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Cerebral Palsy: PT assessment and Management

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neurological physiotherapy, cerebral palsy rehabilitation, APGAR Score

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Cerebral Palsy: PT assessment and Management

  1. 1. CEREBRAL PALSY
  2. 2. Definition It is defined as a group of disordersresulting from permanent nonprogressive cerebral dysfunctiondeveloping before maturation of CNSaffecting the locomotor system It is non-contagious motor conditionsthat cause physical disability inhuman development
  3. 3.  Although brain lesions that result inCP are not progressive, clinical pictureof CP may change with time In addition to primary impairments ingross & fine motor function, there maybe associated problems withcognition, seizures, vision, swallowing, speech, bowel-bladder, & orthopedicdeformities
  4. 4. Criteria of diagnosis◦ Neuromotor control deficit that altersmovement or posture◦ Static brain lesion◦ Acquisition of brain injury eitherbefore birth or in first years of life
  5. 5. History Formerly known as "Cerebral Paralysis,“◦ First identified by English surgeon William Little in1860. (Little’s disease)◦ Believed that asphyxia during birth is chief cause In 1897, Sigmund Freud, suggested thatdifficult birth was not the cause but only asymptom of other effects on fetal development National Institute of Neurological Disorders &Stroke (NINDS) in 1980s suggested that only asmall number of cases of CP are caused by lackof oxygen during birth
  6. 6. Epidemiology The incidence of CP is about 2 per 1000 livebirths The incidence is higher in males than infemales Other associated problems include◦ Mental disadvantage (IQ < 50): 31%◦ Active seizures: 21%◦ Mental disadvantage (IQ < 50) and not walking:20%◦ Blindness: 11%
  7. 7.  During past 3 decades considerable advancesmade in obstetric & neonatal care, but therehas been no change in incident of CP The population of children with CP may beincreasing due to premature infants who aresurviving in greater numbers, higherincidence in normal-weight term infants (3), and longersurvival overall.
  8. 8. Causes of CP Prenatal (70%) Peri-natal (5-10%) Post natal
  9. 9. Prenatal Maternal infections E.g. rubella,herpes simplex Inflammation of placenta (chorionamnionitis) Rh incompatibility Diabetes during pregnancy Genetic causes Exposure to radiations Maternal jaundice
  10. 10. Peri- natal Prematurity- immature respiratory &cardiac function Asphyxia Maconeum aspiration Birth trauma Disproportion Breech delivery Rapid delivery Low birth weight Coagulopathy
  11. 11. Post natal Brain damage secondary to cerebralhemorrhage, trauma, infection oranoxia Motor vehicle accidents Shaken baby syndrome Drowning Lead exposure Meningitis Encephalitis
  12. 12.  Additional risk factors for CPinclude◦ Kernicterus◦ methyl mercury exposure◦ genetic causes
  13. 13. Classification of CP Depending on the topographicaldistribution◦ Monoplegic◦ Diplegic/ Paraplegic◦ Triplegic◦ Hemiplegic◦ Tetraplegic / Double hemiplegia
  14. 14.  Monoplegia is one single limb being affected. Diplegia: LE affected, with little to noupper-body spasticity.◦ The most common form of spastic forms◦ Most people with spastic diplegia are fullyambulatory, but are "tight" & have scissors gait◦ Flexed knees & hips to varying degrees, &moderate to severe adduction are present◦ Often nearsighted & intelligence is unaffected◦ In 1/3rd of spastic diplegics, strabismus may bepresent
  15. 15.  Hemiplegia◦ The most ambulatory of all forms, althoughthey generally have dynamic equinus onaffected side Triplegia: three limbs affected usuallyboth LL & one UL Quadriplegia: all four limbs more orless equally affected.◦ Least likely to be able to walk◦ Some children also have hemiparetictremors (hemiballismus), & impairs normalmovement
  16. 16.  Depending on tone or movementpatterns (physiologic)◦ Spastic◦ Athetoid/ dyskinetic◦ Ataxic◦ Flaccid/ Hypotonic◦ Mixed
  17. 17. Spastic CP It is the most common type of CP,occurring in 70% to 80% of all cases. The cerebral cortex is affected Moreover, spastic CP accompanies anyof the other types of CP in 30% of allcases It can be monoplegia, diplegia,triplegia, hemiplegia or quadriplegia.
  18. 18. Athetoid/ dyskinetic CP It is mixed muscle tone Often show involuntary motions The damage occurs to extrapyramidal motorsystem & pyramidal tract It occurs in 10% to 20% of all cases In newborn infants, high bilirubin levels inblood, if left untreated, can lead to braindamage in certain areas (kernicterus). This may also lead to Athetoid CP
  19. 19. Ataxic CP It is caused by damage tocerebellum They are least common types ofCP, occurring only in 10% of all cases Some of these individuals havehypotonia and tremors
  20. 20. Hypotonic CP Hypotonic CP have musculature that islimp, and can move only a little or not atall (Floppy child) The location of damage is wide spread inthe CNS Although physical therapy is usuallyattempted to strengthen muscles it is notalways fundamentally effective.
  21. 21. Mixed CP Signs & symptoms of spastic CP isseen with any other type of CP◦ Most commonly mixed with Athetoid
  22. 22.  Depending on functional level (GrossMotor Function Classification System)◦ It classifies acc. to age categorizedactivity level
  23. 23. pathology Periventricular leukomalacia (PVL) is themost common finding in CP Corticospinal tract fibers to LL are medial tothose of UL in periventricular white matter.◦ Thus children with PVL typically have spasticdiplegia (common type of CP)
  24. 24.  Bilirubin encephalopathy in basal ganglia is seen inathetoid CP following a diagnosis of kernicterus Focal cortical infarcts involving both grey & whitematter are found in patients with hemiparesis, &are typically related to MCA strokes Brain malformations can be found on neuroimagingin approximately 10% of children
  25. 25. Signs & symptoms (spastic) Hypertonia Exaggerated reflexes &+ve barbinskis Clonus Poor voluntary movement Scissoring gait Low intelligence & loss ofmemory Epilepsy Synergistic pattern Contracture, deformity& wasting◦ Adduction & IR ofshoulder◦ Flexion of elbow &pronation of forearm◦ Wrist flexion & thumbinside hand◦ Flexion & adduction of hip◦ Knee flexion◦ PF of ankle
  26. 26. Extrapyramidal CP May affect limb, face, tongue& speech Characterized by continuousmuscular worm like movement Postural instability Decreased movement in proneposition Fluctuation of tone from highto low Reflexes are usually normal &muscles are able to contract Decreased stability Difficulty to look up Emotional liability Arms are more affected Sucking & feeding problems Delayed head & trunk control May be either quadriplegic orrarely hemiplegic Subtypes -dystonic, athetoid, choroid, hemiballismic, rigid
  27. 27. Ataxic / hypotonic Inco-ordination Intension tremor Hypotonia Nystagmus Diminished reflexes Speech, visual,hearing & perceptualproblems Joint hypermobility Dysmetria Incontinence Postural instability Gait disturbances Imbalance & lack oftrunk control Unsteadiness
  28. 28. risk babies Biological risk Established risk Environmental & social risk
  29. 29. Biological risk Birth weight of 1500g or less Gestational age of 32 weeks or less Small for gestational age (less & 10th percentile ofweight) Ventilator requirement for 36 hours or more Intracranial hemorrhage muscle tone abnormalities Recurrent neonatal seizures (3 or more) Feeding dysfunction Symptomatic (TORCH) Meningitis Asphyxia with apgar score <3 in 1 min after birth or <6in 5 min after birth
  30. 30. Established risk Hydrocephalus Microcephaly Chromosomal abnormalities Musculoskeletal abnormalities (CDH, AMC, limbdeficiencies) Multiple births more than twins Brachial plexus injuries Myelodysplasia Congenital myopathies Inborn errors of metabolism HIV infection
  31. 31. Environmental/ social risk Single parent Parental age less than 17 Poor quality infant parentattachment Maternal drug or alcohol abuse Behavioral state abnormalities(lethargy, irritability)
  32. 32. Detection of risk babies Principles◦ There should be definite objective◦ Some form of action should be possible if thetest is positive◦ The population should be defined◦ Test should be sensitive◦ Test should be specific◦ Screening should start at foetal life &continue into early childhood Some test are for all children but some are for thosewho are known to be at risk
  33. 33. Prenatal screening Routine check up for mother duringpregnancy is beneficial for themother & the foetus Health education◦ Diet advice (avoid tobacco & alcohol)◦ Exercise on prescription◦ Sleep & working habits
  34. 34.  Clinical examination◦ Breast condition◦ Height of uterus◦ Position of foetus◦ BP◦ Samples of blood & urine For special test condition sought are◦ Phenylketonuria◦ Glycosuria◦ Albuminuria◦ Rh incompatibility◦ Congenital syphillis◦ Rubella, AIDS◦ Neural tube defect
  35. 35.  Special test for screening◦ USG from 8-12 weeks For the assessment of the gestational period Congenital abnormalities in various organ defect◦ Amniocentesis from 16-18 weeks of pregnancy To find chromosomal defect, if the test is positiveterminate pregnancy◦ Chorionic villus sampling technique in 8-11weeks of pregnancy For chromosomal study
  36. 36. Post natal screening Starts in the immediate neonatalperiod & during the first two years◦ To find biochemical defects◦ Hearing & visual problems
  37. 37.  Clinical methods (at birth)◦ Examination of weight, height, headcircumference◦ Gestational age◦ Musculoskeletal defects◦ Testicular descent◦ At 6 weeks repeat test
  38. 38.  Chemical methods◦ Blood sample from heel prick at 2-5 daysof age & repeated where necessary Respiratory conditions, cardiac pathology,haemoglobinopathies can be detected Neuromuscular pathologies (cpk level) Metabolic disorders Gene abnormalities
  39. 39.  Electronic scanning◦ USG, CT Scan, MRI To find outAVM, hemorrhage, cyst, leucodystrophiesetc
  40. 40. Diagnosis The diagnosis of CP depends onpatients history & on the basis ofsignificant delay in gross & fine motorfunction, with abnormalities in tone,posture, & movement on neurologicalexamination. Once diagnosed with CP, furtherdiagnostic tests are optional.
  41. 41.  MRI is preferred over CT due to diagnosticyield & safety. The CT or MRI also reveals treatableconditions, such ashydrocephalus, AVM, subdural hematomasetc. Diagnosis, classification, & treatment areoften based on abnormalities in tone Apgar scores have sometimes been used asone factor to predict whether or not anindividual will develop CP
  42. 42. Diagnostic tools Movement Assessment of Infants (MAI): ableto predict CP at 4 months (identifies motordelay) Alberta Infant Motor Scale (AIMS) is able topredict CP at 6 months (Identifies motordelays & measures changes in motorperformance over time) Bayley scale is able to predict CP at 1 year(Identifies devt delay in gross & fine motor, &cognitive domains)
  43. 43. Management Medical Surgical Rehabilitative
  44. 44. Drugs Oral medications such asbaclofen, diazepam, and trihexyphenidylas well as therapeutic botulinum toxin(Botox) Children with dystonic CP have dopa-responsive dystonia, with improvedmotor function using levodopa Children with basal ganglia/thalamicinjury from perinatal asphyxia maydevelop improved expressive speech &hand use with trihexyphenidyl
  45. 45. Surgery Dorsal rhizotomy reduces spasticity Joint & Tendon release most often performed onhips, knees, & ankles. The insertion of a baclofen pump usually duringyoung adolescence.◦ usually placed in left abdomen - a pump that isconnected to spinal cord,◦ sends bits of Baclofen to relax muscle Bony correction E.g. femur (termed femoralanteversion or antetorsion) & tibia (tibial torsion).2ndary complication caused by spastic musclesgenerating abnormal forces on bones
  46. 46. Prognosis CP is not a progressive but the symptomscan become more severe over time Prognosis depends on intensity oftherapy during early childhood Tend to develop arthritis at a youngerage than normal because of pressureplaced on joints by excessively toned &stiff muscles
  47. 47.  Intellectual level among people with CP variesfrom genius to intellectually impaired◦ (it is important to not underestimate a person with CPand to give them every opportunity to learn) The ability to live independently with CP varieswidely depending on severity of each case.◦ Some individuals with CP are dependent for all ADL.◦ Some can lead semi-independent lives, needingsupport only for certain activities.◦ Still others can live in complete independence.
  48. 48.  Persons with CP can expect to have anormal life expectancy Survival is associated with the ability toambulate, roll, & self-feed As the condition does not directlyaffect reproductive function, some havechildren & parent successfully There is no evidence of increasedchance of a person with CP having achild with CP
  49. 49. Notable persons Abbey Curran, American beauty queenwith CP who represented Iowa at MissUSA 2008 and was the firstcontestant to compete with adisability
  50. 50. Prediction of ambulation
  51. 51. Pt assessment Subjective Examination:◦ Obtained from parents especially motheror from relatives and through case-sheet.◦ General details includes Name Age & Sex Address When did the mother first noticed thedysfunctions◦ Siblings having same type of symptoms
  52. 52. PT assessment History◦ Review of complications of pregnancy &delivery, birth weight, gestation, anyneonatal & perinatal difficulties,feeding problems, and other health-related problems◦ Developmental milestones
  53. 53.  Prenatal History◦ Age of mother◦ Consanguity marriage◦ Any drugs taken during pregnancy◦ Any trauma & stress◦ Any addiction – smoking or alcoholism◦ History of TORCH infection◦ History of previous abortions, still born or deathafter birth◦ Multiple pregnancies◦ Status & cast of the mother
  54. 54.  Perinatal History◦ Place of delivery◦ History preterm or post-term delivery◦ History of asphyxia at birth◦ History of prolonged labour pain◦ Type of delivery (Forceps, vacuumdelivery)◦ Presentation of child (Breech)◦ Condition of mother at the time ofdelivery
  55. 55.  Postnatal History◦ Delayed birth cry◦ Weight of the child at birth◦ History of trauma to brain during the first 2 years of life◦ History of neonatalmeningitis, jaundice, hypoglycemia, Hydrocephalus orMicrocephaly◦ Nutritional habits of the child (malnutrition), Feeding difficulties◦ Any medical, surgical or physiotherapy treatment taken before◦ What treatment was used?◦ Was the treatment effective or not?◦ What was the ability level of child at that time?◦ What obstructs the child from progress?◦ Apgar Score from the case-sheet
  56. 56. On Observation: Behaviour of the child◦ Whether child is alert, irritable or fearful in thesession or during particular activities◦ Child becomes fatigued easily or not during activity◦ What motivates his action – particular situation,person or special plaything Communication of the child◦ With the parents◦ Whether child initiates or responds with gestures,sounds, hand or finger pointing, eye pointing or useswords and speech
  57. 57.  Other observations◦ Involuntary movements◦ Deformities & contracture◦ Scar may be present◦ Trophic changes may also be seen due topoor positioning◦ Postural faults◦ Gait abnormalities◦ Use of external appliances
  58. 58.  Attention span◦ What catches child’s attention◦ For how much time child’s attention ismaintained on particular thing◦ How does parent assist him to maintainattention◦ What distracts the child◦ Does child follows suggestions to moveor promptings to act
  59. 59. ◦ Position of the child Which position does the child prefer to be in? Can child get into that position on his own orwith help? With assistance, child makes any effort to go inthat position Symmetry of the child (actively or passivelymaintained) If involuntary movements present, then in whichpositions these movements are decreased orincreased
  60. 60. ◦ Postural control & alignment How much parental support is given Postural stabilization and counterpoising inall postures Proper & equal weight bearing If the child’s center of gravity appears to beunusually high, resulting in floating legs andpoor ability to raise head against gravity Fear of fall in child due to poor balance
  61. 61. ◦ Use of limbs & hands Limb patterns in changing or going into positionas well as using them in position◦ Attitudes of limbs during playing & in allpositions Whether one or both hands are used, type ofgrasp and release Accuracy of reach and hand actions Any involuntary movements, tremors orspasms, which interfere with actions, arepresent
  62. 62. ◦ Sensory aspects Observe child’s use of vision, hearing, oftouch, smell and temperature in relevant tasks Does child enjoys particular sensations Whether child enjoys being moved or havingposition changed◦ Form of Locomotion How child is carried Any use of wheelchair or walking aids Which daily activities motivates child toroll, creep, crawl, bottom shuffle or walk
  63. 63. ◦ Deformities Any part of body, which remains in particular position in allpostures & in the movements The positional preferences typically seen in spastic cerebralpalsies are for mid positions of body – In the UL Shoulder protraction or retraction, adduction and internal rotation,Elbow flexion, Forearm pronation, Wrist & Fingers flexion In the LL Hip semi-flexion, internal rotation and adduction, Knee semi-flexion,Ankle plantar flexion, Foot pronation or supination, Toes flexion Athetoid or dystonic posturing usually incorporatesextremes of movement such as total flexion or extension Windswept Deformity of hip – One hip flexed, abducted andexternally rotated; other hip flexed, adducted and internallyrotated and in danger of posterior dislocation
  64. 64.  Higher cognitive function◦ Drowsy & lethargic◦ Decrease in intellectual function◦ Mental retardation (mild to profound)◦ Attention deficit & easily distractible◦ Poor memory◦ Poor comprehension of speech &language
  65. 65.  Cranial nerve integrity◦ Strabismus or squint (Occulo motornerve)◦ Visual defects (optic nerve)◦ Auditory defects (auditory nerve)◦ Feeding & swallowing problems (lowercranial nerves) etc.
  66. 66.  Special senses◦ Visual & auditory defects◦ Tactile & vestibular hyposensitivity orhypersensitivity
  67. 67. On examination Sensory Assessment◦ It is difficult to assess sensation inbabies and young children with severemultiple impairments.◦ If any hearing or visual or psychologicalabnormalities are present thenassessment done by specialist is required
  68. 68.  Motor integrity◦ Abnormalities of tone Spasticity, hypotonicity, dystonia etc◦ Muscular weakness◦ Loss of voluntary control◦ Decreased co ordination
  69. 69.  Reflex integrity◦ Abnormal DTR◦ Abnormal Superficial reflexes◦ Abnormal primitive reflexes may bepersistent ATNR, Extensor thrust, gallant reflex etc
  70. 70.  ROM & flexibility◦ Decreased in the ROM of the involvedlimbs◦ Tightness & contracture in hipadductors, hamstrings, calf are verycommon
  71. 71.  Anthropometric measurement◦ Height or length decreased (growthretardation)◦ Weight – decreased (thin & lean) or obese◦ Head circumference – decreased (growthretardation or microcephaly), increased(hydrocephalus)
  72. 72. ◦ Growth Parameters Height - Until 24 to 36 months ofage, length in recumbency is measured usingan infantometer. After the age of 2 yearsstanding height is recorded by a stadiometerWeight kg PoundsAt birth 3.25 73-6 months Age in months +9/2 Age in months + 111-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+177-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
  73. 73. Weight kg PoundsAt birth 3.25 73-6 months Age in months +9/2 Age in months + 111-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+177-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5 Weight
  74. 74.  Head circumference of the child -◦ The tape is used to measureoccipitofrontal head circumferencefrom external occipital protuberance toglabellaHead cicumference CmAt birth 353 months 401 yr 452 yrs 4812 yrs 52
  75. 75. Developmental milestones Age Developmental Milestones 4 to 6 weeks Social smile 3 months Head holding 6 months Sits with support 7 months Sits without support 5 to 6 months Reaches out for bright object & gets it 6 to 7 months Transfers object from one hand to other 6 to 7 months Starts imitating cough 8 to 10 months Crawls
  76. 76.  10 to 11 months Creeps 9 months Standing holding furniture 12 months Walks holding furniture 10 to 11 months Stands without support 13 months Walks without much of a support 12 months Says one word with meaning 13 months Says three words with meaning 15 to 18 months Joints 2 or 3 words into sentence
  77. 77.  13 months Feeds self with spoon 15 to 18 months Climbs stair 15 to 18 months Takes shoes and socks off 24 months Puts shoes and socks on 24 months Takes some clothes off 3 to 4 years Dresses self fully 2 years Dry by day 3 years Dry by night 3 years Knows full name and sex 3 years Rides tricycle
  78. 78.  Joint Range of Motion (active & passive)◦ Active head and trunk flexion, extension, rotation observedduring head raise in prone, supine, sitting, standing developmentalchannels◦ Active shoulder elevation, abduction, rotation, flexion andextension movements are observed during functional examinationof creeping, reaching and other arm movements◦ Active elbow flexion and extension observed during child’s reachto parts of body or toys◦ Active wrist and hand movements will be observed duringfunction development◦ Active hip flexion and extension will be observed during allfunctions◦ Active knee flexion and extension seen with active hip flexionextension◦ Foot movements are also check during functional development
  79. 79.  Posture◦ Poor posture in all types of CP◦ Kypho-Scoliosis, knock knee & flexiondeformity & inverted flat foot arecommonly seen
  80. 80.  Balance & gait◦ Compromised static & dynamic balance◦ Balance severely affected in athetoid &ataxic CP◦ Independent walking is rarely achievedby spastic quadriplegic & athetoid CP, few diplegic CP can walk with aids, hemiplegic CP can achieve independentwalking
  81. 81.  Bowel & bladder involvement◦ If the child is able to communicate &understand, training can be helpful◦ In profound MR and those unable tocommunicate have dependent functions
  82. 82.  Functional capacity◦ Varies from complete dependence tocomplete independent
  83. 83. PT MANAGEMENT
  84. 84. INFANCY(FIRST STAGE – BIRTH TO3 YEARS)
  85. 85. PT aims Family education Handling & care Promote infant & parent interaction Encourage development of functionalskills & play Promote sensory motor development Establish head & neck control Attain & maintain upright position
  86. 86. Family education Educate families about CP Provide support in their acceptance of child Goal setting & programming should be donewith family Be realistic about the prognosis & efficacy ofPT while remaining hopeful Honesty & commitment towards child Listening to parental concerns & recognizingpersonal values & strength
  87. 87. Handling & care Promote parents ease, skill & confidence inhandling child Positioning, feeding & carrying techniques shouldbe taught Promote symmetry, limit abnormal posturing &facilitate functional motor activity Use variety of movement & posture to promotesensory function Include position to allow lengthening of spastic orhypoextensive muscles Use positions to improve functional voluntarymovement of limbs
  88. 88. Mother & childrelationship Activities should be done on motherslap, close to body & face so that hertouch & stroking & talking to baby notonly help motor development but alsobody image, movement enjoyment by baby& demonstrate love & security Weaning of child to a PT should becarefully done after mother-child bonding& confidence is established
  89. 89.  Introducing more than one therapistor developmental worker may bedisconcerting to child & even parents Not to overload with exercises, butrather use corrective movements &postures within ADL of child
  90. 90. Feeding & respiration Position in a propped up sitting for feeding For greater hip stability & symmetryduring feeding position in a high chair withadaptation Head & neck position should be in neutralrotation & slight flexion to facilitateswallowing Deep respiration can be facilitated beforefeeding by applying pressure in the thoraxor the abdominal area
  91. 91. Facilitate sensory-motordevelopment (body image) Reaching, rolling, sitting, crawling &transitional movements like standing &pre walking are facilitated◦ Promotes spatial perception, body awareness& mobility, facilitate play, social interaction& exploration of environment Use of equipments that facilitatesfunction when impairment is preventingdevelopment E.g. sitting on adaptedchair
  92. 92.  Practice midline play, reach forfeet, suck on fingers Do not give too many stimuli at once Carefully introduce different surfacesfor child to roll on, creep, crawl, & walkon with bare feet Always give child time to experiencetactile & auditory stimuli & let him reach& find out about himself wheneverpossible
  93. 93. Improve proprioceptive &vestibular function They are compensatory stimuli for visualimpairment & also develop body image Touch, pressure & resistance can becorrectly given to stimulate movementgiving clues as to direction & degree ofmuscle action. Do not use Rx with handling or otherproprioceptive stimuli from behind asleaning back will facilitate extensorthrusts
  94. 94. Visual development Can be easily integrated with methods forhead control, hand function & all balance &locomotor activities Relate appropriate level of visual ability withchilds motor programme. Also one may have to accept unusual headposition & other patterns which make itpossible for the child to use residual vision Use favorite toys or colors to facilitatevisual function
  95. 95. Language development Talk & clearly label body parts used Delay is normal for a child who cannot yetunderstand meaning of sounds, words &conversation Use simple & easy words with appropriateexamples & models Communication is also fostered throughmotor actions, touch & body languagerelevant to sign system of a child
  96. 96. Facilitating motordevelopment Postural stability of the head when◦ lying prone (0-3 months)◦ on forearms (3 months)◦ on hands and on hands and knees (6months),◦ during crawling, half-kneeling handsupport (9-11 months)◦ in the bear-walk (12 months) in normaldevelopmental levels.
  97. 97.  Acceptance of prone position.◦ Accustom child to prone on soft surfaces, sponge rubber, inflatablemattress, in warm water, over large softball, over your lap rock and sway a baby held in pronesuspension.
  98. 98.  Postural stability of the shoulder girdle◦ weight on forearms (3 months),◦ on hands (6 months),◦ on hands & knees & arms held stretched forwardalong the ground to hold a toy at 5-6 months alsoinclude postural stability. Pivot prone with arms held extended in airactivates stabilizers (8-10 months). Maintenance of half-kneeling lean or uprightkneeling (lean on hands) or grasp a support -9-12 months stimulates shoulder girdlestability
  99. 99.  Postural stability of pelvis◦ On knees with hips at right angles (4months)◦ on elbows & knees & on hands and knees(4-6 months),◦ on half-kneeling and upright kneelingwith support (9-12 months) in normalmotor levels.
  100. 100. Maintaining an uprightposition Use of adapted chairs & standingframe Use of orthosis can be delayed untilsome voluntary movement is gained Sitting on swiss ball, vestibular boardetc can be given to improvechallenges
  101. 101. PRESCHOOL PERIOD
  102. 102.  Main aim is to reduce the primaryimpairments & prevent thesecondary impairments
  103. 103. Increase force generation(strengthening) Creating demands in both concentric &eccentric work◦ Transitional movements against gravity, ballgymnastics etc. If a child has some voluntary control inmuscle group, capacity for strengtheningexists Use of electrical stimulation or bystrengthening within synergisticmovement patterns
  104. 104.  Ambulatory children with CP havecapacity to strengthenmuscles, although poor isolated controlor inadequate length To participate in a strength-trainingprogram, child must be able tocomprehend & to consistently producea maximal or near-maximal effort
  105. 105. Reduce spasticity Positioning in anti synergistic pattern Stretching of tight structures MFR ROM exercise Rhythmic rotations Splinting & serial casting Dorsal rhizotomy Botox injection
  106. 106. Increase mobility &flexibility ROM exercise Maintain length of muscle by regularstretching & splinting◦ Prolonged stretching of 6 hours a day withthe threshold at which the muscle began toresist a stretch Strengthening exercise of primemovers of a joint
  107. 107. Prevent deformity Serial Casting techniques Orthosis & night splints Lycra splinting & taping techniques◦ Skin reactions should be carefullyassessed Allignment of the body in a varietyof positions in which they canoptimally function, travel & sleep
  108. 108. Improve physical activity Exercise should be intensive, challenging &meaningful & involve integration of skills intofunction Movement should be goal oriented & interesting tomaintain motivation◦ Kicking a soccer ball Feedback is important & feedforward is alsoconsidered CIMT also improves function in hemiplegic CP Oromotor rehabilitation should also be provided
  109. 109. Improve ambulatorycapacity Weight bearing, promotingdissociation, & improving balance Walkers & crutches may be used◦ Posterior walkers encourages more uprightposture during gait Treadmill training or body weightsupport treadmill training Adapted tricycle, wheelchair ormotorized wheelchair may improvemobility in more disabled children
  110. 110. Improve play Play is the primary productive activity ofchildren it should be motivating &pleasurable Motivates social skills, perceptionconceptual, intellectual & language skills Appropriate toys & play methods shouldbe suggested Parents should encourage to let childrenenjoy their typical play activities s/arolling downhill or getting dirty
  111. 111. SCHOOL AGE & ADOLESCENCE
  112. 112. Improve activity, mobility &endurance Gait training can be continued throughoutschool age with other conjunction s/aspasticity mgt Architectural modification may berequired s/a ramps or rails Orthosis increases energy expenditure Regular exercise, proper diet & nutrition &participation in recreational activities isencouraged
  113. 113. School & communityparticipation Positioning, lifting & transfer techniquesshould be taught to the school personnel Opportunities should be given toparticipate in community & recreationalactivities Adapted games & athletic competition &team participation improves self esteem Introduce to Community fitness program
  114. 114.  Barriers s/a transportation, finances,time preferences & involvement,interest should also be consideredcarefully Injury prevention will limit impairment& disability
  115. 115. TRANSITION TOADULTHOOD
  116. 116. Improve functional skills Maintain & improve cardiovascular fitness Weight control, maintain integrity of joints &muscles, help prevent osteoporosis Fitness clubs, swimming, wheelchair aerobics& adapted sports are options Disability certificate should be provided toreimburse handicap facilities & compensations Introduce to help lines & community carecenters
  117. 117. Transition planning Vocational training & occupationaltraining should be provided Living arrangement, personal mgtincluding birth control, social skill &household management should be madeavailable Continuation of professional healthservice should be done
  118. 118. Characteristics Score 0 Score 1 Score 2 AcronymSkin color/ComplexionBlue or pale alloverBlue at extremitiesbody pink(acrocyanosis)No cyanosis-body & extremitiespinkAppearancePulse rate Absent <100 ≥100 PulseReflexirritabilityNo response tostimulationgrimace/feeble crywhen stimulatedcry or pull awaywhen stimulatedGrimaceMuscle tone None some flexionflexed arms & legsthat resist extensionActivityBreathing Absentweak, irregular,gaspingstrong, lusty cry RespirationApgar score
  119. 119. Scoring Test is done at 1 & 5 min after birth, & repeated later ifscore is/ & remain low◦ 3 & below- critically low,◦ 4 to 6 - fairly low◦ 7 to 10- generally normal. A low score on 1 minute -requires medical attention If score remains below 3 at times s/a 10, 15, or 30min, there is a risk that child will suffer longer-termneurological damage. Purpose of Apgar test is to determine quickly whether anewborn needs immediate medical care or not & notdesigned to make long-term predictions A score of 10 is uncommon due to prevalence of transientcyanosis, & is not substantially different from a score of 9.◦ Transient cyanosis is common, particularly in babies born athigh altitude.

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