REHABILITATION OF CEREBRAL PALSY & MOTOR DELAY

1. REHABILITATION OF CEREBRAL PALSY & MOTOR DELAY :

2. REHABILITATION OF C.P CEREBRAL PALSY Static encephalopathy(=non progressive) caused by an insult to theimmature brain REHABILITATION: The process of making the child w/ disability maximally able again through the application of rehab principles & techniques.

3. REHABILITATION OF C.P Principles of proper rehabilitation : 1. Proper evaluation( individual treatment ) - to plan a therapy program.to assess progress. - to add observation to the diagnostic picture. 2. Early treatment( increasing functional deficits w/ age as secondary effects of spasticity &other primary problems 3. Team work ( global dysfunction )

4. (A) Clinical evaluation 1. Functional : Postural control Mobility Primitive reflexes Motor exam 2. Swallowing & dysphagia 3. Communication:Speech/ language Visual Auditory Mentality 4. Chest 5. Urinary bladder 6. Bowel 7. Self -care activities (ADL) 8. psychosocial EVALUATION OF CP CHILD

5. EVALUATION OF CHILD WITH CP. (B) Imaging 1. Serial X-rays: Hips (dislocation spastic adductors) Th-L-Spine (scoliosis, hyperlordosis in spastic CP kyphoscoliosis in floppy CP) 2. MRI or CT brain (progressive motor deficits ? tumors, hydrocephalus

6. ASSESSMENT OF MILESTONES & POSTURAL CONTROL • Understanding normal development allows to adaptive equipment to assist child in gaining increase the interaction with the environment. • Sitting balance at age 2 yrs. is an indicator of future walking. • Observe how much parental support given to child. child own ability in postural stabilization. collapse on one side of his body, twist to one side, tilt & turn to one side.

7. EVALUATION OF PRIMITIVE REFLEXES • Can be used as indicator of ambulation • Abnormal response for two of the following seven reflexes by age 12 month has a poor prognosis for walking this are Should be absentShould be present ATNR parachute reaction STNR foot placement Moro response Neck righting reflex Extensory thrust • Presence of Moro or ATNR, seizures, ability to sit at 12 month indicate ambulation by age of 6 yrs.

8. MOTOR EXAMINATION GAIT • Hemiplegia Toe walk • Diplegia Bilateral equinovaras, Knee flexed & in valgus Scissoring • Cerebellar Ataxic

9. MOTOR EXAMINATION DEFORMITIES • Hemiplegia : adducted arm, flexed elbow, wrist & fingers equinus foot. • Diplegia: adducted hip, flexed knee in valgus, bilateral EV knee height discrepancy indicates hip dislocation. • Quadriplegia: combination scoliosis & hyperlordosis in spastic CP kyphoscoliosis in hypotonic CP

10. MOTOR EXAMINATION R.O.M. • Degree by goniometry: • Limited (= fixed deformity = ms. Contracture) • Not limited (+ deformity = threatening deformity = muscles imbalance) ABNORMAL MOVEMENT • Dystonia, ( cervical = spasmodic torticollis ) • Chorea & Athetosis • Tremors

11. MOTOR EXAMINATION MUSCLE TONE • Spasticity ( = clasp knife ): - generalized or focal - grade 0 (non) - 4 (severe) [Ashworth scale] • Rigidity ( = lead pipe ) • Hypotonia ( cerebellar ) • Combination : the predominant symptoms will contribute to diagnostic type referred for treatment

12. MOTOR EXAMINATION MUSCLE STRENGTH Grade 0 = No contraction detected 1 = Flicker of contraction w/ no movement. 2 = Joint movement possible only with gravity eliminated. 3 = Muscle contraction possible against gravity without resistance. 4= Muscle contraction against gravity & less than normal amount of resistance. 5 = Normal power against gravity and resistance.

13. MOTOR EXAMINATION MUSCLE STRENGTH Values of muscles grading: - To determine ambulation with or without brace ( grade 3 antigravity muscles can ambulate without brace - Topographic classification for treatment plan ( strengthening exercise for weak muscles ) - Ex. must be low grade and non-fatiguing in ms.<3/5 -N.B (I) grade drops form muscle power following tendon lengthening.

14. SWALLOWING STUDY Values:- To facilitate appropriate position for safe, effective feeding - To increase ability to self feed. Methods: 1. Video fluoroscopic swallowing study - Requires speech - pathologist & radiologist - Patient is given liquid & various consistency of solid food impregnated w/ baruim & folowed by X-ray until be sure safe effective swallowing 2.Fiberoptic evaluation of swallowing ( FEES ) Transnasal endoscopy of hypopharynx to observe foodway & airway before & after( but not during ) the moment of swallowing. 3. EMG, manometry, scintigraphy & U.S: less commonly use.

15. Assessment of speech Speech problems : • Dysarthria (oral motor control problems ) : Spastic Hypokinetic (ataxic ) Hyperkinetic (dystonia,chorea) • Aphasia • Language delay (brain pathology, MR, hearing impairment )

16. VISUAL ASSESSMENT • Problems:Strabismus ( imbalance in eye ms. ) Hemianopsia(in dense hemiplegi w/ MCA occlusion) Blindness ( anoxic cortical vision loss ) • Effects:1. More motor delay 2. Language delay 3. Abnormal movements ( blindism ) 4. More delayed postural mechanism especially hypotonic CP

17. AUDIOLOGICAL EVALUATION • Must be early so that important speech development period not lost. In infant (1-2 d. of birth):Brain stem auditory evoked response (BAER): Electrodes placed on the child & presenting a stimulus picked up from a computerized system. A specific wave form response is recorded from the brain stem if stimulus is heard. Otoacoustic emission testing (OAE): Echo from hair cell of normally functioning cochlea picked by a microphone placed in the middle ear & connected to micro computer.(middle ear pathology is ruled out)

18. AUDIOLOGICAL EVALUATION • 6 months children: Behavioral testing in sound treated room • 2-3 years children : Play audiometry done by presenting auditory stimulus through loud speaker and associate the sound with light or toy

19. CHEST EVALUATION Vital Capacity is measured by spirometry Ventilatory impairment may be caused by: 1. Rib cage abnormalities 2ry. to scoliosis & hyperlordosis (spastic) or kyphoscoliosis (floppy) 2. Respiratory muscle dysfunction (spasticity or hypotonic)

20. ASSESSMENT OF BLADDER DYSFUNCTION • Problems: -incontinence,urgency,hesitancy (brain damage,motor disability, impaired cognition ) -small capacity hypereflexic bladder -detrusor sphincter dyssynergia • Assessment : -Renal function with serial determination of post-voidal volume -Cytometric evaluation with associated EMG monitoring of pelvic floor muscle

21. ASSESSMENT OF BOWEL DYSFUNCTION • Problems : -Fecal incontinence or defecation stress ( brain damage, motor disability, impaired cognition,incoordination of anal sphincter or pelvic floor muscle ) -Constipation : exaggerated by immobility & inadequate fluid intake • Assessment : anorectal manometry

22. SCOPE OF CP REHAB. 1. Neurodevelopmental training. 2. Motor facilitation approach. 3. Treatment of spasticity. 4. Rehab. of swallowing problems. 5. Rehab. of speech problems. 6. Rehab. of auditory problems. 7. Rehab. of visual problems. 8. Rehab. of chest problems. 9. Rehab. of urinary bladder & bowel problems. 10.Rehab. Of ADL & 11.Psychosocial rehab.

23. NEURODEVELOPMENTAL TRAINING EQUIPMENT TRAINING Criteria for selection: 1. to carry out tasks otherwise impossible with his ability. 2. appropriate support to participate in social & educational activities . 3. good alignment & correction of abnormal postures 4. adjust for child” growth, removal of support with increasing ability. 5. modification for different children in schools & clinics 6. provide additional motor experience in different posture 7. Comfort and protect joints & skin.

24. NEURODEVELOPMENTAL TRAINING Equipments varieties: 1. Wedges:Abductor W : prevent adduction deformities 2. Trumble form wedges & trumbles. 3. Large inflatable ball set 4.Crawlers: -platforms on wheels or wedges on wheels -A canavas sling under child” abdomen & supports on casters, straps to hold thighs in flexion. 5. Sitters

25. NEURODEVELOPMENTAL TRAINING 6. Apparatus for supporting standing a) Prone or supine standers to encourage weight bearing & standing b) Standing frames adjusting correct alignment: -checked for height so that child does not grasp them w/ abnormal shoulder hunching , excessive elbow flexion & radial deviation of wrist. -supplied w/ strapping to correct flexed hip & knees -feet held at right angles by a board &/or foot place. c) Parallel bars d) Mirrors e) Stairs with bannisters: very in height. f) Rumps, uneven ground, various floor services for gait training.

26. NEURODEVELOPMENTAL TRAINING 7.Walking aids Walkers Crutches Braces & Calipers: Knee gaiters (polyethylene knee moulds) to keep knee straight abduction parts to keep legs apart. Elbow gaiters which keep elbow straight for correct arm push & grasp of walkers.

27. MOTOR FACILITATION APPROACH 1. Bobath Method:inhibition of abnormal tone & posture of released postural reflex while facilitating specific automatic motor response (by special technique of handling) resulting in performance of skilled voluntary movements. 2. Rood Method:Use of peripheral input of cutaneous sensory stimuli (brushing, tapping, icing, heating, pressure, ms. stretch, muscle contraction, joint approximation. or retraction) Various nerves & sensory receptors are described & classified into types ,location, effect, response, indication.

28. MOTOR FACILITATION APPROACH 3. Propioceptive Neuromuscular facilitation (Kabat & Knott) Use of such mechanisms as maximum resistance , quick stretch & spiral diagonal (mass) movements, sensory afferent stimuli (touch, pressure, traction,compression & visual) to facilitate normal mov . [special techniques: irradiation. stim. of reflexes,reversal(successive induction), relaxation.]. 4. Brunstrom Method ( hemiplegia): Produces motion by provoking primitive movement pattern or synergitic pattern as follows : -Reflex response used initially & later voluntary control -Control of head & trunk by stim. of TNR, tonic labrinythine R -Associated reaction : hyperextension of the thumb produces relaxation of finger flexors.

29. MOTOR FACILITATION APPROACH 5. Motor relearning program of Carr & Shepherd: functional training, practice, repitition, in the performance of tasks & carry over those motor skills into functional activities. 6. Forced use paradigm (= constraint - inducedmovements therapy CIMT): Non hemiplegic limb is restrained in a sling during 90% of waking hrs. to force the patient to use the hemiplegic limb. The minimum amount of motion in the paretic limb before being enrolled into CIMT protocol is 20 of wrist extension and 10 of extension of 2 fingers at MCP or IPJ.

30. TREATMENT OF SPASTICITY Positioning • Avoid prolong sitting (less hip & hamstring flexion ) • Prone lying at night (less hip flexion ) • Abduction wedge at night & in wheelchair (less hip adduction) • AFO splint • Standing frame • Molded thoracolumbar orthosis for early scoliosis or kyphosis • Total contact support incorporated into a contoured seating system

31. TREATMENT OF SPASTICITY Drugs Indication : generalised spacticity to aid in mobility Types : 1. Dantrolene Sodium (Dantrium): Inhibits Ca release in excitation-contraction coupling Used in cerebral form of spacticity Dose: 25- 200mg 2.Baclofen (Lioresal ) [ presynaptic inhibition ] Used in spinal form of spasticity Dose :5-40mg 3.Diazepam (Valium) [postsynaptic inhibition] Used in spinal form of spasticity Dose :2-30mg

32. TREATMENT OF SPASTICITY PHYSIOTHERAPY PHYSICAL AGENTS Aim: a. Analgesia b. Ms. Relaxation c. Collagen extensibility Modalities: 1) Ice 20mins. 2) Heat: Superficial : Dry: I.R. Moist: hot packs Deep : S.W. U.S ELECTRIC CURRENTS Aim: Ms. strengthening (galvanic & faradic) . Analgesia ( TENS, IF) EXERCISES For spasticity : Passive ROM Stretch (short ms.) Strengthening (weak ms., antagonist), resistive > 3/5 For hypotonia : Strengthening ( weak ms) Balance For athetosis : Training to control simple joint motion

33. TREATMENT OF SPASTICITY Nerve/ Motor Point Block IndicationsLocalized spasticity poorly responsive to drugs or PT, interfering w/ mobility, bracing, hygiene & causing pain Contraindication: - Absolute: Allergy Infection Pregnancy - Relative: Coagulopathy Problems: -Loss of motor function of injected ms. -Return of spasticity ( axon sprouting )

34. TREATMENT OF SPASTICITY Nerve/ Motor Point Block Agents : 1- Botulinum toxin(Botox) [inhibits A.C at NMJ] Used in motor point block of UL & LL Antibodies are formed against it 2- Phenol [ produce coagulation of axon protein] Used in nerve motor point block Produces sensory dysesthesia. 3 - Alcohol [produce coagulation of axon protein] Used in motor point > nerve block Produces hyperaemia & transiant burning

35. TREATMENT OF SPASTICITY INTRATHECAL BACLOFEN PUMP Indications: ambulatory or non ambulatory child > 28lbs.w/ spastic diplegia. Method: - Baclofen is delivered via pump implanted S.C.in abdominal wall & surgically placed in subarachnoid space (CSF) close to its site action ( receptors just 1mm under the surface of spinal cord ) - Start with intrathecal test dose via lumbar puncture to assess baclofen effect over 6-8hs (1grade drops of spasticity) . Advantage: avoid high dose of oral baclofen. Risk: Infections e.g. meningitis, hypotonia & resp.problem

36. TREATMENT OF SPASTICIRY SERIAL CASTING Indications:focal contracture (especially elbows, knees, ankles ). Method: • Limb is stretched then casted in a lengthened position ( can be combined with blocks ) • Changed every few days or weeks to gradually stretch contracted structures.

37. TREATMENT OF SPASTICITY BRACES ( = CALIPERS = ORTHOSIS ) Aim:To correct deformity To control athetosis To obtain upright position Types:AFO: For ankle instability w adequate Q > 3/5 Types: solid ( in ankle clonus ) Klenzak ankle joint w/spring(A,P) w/ stop (A,P) Accessories: varus strap valgus strap KAFO: For correction of knee deform. & instab. HKAFO: For ambulation w/ hip instability . Shoe modification

38. TREATMENT OF SPASTICITY ORTHOPAEDIC SURGERY 1. Spastic equinovarus foot: combination of: a. Achillis tendon lengthening ( equinus def. ) b. Split anterior tibial transfer:Splitting TA tendon medial half left attached to its origin lateral half tunneled into 3rd cuneiform & cuboid 2. Tight hip adductor:Adductor tenotomy or derotational osteotomy ( + surgical reduction ) 3. Scoliosis:surgical correction in ambulatory child w/ curvature > 45 & vital capacity < 35%

39. TREATMENT OF SPASTICITY NEUROSURGERY Dorsal Rhizotomy - Ideal patient: young child (3-8 yrs.) w/ spastic diplegia ambulatory w/ spastic gait. - Method:- Surgical cutting of posterior (sensory) root to decrease sensory input to spinal cord reducing muscle tone (but decreases sensation) - Must be followed by PT & OT - Cutting anterior root produces atrophy &? ulcer

40. REHAB OF SWALLOWING PROBLEMS • Team: speech language specialist, OT, Dietary specialist. • Items: • Changes in posture & head position during feeding. • Oral motor exercise for the tongue & lips to increase strength, ROM, velocity, percision. • Use of thickened fluid & soft food in small boluse • Use of alternative feeding routes e.g. nasogastric tube, gastrotomy or jejunostomy tubes with severe aspiration or caloric need.

41. REHAB OF SPEECH PROBLEMS • Team : speech -language pathologist & nurse • Items : 1- oral option : electrolarynx 2 - non oral options : - simple hand writing - gestures - augmentative communication device (simple alphabet & picture board to sophosticated computer systems 3- treatment of hearing & visual problems

42. REHAB OF AUDITORY PROBLEMS • Team: audiologist, speech therapist, OT • Items: Cochlear implants (for profoundly deaf): to stimulate auditory nerve & provid awareness of sound Hearing aid : - Do not help purely central hearing loss. Used for ttt of profound sensorineural hearing loss in infancy & early childhood

43. REHAB OF AUDITORY PROBLEMS • Assistive listening device: Voice amplifiers used with or in place of hearing aids. Speaker microphone is connected to the listener’s head set or hearing aid through a wire, FM radio waves or IR light. The signal is amplified and background noise is not picked. • Compensatory strategies: Hand signs, lip reading, gestures, written communication, speaking clearly at slow speed, visual fire alarms, enrichment of visual & tactile sensory environment, protection of the child”s remaining hearing (use of ear plugs in swimming, ototoxic drugs are avoided)

44. REHAB OF VISUAL PROBLEMS • Training of postural reaction (large balls, rolls) • Use of compensatory stimuli (auditory, tactile, vestibular, propioceptive) for:. -Training of motor function of child’s life e.g dressing, feeding, bathing, roll over, creeping, crawling (listen to sound, reach to sound, move to sound). -Training of body image movements enjoyment (hand to hand, hand to mouth, hand to body) • Mother - child relationship ( kisses, touches, stroking, talking to the baby) is important.

45. REHAB OF VISUAL PROBLEMS • Use of vibrating toys, bells & playthings placed for his tummy legs & similar ideas. • Language development: Important to talk & clearly label the body parts & to encourage the child’s language. • Visual enhancement(illumination, magnification, altered contrast, glare reduction, expanders of visual field) • Visual substitution: Recorded talking books, Computer w/ vebral output, Braille book.

46. REHAB. OF CHEST PROBLEMS • Elimination of air way secretion by manually assisted cough OR mechanical insufflator or exsufflator. • Respiratory ms. aid by manual force (breathing ex) OR mechanical ventillatory assistance(hypoxia) • Mouth intermittent positive pressure ventillation (IPPV) in late stages.

47. REHAB. OF U.B. PROBLEMS Timed bladder emptying schedule Regulation of fluid intake. Use of diapers. Adequate cleaning of perineum Family education about transfer & dressing skill . REHAB. OF BOWEL PROBLEMS A timed toileting schedule for incontinence Use of dietary fibers, adequate fluid intake, stool softeners, supp., & enema for constipation .

48. REHAB OF ADL • Team : occupational therapist • Items : - provision of self help devices - training in activities of ADL - provision of creative interest - training in suitable work

49. PSYCHOSOCIAL REHAB • Team : psychiatrist + social specialist • Items : - provision of recreational activities e.g.- special olympics, athletic competition - horse back riding programs (recreational & therapeutic ) - computers ( for schools & recreation