
conflict resolution,
wait times
Affective:
overcoming fears,
anguishes,
phobias
Sensory:
senses and
perception
Cognitive: memory,
attention, cognition,
logical processing
Communicative:
language, expression,
interaction, dialogues
Essential instrument
in the postural and
movement alterations
that are present in
cerebral palsy

 Video games integrate postural control, mobility and
oculomotricity in the same gesture.
 The use of visual, auditory and proprioceptive feedback is
favored, which affects the awareness of movements.
 On the other hand it favors the learning by trial and error, as
well as the transfer of the learned activities to real contexts.
Computer Play in the rehabilitation of client with
cerebral palsy
Go to: Module 3
Unit 6

 Virtual reality is a complement that allows interaction and
training in realistic environments in three dimensions. Among
its advantages stand out:
Virtual Reality
Framed in
the Theory
of Motor
Learning
Flexible
programs
Attractive
for the
approach in
childhood
Encourage
Feedback
Improve
Atention

 The virtual reality systems used in rehabilitation are classified
according to how the interaction between the person and the
system occurs. They can be based on gestures, feedback or
contact:
Go to: Module 3
Unit 6

 Families, with the necessary support and resources, can favor
and reinforce the learning and development of people with PC
through play. Research shows the benefits of work from
natural environments.
Application Contexts of Play

 Both targeted training, where virtual reality is framed, as well
as programs carried out in natural contexts and in the family
home, favor improvement in motor skills as well as
functionality and self-care.
 The advantages of virtual reality include the realization at
home and the complementary use with other therapies,
favoring the interaction of people with enviroment.

Results of Play in Rehabilitation
When is there a
decline in QUALITY
OF LIFE?
Motor
difficulty
Cognitive
difficulty
Difficulty in self-care
and in interaction
with the Society
Reduce impairments
New technology can reduce disability
HOW?
Games designed simulate
real everyday contexts
that help to develop
motor learning that can
then become
GENERALIZED
Software and games that
develop the OROFACIAL
FUNCTIONS, enhancing
the power and
communication capacity
The play context itself
fosters the ability to
explore, movement and
communication

The actions developed
with VIRTUAL REALITY
affect
Postural Control Movement
Increase functional ability
Virtual reality improves reaction times in children with cerebral
palsy, and improves functionality, because the attentional capacity
is a cognitive function that is involved in the development of
postural control and walking.

Key elements in motor
learning through VR
Repetitions
Motivation
proper to
the task
Feedback
sensorial

Increase of the upper limbs function
Improvement in postural control
Moderate recovery of lower limbs
although better distribution in loads
Increased reaction times, improving
attention and cognitive function

Study that combines others therapies with new
technologies
Other
Therapies
Video game
console
Nintendo Wii
More
functionality
in upper
limbs
Skills in
DLA
(Daily life
activities)
Increased motivation and adherence

Promote greater participation in society
New Technologies
access
- Ease to generalize the learning, what makes possible the
increase of participation in certain tasks and social inclusion.
- Use of robots that incorporate communicative interaction, which
helps transfer learning, encouraging speech and socialization
Virtual reality
provides
experiences to
experience,
sometimes
difficult to
perform in real
contexts for
clients with PC
Go to:
Module 3

Virtual
Reality
Activates the
musculoskeletal
and neuromuscular
capacity
Enables interaction with a specific
task in a given context
Originates diverse sensory
stimuli
Effects of different programmes of Play
Increase in motivation
The choice of the
task and the game
must combine
reachable achievable
objectives

References
 Benitez Lugo ML. El juego y la Parálisis Cerebral. En: Programas de Rehabilitación para pacientes
con Parálisis Cerebral. C Suarez-Serrano y A Gomez-Conesa, editores. Madrid: Asociación Española
de Fisioterapeutas. 2018, 101-110.
 Fung V, So K, Park E, Ho A, Shaffer J, Chan E et al. The Utility of a Video Game System in
Rehabilitation of Burn and Nonburn Patients: A Survey among Occupational Therapy and
Physiotherapy Practitioners. J Burn Care Res. 2010; 31: 768-775.
 Shih CH, Chen LC, Shih CT. Assisting people with disabilities to actively improve their collaborative
physical activities with Nintendo Wii Balance Boards by controlling environmental stimulation. Res
Dev Disabil. 2012; 33: 39-44.
 De Oliveira JM., Fernandes R, Pinto, CS, Pinheiro PR, Ribeiro S, Albuquerque VH. Novel Virtual
Environment for Alternative Treatment of Children with Cerebral Palsy, Comput Intell Neurosci.
2016; 2016:8984379. doi: 10.1155/2016/8984379. Epub 2016 Jun 14.
 Pereira EM, Rueda FM, Diego MA, de la Cuerda RC, Mauro AD, Page CM. Use of virtual reality
systems as propioception method in cerebral palsy: clinical practice guideline. Neurología, 2014,
29(9): 550-559
 Dunst, C. J., Bruder, M. B., Trivette, C. M., Hamby, D., Raab, M., & McLean, M. Characteristics and
consequences of everyday natural learning opportunities. Topics Early Child Spec Educ, 2001; 21,
68-92.
 Dunst CJ, Bruder MB, Sherwindt ME. Family Capacity-Building in Early Childhood Intervention: Do
Context and Setting Matter? School Community Journal, 2014, Vol. 24(1)
 Novak I, McIntyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith
S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev
Med Child Neurol.2013; 55(10):885-910. doi: 10.1111/dmcn.12246.
 De Mello Monteiro CB, Massetti T, da Silva TD, Van del Kamp J, De Abreu LC, Leone C, Savelsbergh
GJP. Transfere of motor learning from virtual to natural environment in individuals with cerebral
palsy. Res Dev Disabil. 2014; 35: 2430-2437

 Park SK, Yang DJ, Heo JW, Kim JH, Park SH, Uhm YH. Study on the quality of life of
chilgren with cerebral palsy. J. Phys.Ther.Sci. 2016; 28: 3145-3148
 Khishner S, Weiss PL, Tirosh E. Meal-Marker: A virtual Meal Preparation Environment
for Children with Cerebral Palsy. Eur J Spec Needs Educ. 2011; 26(3): 323-336
 Martín-Ruiz ML, Maximo-Bocanegra N, Luna-Oliva L. A virtual environtemn to
improve the detection of oral-facial malfunction in children with Cerebral Palsy.
Sensors. 2016; 16(4): 444 dou: 10.3390/s16040444
 Ryalls BO, Harbourne R, Kelly-Vance L, Wickstrom J, Stergiou N, Kyvelidou A. A
perceptual motor intervention improves Play Behaviour in children with moderate to
severe cerebral palsy. Front. Psychol.2016, 7: 643. Doi: 10.3389/fpsyg.2016.00643
 Chen Y, Fanchiang HD, Howard A. Effectiveness of virtual reality in children with
cerebral palsy: A systematic review and Meta-Analysis of randomized controlled
trials. Phys Ther. 2017 Oct 23. doi: 10.1093/ptj/pzx107. [Epub ahead of print]
 Ravi DK, Kumar N, Singhi P. Efectiveness of virtual reality rehabilitation for children
and adolescents with cerebral palsy: an updated evidence-based systematic review.
Physiotherapy. 2017;103(3):245-258. doi: 10.1016/j.physio.2016.08.004.
 Acar G, Altun GP, Yurdalan S, Polat MG. Efficacy of neurodevelopmental treatment
combined with the Nintendo Wii in patients with cerebral Palsy. J Phys Ther Sci.
2016; 28(3):774-80. doi: 10.1589/jpts.28.774.

CP-Care project partners
 Gazi University (Turkey)
 PhoenixKM BVBA (Belgium)
 Bilge Special Education And Rehabilitation
Clinic (Turkey)
 Spastic Children Foundation Of Turkey
(Turkey)
 Serçev- Association For Children With
Cerebral Palsy (Turkey)
 Asociación Española de Fisioterapeutas
(Spain)
 National Association Of Professionals Working
With People With Disabilities (Bulgaria)

CP-CARE curriculum, learning material,
handbook by www.cpcare.eu is licensed
under a Creative Commons Attribution-
NonCommercial 3.0 Unported License.
Based on a work at www.cpcare.eu
Permissions beyond the scope of this
license may be available at www. cpcare.eu
This project (CP-CARE - 2016-1-TR01-
KA202-035094) has been funded with
support from the European Commission.
This communication reflects the views only
of the author, and the Commission cannot
be held responsible for any use which may
be made of the information contained
therein.

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