CEREBRAL PALSY

BY

GOWRI SHANKAR POTTURI

B.PT, M.PT [NEUROLOGY], MIAP

DEFINITION
IT IS A NEUROMOTAR DISORDER RESULTING FROM NON-PROGRESSIVE DAMAGE TO THE DEVELOPING
BRAIN.

CAUSES
• PRENATAL

• ‘TORCH’INFECTIONS[Toxoplasmosis,rubella,cytomegalovirus,herpis simplex virus

• SMOKING/ALCOHOLISM

• DIABETIS/HYPERTENSION

• FALL

• CONSANGINIOUS MARRAIGES

• RH INCOMPATIBILITY

• DRUG ADDICTED MOTHER

• PERINATAL

• FORCEPS DELIVERY

• BREECH PRESENTATION

• PREMATURE DELIVERY

• ENTANGLING OF PLACENTA AROUND THE NECK

• POSTNATAL

• JAUNDICE

• FALL FROM HEIGHT

• NEONATAL INFECTIONS Eg:meningitis

CLASSIFICATION OF CEREBRAL PALSY
• CLINICAL CLASSIFICATION

• SPASTIC

• ATHETHOID

• ATAXIC

• FLACCID

• MIXED

• TOPOGRAPHICAL CLASSIFICATION

• QUADRIPLEGIC

• HEMIPLEGIC

• PARAPLEGIC

• MONOPLEGIC

• DIPLEGIC
CLINICAL TYPES
SPASTIC CEREBRAL PALSY:

Increased tone in muscles

Also called hypertonic kids

May involve all the limbs or half of body

They have fear of fall so should never be treated on beds or couches

Increased tone results in faulty postures resulting in contractures &deformities

ATHETOID CEREBRAL PALSY:

There will be irrhthymical,irregular,jerky purposeless ,involuntary writhing movements

Athetoid movements are present at rest ,increases on activity &decreases at rest

These kids may have normal IQ and can be sent to normal schools
ATAXIC CEREBRAL PALSY

These kids lack balance & equilibrium

Coordination is lost

Shows no interest in activities

Fear of fall is high

FLACCID CEREBRAL PALSY:

These kids are also called as FLOPPYKIDS.

The kids are having low muscle tone[hypotonic]

Usually mentally retarded

Joint sublaxations are common due to decreased muscle tone.

CLINICAL FEATURES
ABNORMAL TONE

ABNORMAL REFLEXES

DISTURBED HIGHER FUNCTIONS

SENSORY DISTURBANCES

DELAYED MILE STONES

CONTRACTURES &DEFORMITIES

RESPRATORY&ORO-MOTAR DYSFUNCTION

DYSMORPHIC FEATURES

MENTAL RETARDATION
MULTIPLE ASSOCIATED DEFICITS

MENTAL RETARDATION

CONVULSIONS

VISUAL DEFICITS

HEARING DEFECTS

PERCEPTUAL PROBLEMS

LEARNING DISABILITIES

FEEDING PROBLEM

EMOTIONAL &BEHAVIOURAL PROBLEMS

SPEECH &LANGUAGE DISORDERS

DYSMORPHIC FEATURES

LOW SET EYES AND EARS

FRONTAL BOSSING

DELAYED CLOSURE OF ANTERIOR FONTANELLAE

CLEFT LIP /CLEFT PALATE

EXCESSIVE DROOLING OF SALIVA

IRREGULAR DENTITION

EARLY INTERVENTION OF CEREBRAL PALSY

“It is always a known fact that ‘EARLY INTERVETION –BETER PROGNOSIS”

As the age at which diagnosis is made goes on increasing ,secondary complications of developmental
delay come into picture.

Therefore the CP child should receive therapeutic intervention as early as possible

The earliest intervention is immediately after birth

The neonate is seen by the therapist earliest in NICU where baby is admitted for medical complications
When neonate is referred to physiotherapist before starting the therapeutic intervention assessment of
the infant has to be carried out.

ASSESMENT OF C.P
Assessment starts with history .Detailed history of prenatal/peri natal & postnatal risk factors has to be
obtained from either from mother or from medical records

APGAR SCORE

It is a quantitative method for assessing infants respiratory ,circulatory , & neurological status
immediately after the birth

Timing : 1min,5min,10-20 min after the birth

SCORING OF APGAR

S.NO FACTOR SCORE=0 SCORE=1 SCORE=2

1 HEART RATE ABSENT LESS THAN MORE THAN

100 BEATS 100 BEATS
/MIN /MIN

2 RESPIRATORY EFFORT ABSENT SLOW GOOD CRY

,IRREGULAR
CRY

3 MUSCLE TONE LIMP SOME FLEXION ACTIVE GOOD

IN FLEXOR TONE
EXTREMITIES

4 RESPONSE TO CATHETAR NO RESPONSE GRIMACE COUGH/

SNEEZE
5 COLOUR OF BABY BLUE/PALE BODY PINK COMPLETELY
&EXTREMITIES PINK
BLUE

INTERVENTION OF APGAR SCORE

APGAR score immediately after birth:

SCORE EFFECT

8-10 NORMAL

5-7 MODERATE ASPHYXIA

LESS THAN 4 SEVERE DISTRESS

As in new born ,extremities are always blue immediately after birth ,ideal score is never 10 at 1 min but
9

ILLING WORTH SCALE

Along with birth asphyxia ,preterm babies also form a major group in cerebral palsy children

Therefore a pre term infant should de identified from normal term infant

Illingworth scale differentiate a pre term baby [risk baby] from full term baby.

There are 14 factors present in the scale

S.NO FACTOR PRETERM FULLTERM

1 SLEEP DISTURBED SMALL SLEEP CYCLES SOUND SLEEP

2 MOVEMENTS FASTER/BIZZARE/UNCORDINATED COORDINATED

3 CRY CRY IS INFREQUENT/FEEBLE/ PROLONGED

VIGOROUS CRY
NOT PROLONGD

4 FEEDING CANNOT RELIED UPON TO CAN BE RELIED

BEHAVIOUR DEMAND FEEDS UPON FOR FEEDS

MAY BE UNABLE TO SUCK & ROOTING/SUCKING/

SWALLOW
SWALLOWING –
REGURGITATION –CYANOTIC NORMAL
ATTACKS

5 MUSCLE LESS FLEXOR TONE GOOD FLEXOR TONE

TONE

S.N FACTOR PRETERM NORMAL

6 POSTURE OF PRONE: flat pelvis & knees at the PRONE: pelvis high
BABY side of abdomen knees drawn up
under abdomen
Acute flexion at hips
SUPINE: Limbs are
SUPINE: lower limbs externally strongly flexed
rotated & abducted .head aligned to
Head turned to side trunk

7 HEAD Head can be rotated so far that Chin can be rotated

ROTATION chin is well beyond acromion only as far as
acromion

8 SCARF SIGN Hand reaches beyond opposite Hand doesn't go

acromion beyond opposite
acromion
9 WRIST Wrist flexion is incomplete Complete wrist
FLEXION flexion .no gap
There is a window between hand
between palm &
& forearm forearm.

s.No FACTOR PRE TERM FULL TERM

10 GRASP Less than 28 weeks it is weak Strong palmar grasp

11 KNEE When hip is flexed completely After complete hip

EXTENSION knee can be fully extended flexion knee
extension is short of
20degrees

12 Dorsiflexion Dorsi flexion of foot is incomplete Complete Dorsi

of foot flexion such that the
dorsum of foot
touches shin of tibia

13 Automatic 28weeks: feeble Normal walk

walking
32weeks:walks on toes

40 weeks walks with foot flat

14 HORIZONTAL Hangs limply no flexion of limbs Flexes upper &lower

SUSPENSION limbs strongly
OTHER FACTORS REGARDING GENERAL CONDITION OF THE BABY

s.no Factor value

1 Height of the baby 50 cms

2 Head circumference 34-35 cms

3 Chest circumference Usually 3-4cms less

than head
circumference

4 Respiratory status 30-40 /min

5 Heart rate 120-140 beats /min

6 Birth weight 2.5-3.5 kg

VOJTA’S REACTIONS
These are useful for diagnosis of brain damage in infants

Dr.Vojta ,a German Pediatric Neurologist standardized 7 postural reflexes along with Neurological &
behavioral assessment technique to diagnose the development of cerebral palsy in the neonate

VOJTA’S REACTIONS

THE 7 RECTIONS ARE AS FOLLOWS:

1]TRACTION
2]LANDAU
3]AXILLARY SUSPENSION
4] VOJTA’S SIDE TILT REACTION
5]COLLI’S HORIZONTAL SUSPENSION
6]PIEPER &ISBERT’S REACTION
7]COLLI’S VERTICAL SUSPENSION REACTION
VOJTA’S RECTIONS
These reactions develop in which are dependent on the age of infant from 0-12 months

Abnormal postural reactions indicate

“disturbed central coordination” [DCC]

The development of cerebral palsy depends upon the severity of DCC

It is scaled as follows

Mild DCC → 3 or less than 3 abnormal reactions

Moderate DCC → 4-5 abnormal reactions

Severe DCC → 6-7- abnormal reactions

AT BIRTH [OMONTHS] THE CHILD WILL SHOW 7 REACTIONS AS FOLLOWS

S.NO REACTION ELICITATION & BODY PART NORMAL RESPONSE

TO BE OBSERVED

1 Traction Infant is slowly pulled up from Complete head lag, but

supine to an angle of 45 head does not fall on one
degrees side. Head remains in
center lower limbs in mild
Head & lower limbs are
flexion
observed

2 Landau Prone infant is held in Head hangs in enter

horizontal suspension
Spine, upper & lower
Head .spine, upper &lower limbs are in flexion
limbs are observed

3 Axillary suspension Infant is lifted in vertical Mildly flexed

suspension holding just below
the axilla

Lower limbs are to be

observed
4 Vojta’s side tilt Vertically held infant suddenly Overlying upper
tilted to lateral horizontal extremity MORO –
position RESPONSE

Overlying upper limb & lower Lower limb flexed

limbs are to be observed

5 Colli’s horizontal Infant is suddenly suspended Free upper limb

suspension by ipsilateral upper limb
&lower limb MORO –RESPONSE

Free upper &lower limb is to Free lower limb flexion

be observed

6 Pieper & Isbert’s The infant is held by its thighs Head hangs in the center
vertical suspension & lifted suddenly head down
Upper limb –MORO
in vertical position
RESPONSE
Head spine &upper limb is
observed No response in spine

7 Colli’s vertical Infant is lifted up with one Flexion of lower limb

suspension thigh ,head down
reaction
Free lower limb to be
observed

REFLEX MATURATION
A REFLEX IS A STERO TYPED RESPONSE TO A STIMULUS

REFLEX TESTING IS REQUIRED FOR

-FOR EARLY INTERVENTION

-LEVEL OF FUNCTION IDENTIFICATION

-TREATMENT PLANNING
NEONATAL REFLEXES

S.NO REFLEX AGE OF STIMULUS RESPONSE

NORMAL
PRESENCE

1 Doll’s eye reflex Birth-10 days Baby head is Eyes lag behind
turned to one
side

2 Rooting reflex Birth-3-4- Light touch Turning of head,

months around lips lowerlip&tongue on the
side of stimulus

3 Sucking reflex Birth-3-4months Place a finger on Sucking movement of

&swallowing baby’s lips lips & swallows

4 Palmar grasp birth -4months Pressure on palm Finger flexion with

reflex of hand from strong grip that persists
ulnar side & resists removal of
stimulus

5 Plantar grasp Birth-10-11 Strong pressure Flexion of toes

months on ball foot

6 Placing of upper Birth -6 months Brush the dorsum Flexion of upper limb
extremity of one of baby’s with placement of hand
hand against edge on the table
of the table

7 Placing of lower Birth – 1 ½ Brush the dorsum Flexion of the lower limb
extremity months of the foot with placement of foot
against the under on the table top
edge of the table

8 Moro ‘s reflex Birth – 3-4 Dropping the Abduction ,external

months baby head rotation ,extension of
 backwards from arms &extension of
semi sitting fingers followed by
position adduction of arm to
midline

9 Automatic Birth- 1 ½ Place the baby in Extension of lower limbs

standing & months the vertical as if baby is standing
walking suspension near
to supporting If pelvis is rotated
surface &touch forwards then child will
automatically put steps
the feet to the
ground forward

10 Gallant's reflex Birth -3- In horizontal Lateral flexion of trunk

6months suspension stroke on the same side
unilateral lumbar
region with blunt
object
SPINAL LEVEL REFLEXES

S.NO REFLEX AGE OF STIMULUS RESPONSE

NORMAL
PRESENCE

1 Flexor Birth-2 months Quick tactile stimulus Uncontrolled flexion

withdrawl applied to the sole of of hip & knee
the foot

2 Extensor thrust Birth-2 months One leg in extension Uncontrolled

&other fully flexion extension of same leg
.apply pressure on the
ball of the foot of flexed
leg

3 Crossed Birth-2 months One leg in flexion & The flexed leg extends
extensor other in extension. Give
pressure on the ball of
the foot of extended leg
without allowing flexion
of the same leg
BRAIN –STEM REFLEXES

S.NO REFLEX AGE OF STIMULUS RESPONSE

NORMAL
PRESENCE

1 ASYMMETRIC TONIC Birth-4 months Passively turn the Increase in the

NECK REFEX[ATNR] head 90 degrees extensor tone on
face side &increase
in flexor tone of
limbs on occipital
side

2 Symmetrical tonic Birth-4-5 months Sti1:Flex the child Res1:Flexion of

neck reflex[STNR] head bringing his upper extremities
chin towards chest & extension of
lower extremities
Sti2:extension of
baby’s head Res2: Extension of
upper extremities
& flexion of lower
extremities

3 Tonic labyrinthine Birth-3-4 months Patient in supine & Increase in flexor

reflex prone position tone in prone
position &extensor
tone in supine

4 Positive supporting Birth- 6 months Patient upright Rigid extension of

reactions standing .firm lower limbs
contact on ball of resulting from co-
foot to floor contraction of
flexors & extensors
MID BRAIN REACTIONS

S.NO REFLEX AGE OF STIMULUS RESPONSE

NORMAL
PRESENCE

1 Neck righting Birth-months In supine position Body rotates on

reflex turn the baby’s head the same side as a
to one side &hold it whole [log rolling]
in that position

2 Labyrinthine 2month-life Baby is blind folded Head brought into

righting long suspended in space horizontal position
by holding at pelvis
.the baby is tipped
sideways so that
head is laterally
flexed

3 Body righting on 6months-5years Baby is blind folded The head is

head & first placed in brought back to
supine then in prone vertical position

S.NO REFLEX AGE OF STIMULUS RESPONSE

NORMAL
PRESENCE

4 Body on body 6months-4-5 Baby in supine Segmental rolling

righting years ,passively turn the on turned side
head to one side
5 Parachute 6months – Baby is held in prone Extension of all the
reaction lifelong suspension at pelvis four limbs
,push baby to the
side with sufficient
surprise & force that
he/she believes his
head will contact the
supporting surface

CORTICAL REACTIONS
Equilibrium:

Is tested on equilibrium board in all the functional positions or by pushing the baby from static posture.

Equilibrium Age attained

Prone 6months

Supine 8 months

Quadriped 8-10 months

Sitting 8-10 months

Kneeling 15 months

Standing 15-18 months

MANAGEMENT OF CEREBRAL PALSY
AIMS :

TO enable the baby to use his/her potential to maximum extent

To enable the baby to have some kind of locomotion &interact with environment

To enable him to have some kind of communication.

AIMS OF PHYSIOTHERAPY

DEVELOPING RAPPORT WITH PARENTS & BABY

MANAGEMENT OF ABNORMAL TONE

MAINTAINING THE LENGTH OF MUSCLE

DEVELOPING POSTURAL REACTIONS

SENSORY INTEGRATION

TRAINING THE RESPIRATORY &ORO-MOTAR FUNCTONS

PLANS OF PHYSIOTHERAPY

Developing rapport: developing rapport with the kid is very important as any goal will be
difficult to achieve without the cooperation of the baby. The baby has to be motivated well
enough to gain the confidence .The goals set for the baby must be challenging at the same time
achievable

False appreciation must be avoided

Initially maximum support & feed back must be given

Never give false hope to parents

Explain the role of mother & teach the home exercises so that it can be carried at home as
treatment of cerebral palsy is whole day management

Remember always the therapy should be play therapy .Try to include games or play items into
the therapy or else the kid will not show interest in the treatment
MANAGEMENT OF ABNORMAL TONE

HYPERTONICITY
• SLOW PASSIVE MOVEMENTS

• SUSTAINED STRETCH

• CRYOTHERAPY

• FACILITATING THE OPPOSITE MOVEMENT

• VIBRATIONS

HYPOTONICITY
• WEIGHT BEARING

• JOINT COMPRESSIONS

• RHYTHMIC STABILIZATION

• VIBRATIONS

• CRYOTHERAPY

• TAPPING

MAINTAINING LENGTH OF THE MUSCLE

Appropriate length of the muscle is a prerequisite to the normal control &normal postural
adjustments

In cerebral palsy ,because of delay or absence of normal movements ,muscles are usually in
shortened state

Stretching of the muscle is carried before the exercises

Orthotic supports/night splints are given

DEVELOPING THE POSTURAL REACTIONS
Equilibrium exercises are taught with the help of Swiss ball ,tilt board & bolster

Righting reactions ,protective reactions &equilibrium reactions are taught

Equilibrium reactions are necessary before the next mile stone is achieved

SENSORY INTEGRATION
Perception includes whole of sensorimotor experience. Sensory integration is ability to organize
the sensory inputs for use.

Various functional activities incorporating different objects /sizes /colours/textures can be used
in therapy

Eg:beading ,putting different size objects into respective holes, getting the object under the
chair,sandplay.putti-clay,colouring squares circles, obstacle walking

PLANS OF PHYSIOTHERAPY

TRAINING FOR THE ORO-MOTAR CONTROL

Oromotar function depends on well controlled head &neck flexion which is dependent upon the
active use of supra&infra hyoid muscles that have the primary action on jaw ,tongue &hyoid
movements.

COMMON OROMOTAR PROBLEMS ARE

Drooling

Problems in sucking &swallowing

Body movements associated with speech

Inadequate tongue movements

THERAPY:
Develop good neck control[wedge exercises]

Develop good trunk control

Use of nook brush to decrease the drooling