Cerebral Palsy Physiotherapy

Cerebral Palsy Physiotherapy Treatment Aims (Goals):

• To normalize the tone
• To achieve normal milestones
• To maintain muscle length
• To correct the posture
• Teach activities of daily living
• Parent’s counselling

cerebral palsy definition

Cerebral palsy (CP) is a common cause of childhood disability. It is defined as a group of nonprogressive but often changing motor impairment syndromes secondary to lesions or anomalies of brain arising in early stages of its development. Although the damage is non-progressive, the clinical picture changes as the undamaged nervous system develops and the child grows. It can also be defined as a non-progressive neuromotor disorder of cerebral origin. Cerebral palsy includes a group of heterogeneous clinical syndromes of variable severity ranging from minor incapacitation deficits.

Cerebral palsy is a form of chronic motor disability, which is non-progressive, nonfatal and yet noncurable, and results from damage to the growing brain before or during birth, or in postnatal period. It is the commonest cause of crippling in children. Though mental retardation is associated in about 25% to 50% cases of cerebral palsy, it is, by no means, an essential feature of the clinical picture. The other handicaps that the patient may have are epilepsy, orthopedic deformities, partial or complete deafness and blindness, psychologic disturbances, etc.

Associated Handicaps

• Brain damage in cerebral palsy may also be responsible for special sense defects of vision and hearing, abnormalities of speech & language and aberrations of perception.
• Perceptual defects or agnosias are difficulties in recognizing objects or symbols, even though sensations are normal.
• There may be apraxias, some of which are also called visuomotor defects. This means that the child is unable to perform certain movements even though there is no paralysis, because the patterns or engrams have been lost or have not developed. Apraxia can involve movements of the limbs, face, eyes, and tongue or specially restricted to such acts as writing, drawing, and construction or even dressing. In other words there seems to be problem in motor planning in those children who are apraxic.
• Cerebral palsied children may also have various behavioral problems such as distractibility and hyperkinesis, which are based on the organic brain damage.
• All these defects result in various learning problems and difficulties in communication.
• In addition there may also be various epilepsies or intellectual impairment.
• Not every child has some or all of these associated handicaps. Even if the handicap were only physical, the resulting paucity of movement would prevent the child from fully exploring the environment.
• Child is therefore limited in the acquisition of sensations and perceptions of everyday things. A child may then appear to have defects of perception, but these may not be organic but caused by lack of experience.
• Similarly, lack of everyday experiences retards the development of language and affects the childs speech.
• His general understanding may suffer so that he appears to be mentally retarded.
• Lack of movement can affect the general behavior of the child. Thus some abnormal behavior may be due to lack of satisfying emotional and social experiences for which movement is necessary.

Causes of Cerebral Palsy

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

Types of cerebral Palsy

• Spastic Cerebral Palsy: Spastic Quadriplegia, Spastic Diplegia, Spastic Hemiplegia
• Athetoid Cerebral Palsy (Dyskinetic) 
• Ataxic Cerebral Palsy
• Hypotonic cerebral palsy
• Mixed

Complications:

• Tightness
• Spasm
• Contractures & Deformities
• Joint Stiffness
• Irritation and mood swinging (Emotional Sway)
• Depression
• Secondary respiratory complications
• Pressure sores

Cerabral Palsy Management:

Proper management of a child with CP requires a detailed assessment to find out the functional capacity of the child and the nature and extent of the motor as well as associated deficits.

This is best done by a multidisciplinary team comprising of

• Neuro-developmental pediatrician as a team leader
• Physiotherapist
• Occupational therapist
• Clinical psychologist
• ENT specialist
• Ophthalmologist
• Orthopedic surgeon
• Teacher & Social worker

The main aim is to maximize the functional capacity of the child and make him or her as independent as possible through a planned intervention program. Involvement of the family is essential for the success of any management plan. 

Counselling:

Early counselling of parents is important and difficult. Professionals must explain their plans based on assessment and taking into account the problems and prospects as seen by the family. 

Medical Treatment:

Medical treatment for the cerebral palsy child is symptomatic depending on the symptoms present. The use of drugs in cerebral palsy may be helpful at times, but any prolonged use should usually be unnecessary.

Surgical Treatment:

Surgery is not always necessary, but it is sometimes recommended to improve muscle development, correct contractures, and reduce spasticity in the legs.

Aims of surgery:

The following are the surgical procedures commonly used: 

Assistive & Adaptive Devices:

Various simple modifications like angled spoons, two handled cups etc can be made to help the child.

Splints, Casts & Calipers:

Rehabilitation:

Speech & Language Therapy:

Occupational Therapy:

Recreational Therapy:

Cerebral Palsy Physiotherapy Treatment Approaches:

Muscle Education & Braces (W.M. Phelps): in Cerebral Palsy Physiotherapy

• He prescribed special braces to correct deformity, to obtain the upright position and to control athetosis.
• Children with spasticity are given muscle education based on an analysis of whether muscles are spastic, weak, normal or zero cerebral, or atonic.
• Muscles antagonistic to spastic muscles are activated. This is to obtain muscle balance between spastic muscles and their antagonists.
• Athetoids are trained to control simple joint motion and do not have muscle education.
• Ataxics may be given strengthening exercises for weak muscle groups.

Progressive Pattern Movements (Temple Fay): in Cerebral Palsy Physiotherapy

• He recommended that the cerebral palsied betaught motion according to its development in evolution.
• He regarded ontogenetic development (in humans) as a recapitulation of phylogenetic development (in evolution of the species).
• He suggested building up motion from reptilian squirming to amphibian creeping, through mammalian reciprocal motion ‘on all fours’ to the primate erect walking. Fay also described ‘unlocking reflexes’ which reduces hypertonus.
• He developed progressive pattern movements based on above ideas which consist of five stages:

Stage 1 – Prone lying

-Head and trunk rotation from side to side •

Stage 2 – Homolateral stage

-Prone lying, head turned to side

-Arm on the face side in abduction-external rotation, elbow semi-flexed, hand open, and thumb out towards the mouth

-Leg on the face side in abduction, knee flexion opposite stomach, and foot dorsiflexion -Arm on the occiput side is extended, internally rotated, hand open at the side of the child or on the lumbar area of his back

-Leg on occiput side is extended.

-Movements involves head turning from side to side with the face, arm and leg sweeping down to the extended position and the opposite occiput arm and leg flexing upto the position near the face as the head turns round •

Stage 3 – Contralateral stage

- Prone lying -Head turned to side, arm on the face side as in stage 2

-Leg on the face side is extended

-Other leg on the side of occiput is flexed

-As the head turns this contralateral pattern changes from side to side •

Stage 4 – On hands and knees

-Reciprocal crawling and on hands and feet stepping in the bear walk or elephant walk •

Stage 5 – Walking pattern

-This is sailor’s walk called by Fay ‘reciprocal progression on lower extremities synchronized with the contralateral swing of the arms and trunk’

-A wide base is used and the child flexes one hip and knee into external rotation and then places his foot on the ground, still in external rotation

-As the foot is being placed on the ground, the opposite arm and shoulder are rotating towards it

-As weight is taken on the straight leg, other leg flexes up

Synergistic Movement Patterns (Signe Brunnstrom): in Cerebral Palsy Physiotherapy

• He produced motion by provoking primitive movement patterns or synergistic movement patterns, which are observed in fetal life or immediately after pyramidal tract damage.
• Reflex responses are used initially and later voluntary control of these reflex patterns is trained.
• Control of head and trunk is attempted with stimulation of attitudinal reflexes such as tonic neck reflexes, tonic lumbar reflexes, and tonic labyrinthine reflexes.
• These are followed by stimulation of righting reflexes and later balance training.
• Associated reactions are used as well as hand reactions.

Proprioceptive Neuromuscular Facilitations (Herman Kabat): in Cerebral Palsy Physiotherapy

Movement patterns (mass movement patterns) based on patterns observed with functional activities are spiral and diagonal with synergy of muscle groups.

-The movement patterns consist of the following components:

• Flexion or extension
• Abduction or adduction
• Internal rotation or external rotation

-Sensory (afferent) stimuli are skillfully applied to facilitate movement.

-Stimuli used are touch & pressure, traction & compression, stretch, proprioceptive effect of muscle contracting against resistance and auditory and visual stimuli. Resistance to motion is used to facilitate the action of the muscles, which form the components of the movement patterns.

Special techniques that can be used in cerebral palsy physiotherapy

• Irradiation
• Rhythmic Stabilization
• Stimulation of Reflexes
• Repeated Contractions
• Reversals
• Relaxation techniques – Hold Relax & Contract Relax

Neuromotor Development (Eirene Collis): in Cerebral Palsy Physiotherapy

• Strict developmental sequence was followed. The child was not permitted to use motor skills beyond his level of development. 
• She placed the child in normal postures in order to stimulate normal tone.
• Once postural security was obtained, achievements were facilitated and developmental sequences were followed throughout this training.

Neurodevelopmental with Reflex Inhibition & Facilitation (Karl Bobath): in Cerebral Palsy Physiotherapy

• According to Bobath, once the reflex patterns of abnormal tone are inhibited the child is said to have been prepared for movement.
• Reflex inhibitory patterns specifically selected to inhibit abnormal tone associated with abnormal movement patterns and abnormal posture.
• Sensory motor experience – The reversal or break down of these abnormalities gives the child the sensation of more normal tone and movements.
• The therapist tries to attempt to change the patterns of spasticity so that child is prepared for movement and mature postural reactions uses key-points of control.
• The key-points are usually head & neck, shoulder & pelvic girdles, but there is also work from distal key- points.

Sensory Stimulation for Activation & Inhibition (Margaret Rood): in Cerebral Palsy Physiotherapy

Techniques of stimulation, such as stroking, brushing, icing, heating, pressure, bone pounding slow & quick muscle stretch, joint retraction & approximation, muscle contractions (proprioception) are used to activate, facilitate or inhibit motor response in cerebral palsy physiotherapy.

-Ontogenetic developmental sequence is strictly followed in the application of stimuli.

• Total flexion or withdrawal pattern (in spine)
• Roll over (flexion of arm & leg on the same side and roll over)
• Pivot prone (prone with hyperextension of head, trunk & legs)
• Co-contraction neck (prone head over edge for co- contraction of vertebral muscles) 
• On elbows (prone & push backwards)
• All fours (static, weight shift & crawl)
• Standing upright (static, weight shifts)
• Walking (stance, push off, pick up, heel strike)

 Reflex Creeping & other Reflex Reactions (Vaclav Vojta): in Cerebral Palsy Physiotherapy

• Reflex creeping – The creeping patterns involving head, trunk and limbs are facilitated at various trigger points or reflex zones.
• Touch, pressure, stretch and muscle action against resistance are used in triggering mechanisms or in facilitation of creeping.
• Resistance is recommended for action of muscles.

Balance Interventions in Cerebral Palsy Physiotherapy

Cerebral palsy is a disorder with multisystem impairments, which may affect the visual, vestibular, and/or somatosensory systems. Nasher et al. found inappropriate sequencing of muscle activity, poor anticipatory regulation of muscle sequencing during postural control, and postural stability that was frequently interrupted by destabilizing synergistic or antagonistic muscle activity in individuals with CP. It is evident that physical therapists working with individuals with CP need to assess as well as address these balance issues, keeping in mind the action that is required and the environment in which it is being performed.

Electrical Stimulation Techniques in Cerebral Palsy Physiotherapy

Making recommendations regarding which children should receive neuromuscular electrical stimulation (NMES) or transcutaneous electrical stimulation (TES) in cerebral palsy physiotherapy. 

Hippotherapy in  Cerebral Palsy Physiotherapy

Hippotherapy is preformed on horseback with a thin soft saddle. Work on balance and motor coordination is often preformed with the child seated backward on the horse. Upright sitting stresses balance reactions. Performing hippotherapy requires three staff people. One individual leads the horse while the therapist works with the child, standing alongside the horse. A third assistant is required on the side opposite the therapist to prevent the child from falling and to assist the child in changing positions.

Children benefit from movement and novelty. There have been some improvements in limb placement and balance and equilibrium seen in children who worked on the Bobath balls during neurodevelopment therapy. Hippotherapy gives them, if you will, a hairy, olfactory-stimulating, warm, four legged Bobath ball platform on which a trained therapist can capitalize on motor control, stretching, and equilibrium as the therapist works with the child.

Benefits of hippotherapy

• Improves joint co-contraction
• Decreases tone
• Decreases energy expenditure with
• movement
• Improves stability
• Facilitates weight–shifting
• Facilitates postural and equilibrium
• responses
• Increases visual perception
• Increases self-confidence
• Improves respiration
• Increases coordination
• Increases attention span
• Mobilizes pelvis, hips, and spine
• Increases muscle ROM, flexibility, and
• strength
• Increases body awareness
• Improves balance
• Improves posture/alignment
• Increases listening and vestibular skills
• Improves gait
• Improves speech and language
• Improves relationships

Aquatic Therapy in  Cerebral Palsy Physiotherapy

Aquatic therapy provides countless opportunities to experience, learn, and enjoy new movement skills, which leads to increase functional skills, mobility and builds self-confidence. The relief of hypertonus in the spastic type of CP is one of the major advantages of aquatic therapy. When a body is immersed in warm water (92° to 96°F), its core temperature increases, causing reduction in gamma fiber activity, which in turn reduces muscle spindle activity, facilitating muscle relaxation and reducing spasticity, thus resulting in increased joint range of motion and consequently creating better postural alignment.

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