CASE: CEREBRAL PALSY

DEFINITION:
-A neurological disorder cause by a
non-progressive
brain
injury
or
malformation that occurs while the
childs brain is under development. It
primarily affects body movement and
muscle coordination.
P-ermanent

O-thers (chicken pox)

R-ubella (german measles)
C-ytomegalovirus
H-erpes Zuster
PERINATAL

-asphyxia
-intraventricular hemorrhage
-preeclampsia

NP-on progressive (one time insult)

-respiratory
prematurity

M-anageable

-sepsis/ CNS infection

EPIDEMIOLOGY:

-most common disabling conditions

affecting children

-CHORIOAMNIONIEIS

-1.54 per 1,000 live births

- 30% among African-Americans
-lower socioeconomic class= increased
risk factor of CP
- estimated that each year, 8,000
infants and 1,200 to 1,500 preschoolage children are diagnosed with
cerebral palsy (United Cerebral Palsy
Research and Educational Foundation,
2001)
ETIOLOGY:

-fever during labor

-bleeding
-Placental infection

POSTNATAL

-anoxia
-toxin exposure
-traumatic head injury
-viral or bacterial meningitis
BASIC MEDICAL SCIENCES:
AREAS OF THE BRAIN
AFFECTED:

-infections
-inflammation
-PREMATURITY
COMMON)

(MOST

PRENATAL

-very low birth weight

- infections
-cytomegalovirus
-evidence of stroke
-chromosomal abnormalities
-radiation exposure
-twin or multiple pregnancies
-

S-yphillis
T-oxoplasmosis
meat)

of

MATERNAL RISKS:

GENERAL CAUSES:

disorders

(uncooked

Cerebral palsy affects the

cerebrum, the largest portion of the
brain. The cerebrum controls voluntary
movements, thinking, reasoning and
emotions, as well as some specialized
functions such as visual processing,
speech and hearing. Damage often
occurs to the cerebral motor cortex, a
portion of the brain that lies at the
back of the frontal lobe just before the
fold that separates the frontal lobe
from the parietal lobe.
The
abnormalities
in
the
cerebral motor cortex disrupt the
brain's
ability
to
control
both
movement and posture. This results in
the characteristic symptoms including
a lack of muscle coordination, stiff or
tight muscles, walking on the toes,
muscles that appear too tight or too
floppy, tremors and difficulty with
precise movements. The severity of

cerebral palsy varies depending on the

extent of the damage to the cerebral
motor cortex. Patients with mild
cerebral palsy may exhibit slightly
awkward movements, while severe
cerebral palsy results in the inability to
walk.

o H-erpes Zuster
Perinatal
o Bridge birth(butt first)
o Lack of oxygen in the
brain
Postnatal
o Falls
o Trauma

SIGNS AND SYMPTOMS:

-

PATHOPHYSIOLOGY: (diagram)

1. hypoxia
2. intracerebral hemorrhage
3. Hyperbilirubinemia
Grading for Severity of Pathology
Grade I - isolated subependymal
hemorrhage
Grade II - bleeding into the ventricle
without dilation
Grade III - bleeding into the ventricle
with dilation
Grade IV - intraventricular hemorrhage
with ext to the surrounding mater
parenchyma
-

Prenatal
o Maternal History
o S-yphillis
o T-oxoplasmosis
(uncooked meat)
o O-thers (chicken pox)
o R-ubella
(german
measles)
o C-ytomegalovirus

Tone Abnormalities
o Either
decreased,
increased or fluctuating
movements
o Fluctuating tone shifts in
varying degrees from
hypotonic to hypertonic
o Hypo(dyskinesia)
o Hyper(spastic/rigid)
Reflexes Abnormalities
o Retained
primitive
infantile reflexes
o delay in the acquisition of
righting and equilibrium
reactions occur
o hypotonia (areflexia)
Postural abnormalities
o hypertonicity in the lower
extremities=often
lies
supine with the hips
internally rotated and
adducted and the ankles
plantar flexed
o hypotonicity=
typically
lies
with
the
hips
abducted, flexed, and
externally
rotated
because of low muscle
tone, weakness in the
affected muscles, and the
influence of gravity
Delayed
motor
development(universal sign
for CP)
o delay in the childs ability
to sit independently
o often not recognized until
the child fails to achieve
these
early
motor
milestones.
Atypical motor performance
o Child may demonstrate a
variety
of
motor
abnormalities such as

asymmetrical
hand use
unusual
crawling
method or gait

uncoordinated
reach

difficulty sucking
chewing
swallowing

Spastic Quadriplegiao Entire

body
in
involved
o UEspasticity
on
flexor muscles; LEspasticity on extensor
muscles

CLASSIFICATIONS:
-

Topographical
distribution
(body part/ motor function
classification system)
o Mono-one limb
o Diplegia-severely involve
LE, less affectation of UE
o Hemi-one side of the
body
o Para-only LE (cognitively
okay)
o Tri-three
extremities
involved
o Tetrafour
(3
parts
severely affected, one
part less)
Classification according to
Movements disorders:
o Spastic
o Athetoid
o Ataxic

Spastic

Hypertonicity
Most common (70-80% of the
cases of CP)
Result of Upper Motor Neuron
Involvement
Retained primitive reflexes in
affected areas of the body
Impact on motor function:
o Mild impairmentdoes
not
interfere
with
functional limits
o Severe Inability to reach
and grasp
Contractures
leading
to
deformity are common

Categorized Anatomically:
Spastic Hemiplegia
o One entire side of the
body including neck,
head and trunk.
o UE is usually affected
o Early signs dragging
one side of body
Spastic Diplegia
o Both LE,
o mild
coordination,
tremors or less severe
in UE
o Bunny hop- rely on
the arms for support

Dystonia
-Abnormality in muscle tone
Athetosis
Most
common
type
of
dyskinesia or dystonia
Slow,
Writhing
involuntary
movements
Involuntary and uncontrolled
movements
10-20% of the cases of CP
Basal Ganglia involvement
Choreiform

Abrupt, Jerky distal movements

Ataxia

Unsteadiness and difficulties

with balance
Involvement of Cerebellum
Much less common
Characterized by:
o Wide-based,
staggering, unsteady
gait
o Walk
quickly
(compensate for lack
control and stability)
o Clumsy
controlled
movements
o Intention Tremors

Gross
motor
classification system

function

Level 1: walks without restriction,

limitations in high level skills
Walks independently by age 2 years
without devices
Walks as preferred mobility by age 4
Difficulty with speed, coordination,
and balance for high-level tasks
Level 2: walks without devices,
limitations walking outdoors
Sits with hand support by age 2
Crawls reciprocally or walks with
device as preferred mobility by age 4

 Uses hands to get up from the floor

or a chair by age 6
Walks without devices indoors by
age 6
Level 3: walks with devices,
limitations walking outdoors
Sits with support by age 2
Cruises by age 4, walks with device
short distances
Does stairs with help by age 6
Walks indoors with a device by age
12

o
o

-Children typically develop motor skills

craniocaudally. A child will first
develop neck control, then upper trunk
control, and then lower trunk control.
DIFFERENTIAL DIAGNOSIS:

Traumatic brain injury is one of

the leading causes of acquired
disability and death in infants
and children.
Falls and motor
vehicular accidents are common
unintentional causes. Children
are more vulnerable to injury
through
deformation
and
fracture of the skull, thus
causing injury to the brain. In
children,
some
neurologic
deficits after head trauma may
not manifest for many years.
Impairments of children with TBI
occur at different degrees.
Symptoms can vary greatly
depending on the extent and
location of the brain injury.
Some
symptoms
include
spasticity of muscles, motor
incoordination,
fatigue,
impairment in communication
skills, balance problems, and
short-term memory deficits.

Stroke can also occur in

children. Pediatric stroke is one
of the leading causes of death
in children. Children who suffer
from pediatric stroke have a
high chance of developing
cerebral
palsy.
Perinatal,
neonatal, infant and childhood
stroke are some of the most
common causes of hemiplegia,
hemiparesis,
or
hemiplegic
cerebral palsy in children. Like
adults, pediatric stroke fall into
two categories: hemorrhagic
and ishemic.
Children are
equally at risk for both of these
types. It is difficult for the child
to express when they are
experiencing something since
pediatric stroke mostly occur in
children less than one year old.

Muscular Dystrophy may also

be mistaken for cerebral palsy

Level 4: limited mobility, power

mobility outdoors
Rolls by age 2 years
Sits with hand support by age 4
May walk short distances indoors
with device, poor balance
Preferred independent mobility is a
wheelchair by age 12
Level 5: very limited self-mobility,
even with assistive technology
Needs help to roll by age 2
Does not attain independent mobility
by age 12
With high-level assistive technology,
may learn to use power mobility
COURSE AND PROGNOSIS:
MOLNAR PROGNOSTICATION
INDEX
Based on the type of
CP
o Best- spastic hemiplegia or
ataxia
o Poor-quadriplegic
Based on onset of
sitting
o Good- if px can sit by 2 years
o Fair- if px can sit between 2-4
years
o Poor- if px cannot sit by 4 years
old
Based
on
onset
of
standing
o Good- if px can stand by 4 years
old
o Fair- if px can stand bet. 4-6
years old
o Poor- if px cannot stand by 6
years old
BLECKS PROGNOSIS:
o Good- if at 1 year old there is
(+) parachute reflex and no
primitive reflex.

Fair- if at 1 year old there is (+)

parachute and 1 primitive reflex
Poor- if at 1 year old there is (+)
parachute reflex and 2 primitive
reflexes

but in muscular dystrophy,

there is no spasticity, but
patients
can
develop
contractures. There are various
subtypes, including Duchenne's,
Becker's, and limb girdle. Child
may be weak at birth or may
have
apparent
normal
development
until
approximately 3 years of age
followed by a progressive loss of
function and muscle weakness.
There may be a positive family
history. Examination reveals a
positive Gowers' sign with
regression of walking ability.
Becker's type is less debilitating
and
manifests
later
in
childhood. Limb girdle type may
not present until late teens or
20s.

With familial/primary dystonia,

onset of muscular deformity
occurs after several years of
normal
development.
It
presents with sustained periods
of muscle contraction and
dystonia
but
without
development of contractures.
There may be abrupt and
violent movements. Patients
may even sit on their limbs. This
may be mistaken for the
dyskinetic type. Determining
tests may be done as this
condition has positive family
history.

LAB TESTS:
-

Magnetic resonance imaging

(MRI) or computed tomography
(CT) scan :
o
provide evidence of
hydrocephalus
o help
determine
the
location and extent of
structural lesions
o help
rule
out
other
conditions
Electroencephalogram
(EEG)used to determine the cause of
cerebral palsy but should be
obtained if there is an indication
that the child may be having
seizures.

SPECIAL TESTS:
Reflex Testing
M Moro reflex

A ATNR
S STNR
S Stepping reflex
P Parachute reflex
E Extensor thrust
N Neck righting on body

MEDICAL/PHARMACOLLOGICAL
MANAGEMENT:
- Oral medications used to reduce
spasticity in severe cases with
mixed results such as:
o diazepam (Valium)
o dantrolene (Dantrium)
o baclofen have been.
-

Intrathecal caclofen infusion

(ITB) administered through a
pump
implanted
in
the
abdominal wall to the spinal
cord fluid= more effective than
oral medications in reducing
severe spasticity and dystonia
in cerebral palsy.
injection of botulinum toxin
(Botox) into muscles.
o Spasticity is reduced for a
period of 3 to 6 months
after injection.
o Botox is injected into
specific muscles, which,
in addition to reducing
tone, increases range of
motion
and
reduces
deformities as well as
provides an opportunity
to
work
on
muscle
strengthening.
o Minimal
side
effects,
however, its long term
effectiveness on function

SURGICAL MANAGEMENT:
1. Gastroenterology Surgery
a. Nasogastric tube tube
placed through the nose
to introduce food to the
stomach
b. Gastrostomy tube tube
inserted
through
the
abdominal wall to the
stomach
allowing
uninterrupted feeding
2. Hearing Surgery
a. Hearing aids amplify
sounds
without
distortions
b. Radio aids the use of
microphone
and
transmitters

3. Medicine Related Surgery

a. Baclofen Pump a device
about the size of a
hockey puck implanted
in the abdomen that is
connected to the spinal
cord with a thin tube that
threads under the skin
b. Lumbar puncture
4. Neurosurgery
a. Baclofen Pump
b. Selective
Dorsal
Rhizotomy a procedure
where 30-50 percent of
sensory nerves are cut to
decrease spasticity
5. Orthopedic Surgery
a. Any surgery that is done
on
bones,
ligaments,
joints, tendons, muscles
and nerves
i. Considered as last
resort when other
less
invasive
treatments
and
therapies
have
been exhausted
ii. The focus is to
manage
impairment,
control
pain,
optimize
independence and
self-care, maximize
movement,
balance
and
coordination
and
maintain
functionality.
OT APPLICATION
FORS:
NDT
-

To facilitate normal pattern of

movements and postural tone
and inhibits spasticity.

Developmental
-

assists the child in achieving

mastery of life tasks and the
ability to cope as efficiently as
possible
with
the
life
expectations made of him or
her through the mechanisms of
selected input stimuli and
availability of practice in a
suitable environment.

used to identify if childs skills

are at par with childs age
help
in
identifying
the
appropriate
activities
given
during intervention

Acquisitional
-

Focuses on skill acquisition for

optimal performance in the
environment.
Allows the child to acquire and
learn the skills the child needs
to participate in the different
occupations.

Rehab
-

Allows the person to perform

the different occupation through
the
use
of
compensatory
strategies, adaptive devices and
environmental modifications.

OT EVALUATION:
o
o
o
o
o
o
o
o
o
o

Modified Ashworth Scale (MAS)

Goniometry
Manual Muscle Testing
Reflex Testing
WeeFIM
Sensory Integration and Praxis
Test (SIPT)
Pediatric Evaluation of Disability
Inventory (PEDI)
Quality of Upper Extremity Skills
Test (QUEST)
Functional
Independence
Measure
School Function Assessment

OT ASSESSMENT:
o

OCCUPATIONS
AND
ACTIVITIES AFFECTED:
Self-care:
-Child
usually
has
difficulty
performing
basic activities of daily
living such as eating
independently, dressing,
toileting, grooming and
hygiene, and lacks the
ability to be mobile.
-Child
usually
needs
assistance to develop and
achieve
independent
living status.
Productivity:
-Childs play skills may be
delayed due to lack of

exploratory
play
behaviour.
-Child
may
need
assistance in adapting
the working environment
to his or her own abilities.
Child
may
have
difficulty with schoolwork
such as learning how to
read and how to write.
Leisure
-Child
may
need
assistance in exploring leisure
options
-Child
may
need
assistance in adapting
the leisure environment
to his or her own abilities
Cognitive
-Child may have learning
disabilities related to perceptual
disorders
-Child may have difficulty
in learning due to mental
retardation
Psychosocial
-Child
may
become
depressed and express feelings
of
hopelessness
and
helplessness
-Child may have poor
self-image and low selfesteem
-Child
may
have
inadequate coping skills and
become easily frustrated
-Child may have limited
opportunities for self-expression
-Child may have difficulty
developing social relations
OT INTERVENTION
Self-care
-Promote oral motor skills
to facilitate feeding
-Suggest clothing
adaptations
that
may
facilitate
independent dressing
positions that
during dressing

-Suggest various
promotes stability

-Suggest
adaptive
equipment
that
may
facilitate
activities
of
daily
living
such
as
bolsters, wedges, aids for
standing and side lying,

adapted
chairs,
mobility aids.

and

Productivity
-Increase
opportunities
for play development.
Adapted
toys
and
computer aided games
and toys may expand the
childs play environment.
-Encourage
parents,
caregivers or teachers to
assign
responsibilities
and duties for child to
perform
-Explore
vocational
interests and career options
-Encourage development
of independent living skills

Leisure
-Explore leisure interests
-Develop leisure skills by
providing
opportunities
to
participate in activities.
Cognitive
-Increase
attending
behavior and attention
span.
-Instruct the child to
instruct others regarding
need for assistance.
-Use of computers may
facilitate learning tasks
and improve the persons
ability to function.
Psychosocial
-Provide
a
safe
environment in which the
person can experience
movement without fear.
-Provide opportunities for
socialization.
-Assist in development of
functional communication
and language skills.
-Help the family identify
community resources.
-Facilitate
improvement
of self-image`

-Encourage development
of social skills.

Eight general methods

inhibit spasticity:

that

o Passive elongation
o Limb dissociation

o Normal weight shifts

o Normal limb movements free
in space

o Positioning
o Orthotics

o Reflex-inhibiting patters.
These methods are
administered in three stages:
o First stage:

To use handling
techniques to give the
sensation
of
what
normal
tone
and
movement feel like

o Second stage:

To let the patient initiate

movement
during
a
purposeful activity while the
occupational
therapist
maintains
inhibition
or
facilitation
o Third stage:
To fade control from proximal
key points of control, like the
scapula or pelvis, to distal key
points of control, like the hand
or foot.

Adaptive devices
o Use of a jelly bean switch
which is a single switch
to those patients who
can only perform
movement such as press
and release to a switch.
o Use of zipper pull to
compensate for difficulty
in stabilizing the hand.

Use of alternative and

augmentative
communication to
patients who has
difficulty in speaking
verbally such visual
bridges.
Use of keyguard when
patient has difficulty in
pressing on or more keys
on the keyboard.
Use onscreen keyboard
and mouse for typing
when the patient has the
ability to use one hand.
Use of page fluffers
such as foam, sponges,
giant paper clips,
clothespin to provide
physical access to the
texts in books.
Use of book holders for
stabilization.
Change the font size and
color, magnification,
contrast for patient with
visual-perceptual
problems.

Orthotics
o Use of splint such as
AFO, KAFO, resting hand
splint, dynamic splint,
wrist cock-up splint, antispasticity and deformity
splint to improve
function and reduce or
prevent deformity.
Environmental modification
o Provide grab bars in
private bathroom to
facilitate safety of the
patient.
Wheelchair modification
o Detachable leg rests to
facilitate w/c transfers
o Arm trough for upper
extremity to facilitate w/c
proper positioning
Adapted procedures
o Propel w/c using sound
arm and leg to substitute
for loss of lower
extremity ROM
Safety education

Use verbal cues to

attend to affected side to
compensate for
hemianopsia.
Turn on cold water before
hot to compensate for
sensory loss of limbs.

Roles of OT
The roles of an occupational
therapist in treating a client with
Cerebral Palsy are the following:
-

To improve function, develop

compensatory strategies, and
encourage independence

To achieve optimal development

Provide early intervention

Improving infant-caregiver
interaction, family support for
coping, and home modifications

Provide age-appropriate play

levels

Parental education for handling a

child at home

Promoting motor and other

developmental skills