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CEREBRAL PALSY
Definition- Cerebral Palsy is term used to refer to a non-progressive group of brain disorders
resulting from a lesion or developmental abnormality in fetal life or early infancy. Although the damage is non-progressive (static encephalopathy) but the clinical picture changes as the nervous system develops and child grows. These disorders are characterized by the poor control of the movement. Adaptive length changes in muscles Skeletal deformities Other associated problem like hearing, visual and mental handicaps. Etiology and pathology (etiopathogenesis) - C.P. can be attributed to many causes, which can be:- a) Prenatal: Maternal infections (Rubella, CMV in infections) Maternal drug addiction or drug abuse Abnormal fetal positions Rhesus incompatibility Low blood sugar b) Perinatal: Main is asphyxia, due to knotted umbilical cord, low birth weight, antepartum hemorrhage, malpresentation, breech delivery, forceps, disproportion c) Postnatal: Infections, early meningitis, prematurity, severe jaundice, hypoglycemia, vascular abnormality, genetic causes Pathology - In both preterm and full term infants, pathology mechanisms, include Hemorrhagic lesions & Hypoxic-Ischemic lesions Hemorrhagic lesions: These include subepedymal and intraventricular hemorrhages with parenchymal extension or development of hemorrhagic hydrocephalus. Commonly in premature infants, because of fragility of vessel walls and inability to regulate the cerebral blood flow.
Hypoxic-Ischemic lesions: These lesions will be of following types:- a) Selective Neuronal Necrosis: Affecting cerebral cortex, thalamus, reticular formation and brain stem nuclei b) Status Marmoratus: Affecting cerebral cortex and basal ganglia. c) Parasagittal Cerebral Injury: Affecting the cerebral cortex and subcortical white matter These all above are implicated in spastic Quadriplegia and intellectual impairment. d) Focal or Multifocal Ischemic Lesions (CVA) may be associated with hemiplegia and intellectual impairment. These are caused by impairment of arterial blood flow as a result of thrombus and embolus. e) Intracranial Hemorrhage mainly caused by trauma f) Periventricular Leukomalacia is underlying cerebral lesion in spastic diplegia. The pyramidal pathways to lower limbs traverse the internal capsule close to the lateral ventricles. So both hemorrhagic and periventricular leukomalacia can, therefore, lead to clinical picture of spastic diplegia g) Other pathology seen in C.P. are Hyper Bilirubinaemia caused by rhesus incompatibility used to be a common cause of Athetoid type of C.P., due to insult to the basal ganglia, cerebellum and brainstem nuclei Maldevelopment of Nervous System: both pre and post natally, may play a larger role in pathogenesis of C.P. Classification :- C.P. is not a single entity but group of conditions classified according to the parts of the body involved and by clinical description of tone and involuntary movements. The C.P. can therefore be classified according to various ways.
- According to area of body (distribution) showing impairment. a) Monoplegia:- when one limb is involved b) Two limbs (lower):- diplegia c) Upper and Lower limbs of one half of the body:- hemiplegia d) All four limbs:- quadriplegia
It is due to that certain muscles of limbs and trunk contract simultaneously when child attempts to move. There may be alteration in tone when child is moved from supine to prone due to influence of Tonic Labyrinthine and Tonic Neck Reflexes Exaggerated stretch reflexes, abnormal muscle activity elicited by changes in head and body position Spasticity is considered major barrier to the development of more normal motor performance Abnormal patters of movements have been described in children with spasticity, both at rest and during movement, with pattern of flexion in upper limbs and of extension in the lower limbs Excessive muscle activity and muscle shortening involving the limbs must also affect the trunk due to intersegmental attachments of muscles Child may demonstrate an abnormal amount of muscle activity (Associated Movements) Contractures and deformities may develop in these children if the normal muscle length is not maintained. These can occur due to prolonged abnormal positioning, affect of gravity, imbalance of muscle activity and lack of active use. Spastic child will have their major problem as inability to activate muscle and control muscle force to produce an intentional movement Athetoid C.P.:- This child may have various problems. These children demonstrate involuntary movements which can occur both at rest and during voluntary movements. Involuntary movements are trunk and head extension particularly when supine Control of head position is usually slow to develop and inability to hold the head steady may affect the development of vision and the visual control of actions such as reaching The inability to hold a steady position and to perform smooth joint displacements make the development of postural adjustments, reaching and manipulation particularly difficult
Grimacing of face and difficulty coordinating breathing and swallowing may also be evident and eating, drinking and vocalization may be impaired. Joints are often hypermobile and joint dislocations can occur in older children when there are spasms. Chorieform movements- more jerky movements may be present Sometimes dystonia is present, disordered muscles tone, expressed as postural abnormality and complex action dystonia where purposeful movements are deformed. Ataxic C.P.:- Uncommon in C.P. commonly associated with hydrocephalus, head injury, encephalitis or cerebellar tumor The child demonstrate difficulty in controlling rate, range, direction and force of movement Balance impairments, gait impairments, tremors are present Hypotonic C.P.:- Severe hypotonus is present in some infants, later it may become as weakness, seen in premature infants or in infants with Down’s syndrome Some hypotonic infants develop athetosis. Hypotonus infant or child lives with arms and legs abducted, externally rotated and flexed. When pulled to sitting, there is usually head lag. In supine, child may have respiratory problems In prone, protective side turning of head may be absent and infant risks suffocation. Held in sitting or standing, the child may be unable to hold the head and upper body erect Kicking may be absent or feeble Suckle and swallowing difficult Coughing ineffective and episodes of respiratory distress are common. Common Associated Problems Visual Handicaps:- Optic nerve damage
PHYSICAL THERAPY EVALUATION
The physical therapist should conduct thorough evaluation and examination of the child with C.P. that includes History, observation, Examination. Physical therapist should gather information on child’s evaluation – a) History – social, family, medical history b) Assessment of range of motion, strength, muscle tone, bulk, reflexes and postural reactions, mobility skills, transfers, ADLs, recreation, leisure and adaptive equipment. Before training and implementing the treatment and management, it is necessary to have an idea of major impairments and functional limitations in child with different types of C.P.
IMPAIRMENTS AND FUNCTIONAL LIMITATIONS IN CHILD WITH
SPASTIC CEREBRAL PALSY –
a) Child with spasticity moves slowly and with difficulty. b) Stereotypical patterns of movements are present whenever movement is attempted or produced. c) There functional limitations in head and trunk control. d) Difficulty and limitation in performance of movement transition, ambulation, use of extremities for balance and reaching. IMPAIRMENTS FUNCTIONAL LIMITATIONS
TREATMENT
FOCUS
Increased muscle tone Stereotypical movement patterns Decrease tone, increase movement Slow, labored movement Poor static and dynamic balance, postural insecurity Establish head& trunk righting &equilibrium reactions, extremity protective reactions Decreased trunk rotation Poor movement transition Practice movement transition, like trunk rotation, i.e. rolling, coming to sit and walking Decreased ROM Reaching & walking Increase ease of movements in all ranges, vary speed and excursion of goal directed movements Skeletal malalignment Scoliosis, deformities Position property for function, use orthosis Muscle weakness Movement against gravity Strengthen through movement experiences Inaccurate muscle recruitment Inefficient movement, high energy lost Use new environments and encourage appropriate sequences of movement
HEAD CONTROL –
Difficulty in developing head control because of increased tone. Persistent primitive reflexes Exaggerated tonic reflexes or absent or impaired sensory input Because the child often has difficulty in generating enough muscle force to maintain a posture or to move, substitution and compensatory movements are common. For e.g. an infant who cannot control the head when held in upright or supported in sitting may elevate the shoulders to provide some neck stability. TRUNK CONTROL – Lack of trunk rotation and predominance of extensor or flexor tone can impair the child; ability to roll. Inadequate trunk control prevents independent sitting. In child with predominantly lower extremity problems, the lack of extensibility at the hips may prevent the attainment of aligned sitting position. The child compensates by rounding the upper back to allow for sitting. Trunk rotation can be absent or impaired secondary to the lack of balanced development of trunk extensors and flexors, without this balance control, lateral flexion is not possible, nor is rotation. Absent of trunk rotation makes the transition of movement from one posture to another very difficult. Child with spasticity may discover that it is possible to achieve a sitting position by pushing the body backwards and W sitting. This posture should be avoided as its use can impede further the development of trunk control and lower extremity association. INFLUENCES OF TONIC REFLEXES – Tonic reflexes are often obligatory in spastic children. When reflex is obligating it dominates child’s posture. Obligatory reflexes produces tone and postures that can interfere with adaptive movements. When they occur during the normal development they do not interfere with infants ability to move. Typically, TLR is present at birth and then is integrated by 6 months. If this reflex persists, it can impair the infants ability to develop antigravity motion (i.e. to flex against gravity in supine and to extend against gravity in prone)
Trunk symmetry Scoliosis Bring hand to mouth Sitting STNR Contractures Lack of u/l and l/l dissociation Lack of trunk rotation Sitting Creeping Kneeling Walking MOVEMENT TRANSITION – The child with spasticity lacks the ability to control or to response appropriately to shifts in COG that should otherwise result in righting equilibrium or protective reactions. These children are fearful and do not feel safe due to lack of static and dynamic balance. The inability to generate sufficient muscle activity in postural muscles for static balance is further compounded by difficulty in anticipating the postural changes in response to body movement. These features make performance of the movement transitions such as prone to sitting or reverse, i.e. sitting to prone more difficult. MOBILITY AND AMBULATION – Impaired lower limb separation hinder reciprocal leg movements for creeping and walking; therefore, some children learn to move forward across the floor on their hands and knees by using a “bunny hopping” pattern that pulls both legs together. Spastic child with spasticity may attempt to move is by “ Commando Crawling” forcefully pulling the arms under the chest and simultaneously dragging stiff legs along the floor. The additional effort by the arms increases lower extremity muscle tone in extensor muscle groups and also interfere when the child pulls to stand and to cruise around furniture. The child may attain a standing position only on tip toes and with legs crossed. Cruising may not be possible because of lack of lower extremity separation in lateral direction. Adequate trunk control is lacking to provide stable base for stance leg and inadequate force production may prevent controlled movement of swing leg. Arms may remain in a high – guard position to reinforce weak trunk muscles by sustaining an extended posture and thus delay the onset of arm swing. Spastic child is at high risk of contractures and deformities secondary to muscle and joint stiffness and to muscle imbalances from increased tone.
GENERAL TREATMENT IDEAS
IN CHILD WITH SPASTICITY
Treatment for child with spasticity focus on mobility in all possible postures and transitions between these postures. Tendency for postures is to be counteracted by a) Range of motion exercises b) Positioning c) Development of active movement Useful techniques to inhibit spasticity include
- Weight bearing
- Weight shifting
- Slow, rhythmic rocking
- Rhythmic rotation of trunk and body segments
- Active trunk rotation
- Dissociation of body segments and isolated joint movements should be included in the treatment activities and home program Appropriate handling can increase likelihood that the child will receive more accurate sensory feedback for motor learning. Further child should be placed in different positions to foster motor development, prevent major complications like contractures and deformities and to inhibit abnormal reflexes. The advantages/disadvantages of different positioning for spastic CP SUPINE Advantages a) Can begin early weight bearing through lower extremities when knees are bent and feet flat on support surface.
d) In addition if prone on movable surface (ball) upper extremity protective reactions can be elicited. Disadvantages a) Flexor tone may increase because of PTLR. b) Breathing may be difficult for some children because of inhibition of diaphragm. c) Prone is not recommended for young children for sleeping posture due to increased incidence of SUDDEN INFANT DEATH SYNDROME. SITTING Advantages a) Promote weight bearing through upper extremity with active control of head and trunk. b) Frees arms for play ad explorations. c) Trunk can be extended and dissociated from flipped lower extremities. d) Helps to normalize visual and vestibular input as well as in feeding. e) Excellent position to facilitate head and trunk righting reactions, trunk equilibrium reactions to upper extremity, protective reactions. f) Side sitting promotes trunk elongation and rotation. g) ADL’s such as feeding, dressing, bathing and movement transition can all be encouraged while child is sitting. Disadvantages a) Sitting can enhance flipped posture. b) Child can have difficulty in maintaining the trunk extension due to lack of strength or too much flexor tone. c) Child can assume abnormal sitting postures like w-sitting and cross leg which can promote muscular tightens and may predispose to contractures in lower limbs. QUADRUPED Advantage
a) Main advantage is that all extremities are in weight bearing and trunk works directly against gravity. b) Provides excellent opportunities for dissociation and reciprocal movement of extremities. Disadvantages a) Can be difficult to maintain due to STNR. b) When trunk rotation is lacking children often end up w-sitting. KNEELING Advantages a) It is a dissociated posture; i.e. trunk and hips are extended while knees are flipped. b) Provides stretch to hip flexors. c) Hip and pelvic control can be developed. d) Balance responses can be practiced without having to control all the lower limb joints. e) Transition of movement to half kneeling in back to sitting can be practiced. Disadvantages Kneeling can be difficult to control and children often cannot extend hip completely due to STNR. STANDING Advantages a) Allows weight bearing through entire lower limbs is of great importance for long bone growth. b) Weight bearing can provide prolonged stretch on heel cords and knee flexors while promoting active head and trunk control. c) Provides appropriate visual input and enhances intervention. Disadvantages a) Significant amount of external support may be required.
Lack of head control Inability to track visually Dislike of prone position Asymmetric postures due to exaggerated tonic reflexes Tonal abnormalities Breathing and feeding problems f) Early intervention spans for 3 years of life. During this period infant is learning to move about safely within their environment and explore more and are establishing trust in their caregivers g) Family has to play vital role during this period h) Family is to be therefore educated about ways to position, carry, feed and dress the child. Physical therapy is usually family-oriented intervention
GENERAL GOALS FOR PHYSICAL THERAPY IN EARLY INETRVENTION
1. PROMOTE INFANT-PARENT DEVELOPMENT
2. ENCOURAGE DEVELOPMENT OF FUNCYIONAL SKILL AND PLAY
3. PROMOTE SENSORY-MOTOR DEVELOPMENT
4. ESTABLISH HEAD AND TRUNK CONTROL
5. ATTAIN AND MINTAIN UPRIGHT ORIENTATION
INTERVENTIONS
HANDLING AND POSITIONING
POSITIONING FOR FUNCTION
One of the fundamental skill therapists should learn is how to position a child. Principles for positioning include:-
- Alignment- helps to prevent deformity and contractures
- Comfort – position should be comfortable
- Support Additional consideration include
- Prevention of deformity
- Readiness to move Safe and stable postures should be used that can be used for ADLs e.g. child who uses w-sitting because this leaves hands free to play needs to be given an alternating sitting postures that affords some opportunities to play. A simple solution may be to have child sit on char at table to play, rather than sitting on floor. Important consideration for positioning is the idea that position provides posture from which movement occurs. Safety is very important when child is positioned for position Child should be safe in posture i.e. able to demonstrate protective response if child falls out of the posture Usually child may be using one or both U/L for propping when sitting, if not able to do so, should be provided assistance, with device or by person to ensure safety Proper alignment of trunk must always be provided to prevent unwanted spinal curvatures, which can hamper independent sitting and respiratory function. Any position in which you place child, he should be able to shift weight within posture for pressure relief and next important is to provide movement possibility to move from one posture to another When we work with children, we must take into account both mobility and stability, so selected those therapeutic postures that encourage static and dynamic balance. DYNAMIC POSTURES are those in which weight shifting is possible keeping COG within base of support. Examples: child rocking or shifts weight in hands and knees position for long periods before making transition to creeping. The ability to shift weight with control within posture indicates preparation and readiness to move out of that posture into another posture. Child’s position must be changed often during the day. Child‘s job is to play, although it may appear to be a simple task, but can be challenge to child. Parents should identify the ways to allow the child to fully participate in world.
HANDLING AT HOME:
Parents and care givers should be taught the easiest ways to move the child from one position to another.
A) Allow the child to be having a child into lifting into sitting position from supine position, roll the child to one side and give the child time to push up onto his hand, even if he can only do this part of way. B) When carrying child encourage as much head and trunk control as child can demonstrate i.e carry child in such a way that he uses head and trunk muscle to maintain head and trunk upright against gravity. C) When trying to move the child with spasticity, do not pull against tightness. Move slowly and rhythmically starting proximally at shoulder girdle or pelvic girdle. D) Athetoid child have increased sensitivity to touch, sound and light. They startle easily and withdraw from contact on their hands, feet and mouth. Encourage child to keep her/his head in midline and hands in sight. Weight bearing on hands and feet is an important activity for these children. E) Hypotonic child need to be handle vigorously, but they tire easily and need more rest periods. Avoid them to be placed in supine to play because they need to work against gravity in prone position to develop extensors. In supine they assume “FROG” position of abduction. In semi- reclined supine position strengthening of abdominal muscles can be done. Engage child in visual tracking, the child learn to use the eyes to encourage head and trunk movement. Low tone child should place appropriate seat or chair if older. F) When encouraging movement from proximal joints, remember that wherever you hands are the child will not be in control has to be developed. G) Ultimately, the goal is for the child to guide her/his own movement. Handling should be decreased as the child gains control.
FEEDING AND RESPIRATION:
An upright flexed posture facilitates feeding and social interaction between the child and the caregiver. Face to face position should be used. Child can also be placed in appropriate chair. Deeper respiration can also be encouraged prior to feeding by applying slight pressure to child’s thorax and abdominal area before inspiration.
THERAPEUTIC EXERCISES:
Gentle range of motion is indicated if infant has difficulty in reaching to the midline, difficulty in reaching in diapering or tight heel cords. Hips should never be forced into forceful range of abduction or extension. These should be carried out in diapering bathing and dressing. Parents should be taught.
MOTOR SKILL ACQUISITION:
Adequate time should be given to child to play on floor to encourage the movement of body against gravity. Body movement during play is crucial to body awareness. Movement within the environment is necessary for spatial orientation to the external world. Child should experience different postures, to encourage head and trunk and control, extremity usage and transitional movements.
FUNCTIONAL POSTURES:
Two most functional posture for the person is setting and standing, and are very important for child to experience these. It might be difficult for child to maintain upright position in standing but sitting can be assumed by appropriate seating devices, inserts and supports. Upright standing can be achieved by using the supine or prone standers, along with orthosis for distal control. Standers provide lower extremity weight bearing while they support the child’s trunk. Hands are free for reaching and manipulation.
- Correct alignment should be maintained.
- Standing programmes typically start around 12-16 month/age. Goals of standing are to improve bone density and development. Prevention of contracture development is also needed. It is recommended that standing for 45 minutes daily three times daily controlled contractures and bone density is promoted in c.p’s.
INDEPENDENT MOBILITY:
Child is to be encouraged to achieve independent mobility. There are many ways to achieve these.
- Rolling is one way of mobility.
- Sitting, hitching and scooting with or without assistance of extremities.
- Creeping on hands and knees. But upright ambulation is most acceptable way to achieved independent mobility.
