Cerebral Palsy = Brain ParalysisCerebral Palsy = Brain Paralysis

DefinitionDefinition PrevalencePrevalence EtiologyEtiology ClassificationsClassifications Clinical PresentationClinical Presentation Treatments & managementTreatments & management

Cerebral Palsy: DefinitionCerebral Palsy: Definition

Cerebral palsy is a Cerebral palsy is a static encephalopathystatic encephalopathy Encephalopathy = Encephalopathy = Brain InjuryBrain Injury that is that is non-non-

progressiveprogressive disorder of disorder of posture and posture and movementmovement

Variable etiologiesVariable etiologies Often associated with epilepsy, speech Often associated with epilepsy, speech

problems, vision compromise, & cognitive problems, vision compromise, & cognitive dysfunctiondysfunction

Cerebral Palsy: PrevalenceCerebral Palsy: Prevalence

2-4/1000; 7-10,000 new babies each 2-4/1000; 7-10,000 new babies each yryr

150 years ago described by Dr. Little 150 years ago described by Dr. Little an orthopedic surgeon and known as an orthopedic surgeon and known as Little’s DiseaseLittle’s Disease

During past 3 decades considerable During past 3 decades considerable advances made in obstetric & advances made in obstetric & neonatal care, but unfortunately neonatal care, but unfortunately there has been virtually no change in there has been virtually no change in incident of CPincident of CP

Cerebral Palsy: ClassificationCerebral Palsy: Classification

Various classifications of Cerebral Various classifications of Cerebral PalsyPalsy

PhysiologicPhysiologic TopographicTopographic EtiologicEtiologic

Cerebral Palsy: PhysiologicCerebral Palsy: Physiologic

AthetoidAthetoid AtaxicAtaxic Rigid-SpasticRigid-Spastic AtonicAtonic MixedMixed

Types of Cerebral PalsyTypes of Cerebral Palsy

Spastic (70%)Spastic (70%)Quadriplegia, hemiplegia, diplegiaQuadriplegia, hemiplegia, diplegia

Athetoid (15%)Athetoid (15%)Choreoathethoid, DystonicChoreoathethoid, Dystonic

Ataxic (5%)Ataxic (5%)Mixed (10%)Mixed (10%) Combination of any two types of CPCombination of any two types of CPHypotonic Hypotonic

Early stages of the Spastic, Dyskinetic and Early stages of the Spastic, Dyskinetic and Ataxic formsAtaxic forms

CP Spastic HemiplegicCP Spastic Hemiplegic Clinical features are those of pyramidal Clinical features are those of pyramidal

release involving one side of the bodyrelease involving one side of the bodyPosture and gaitPosture and gait

Tone & Deep tendon reflexesTone & Deep tendon reflexes

Contractures and DeformitiesContractures and Deformities

Wasting of affected limbsWasting of affected limbs Note any facial muscle weaknessNote any facial muscle weakness

CCortical sensory lossortical sensory loss

Visual field defectVisual field defect

Speech defectsSpeech defects

Ataxic Cerebral PalsyAtaxic Cerebral Palsy Rare form of CPRare form of CP Hypotonic and hyporeflexic in infancyHypotonic and hyporeflexic in infancy Ataxic – Titubation( a tremor of the Ataxic – Titubation( a tremor of the

head and sometimes trunk, commonly head and sometimes trunk, commonly seen in cerebellar disease )seen in cerebellar disease )

Intention tremors and IncoordinationIntention tremors and Incoordination Mental deficit is MildMental deficit is Mild Nystagmus is uncommonNystagmus is uncommon

Cerebral Palsy: TopographicCerebral Palsy: Topographic

MonoplegicMonoplegic ParaplegicParaplegic HemiplegicHemiplegic TriplegicTriplegic QuadraplegicQuadraplegic DiplegicDiplegic

Cerebral Palsy: EtiologicCerebral Palsy: Etiologic

Prenatal (70%)Prenatal (70%)Infection, anoxia, toxic, vascular, Rh Infection, anoxia, toxic, vascular, Rh disease, genetic, congenital disease, genetic, congenital malformation of brainmalformation of brain

Natal (5-10%)Natal (5-10%)Anoxia, traumatic delivery, metabolicAnoxia, traumatic delivery, metabolic

Post natalPost natalTrauma, infection, toxicTrauma, infection, toxic

Causes of Cerebral PalsyCauses of Cerebral Palsy 90% of the causes are Idiopathic90% of the causes are Idiopathic Prenatal (Before delivery)Prenatal (Before delivery)

MaternalMaternal Infection, Genetic, Developmental, Infection, Genetic, Developmental, Vascular problemsVascular problems

Natal (During the time of Delivery)Natal (During the time of Delivery)Anoxia, Asphyxia, Birth Trauma such as Anoxia, Asphyxia, Birth Trauma such as Dispropotion , Forceps, Rapid or Breech Dispropotion , Forceps, Rapid or Breech deliverydelivery

Postnatal (After Delivery)Postnatal (After Delivery)Trauma to Skull, Kernictures (Jaundice after Trauma to Skull, Kernictures (Jaundice after birth), Infections, Vascular complications birth), Infections, Vascular complications such as Thrombosis, Embolism, such as Thrombosis, Embolism, HaemmorhageHaemmorhage

DiagnosisDiagnosis

Medical HistoryMedical History

CT Scan / MRI ScanCT Scan / MRI Scan

Cerebral Palsy: Cerebral Palsy: Clinical PresentationClinical Presentation

Remember that motor Remember that motor developmental progression is from….developmental progression is from….

Head to ToeHead to Toe

Cerebral Palsy: ComplicationsCerebral Palsy: Complications

SpasticitySpasticity WeaknessWeakness Increase reflexesIncrease reflexes ClonusClonus SeizuresSeizures Articulation & Articulation &

Swallowing Swallowing difficultydifficulty

Visual compromiseVisual compromise DeformationDeformation Hip dislocationHip dislocation KyphoscoliosisKyphoscoliosis ConstipationConstipation Urinary tract Urinary tract

infectioninfection

On ExaminationOn Examination

1.Assessment of higher functions1.Assessment of higher functions

Orientation-Normal (except in MR Orientation-Normal (except in MR cases)cases)

Speech- Dysarthria , AphasiaSpeech- Dysarthria , Aphasia

Vision-Squint or BlindnessVision-Squint or Blindness

Learning – May be lostLearning – May be lost

Memory-will be impaired in most of the Memory-will be impaired in most of the casescases

Emotional State- Apathic , FrightenedEmotional State- Apathic , Frightened

Contd….Contd….2.Assessment of Muscular System2.Assessment of Muscular System

Tone –Tone – Spastic Spastic

FlaccidFlaccid

Rigid Rigid

Mixed (depends on the type of Mixed (depends on the type of CP)CP)

Muscle Power- Assessed by Muscle Power- Assessed by MRCMRC Grading Grading

Girth Of the Muscle- Its is usually Girth Of the Muscle- Its is usually reduced due to reduced due to DISUSE . DISUSE .

Contd….Contd….3.Assessment of Sensory System3.Assessment of Sensory System

1.Spinothalamic sensations are 1.Spinothalamic sensations are NormalNormal

2.Posterior column is involved.2.Posterior column is involved.

So Joint position sense, Vibration So Joint position sense, Vibration sense are usually affectedsense are usually affected

Contd….Contd….4.Assessment of Reflexes4.Assessment of Reflexes

Deep Tendon Reflex – exaggerated in Deep Tendon Reflex – exaggerated in spastic CPspastic CP

Neonatal reflexes – Delayed or AbsentNeonatal reflexes – Delayed or Absent

Superficial reflexes may be affected in Superficial reflexes may be affected in spastic CP.spastic CP.

5.Assessment of Chest5.Assessment of Chest

Normal .Normal .

6.Assessment of limbs6.Assessment of limbs

1.Alteration of Tone in both upper and 1.Alteration of Tone in both upper and Lower limb.Lower limb.

Contd….Contd….7.Assessment of Co-ordination7.Assessment of Co-ordination

In co-ordination is seen in In co-ordination is seen in Athetoid, Ataxic & Mixed type.Athetoid, Ataxic & Mixed type.

8.Assessment of Spine8.Assessment of Spine

Spinal deformity – Scoliosis or Spinal deformity – Scoliosis or Lardosis is seenLardosis is seen

9.Assessment of Balance9.Assessment of Balance

Affected.Affected.

Contd….Contd….10.Assessment of Posture10.Assessment of Posture

Three types of posture are Three types of posture are usually seen according to the type of usually seen according to the type of CP. They are CP. They are

1.Flexion posture1.Flexion posture

2.Extension Posture2.Extension Posture

3.Adduction Posture3.Adduction Posture

11.Assessment of compound 11.Assessment of compound movementsmovements AffectedAffected

Contd….Contd….12.Assessment of Gait12.Assessment of Gait Scissoring gait – The patients try to catch their Scissoring gait – The patients try to catch their

own centre of Gravity.own centre of Gravity.This is due to weakness of Abductors and This is due to weakness of Abductors and

Spasm of AdductorsSpasm of Adductors

13.Assessment of Other Problems13.Assessment of Other Problems1.Ortho Problems-Stiffness, Pain & Deformity in 1.Ortho Problems-Stiffness, Pain & Deformity in JointsJoints2.Pressure sores – Ulcers over the Bony 2.Pressure sores – Ulcers over the Bony prominenceprominence

Cerebral Palsy: ManagementCerebral Palsy: Management

Neurologic and PhysiatricNeurologic and Physiatric OT and PTOT and PT SpeechSpeech Adaptive equipmentAdaptive equipment SurgicalSurgical Rhizotomy, Baclofen pumps, Botoxin Rhizotomy, Baclofen pumps, Botoxin

Different approaches to Different approaches to Neuromuscular educationNeuromuscular education

W M Phelps-diagnosed five types of CPW M Phelps-diagnosed five types of CP Specific combinations of muscle education Specific combinations of muscle education

& bracing were prescribed for different & bracing were prescribed for different types of CP.types of CP.

Muscles were assessed,classified as Muscles were assessed,classified as spastic,weak,normal or atonic & re-spastic,weak,normal or atonic & re-education was given based on their education was given based on their condition.condition.

In this system muscles antagonistic to In this system muscles antagonistic to spastic ones are activated.spastic ones are activated.

Neuro developmental treatment Neuro developmental treatment with Reflex inhibition & facilitation with Reflex inhibition & facilitation

(NDT)(NDT) Berta Bobath-Berta Bobath- This technique is based on the inhibition of This technique is based on the inhibition of

tonic reflexes,such as symmetrical& tonic reflexes,such as symmetrical& asymmetrical tonic neck reflexes,tonic asymmetrical tonic neck reflexes,tonic labyrinthine reflex.labyrinthine reflex.

Ones the reflex patterns of abnormal tone Ones the reflex patterns of abnormal tone are inhibited the child is said to have been are inhibited the child is said to have been prepared for movements.prepared for movements.

Various primitive reflexes of infancy Various primitive reflexes of infancy should also be inhibited.should also be inhibited.

Features of the approach areFeatures of the approach are

Reflex inhibitory patterns-Reflex inhibitory patterns- Selected to inhibit abnormal tone associated with Selected to inhibit abnormal tone associated with

abnormal movement patterns & abnormal posture.abnormal movement patterns & abnormal posture. Sensory Motor Experience- Sensory Motor Experience- The reversal of these abnormalities gives the child The reversal of these abnormalities gives the child

the sensation of more normal tone.the sensation of more normal tone. Sensory stimuli are also used for inhibition & Sensory stimuli are also used for inhibition &

facilitation & voluntary movement.facilitation & voluntary movement. Facilitation Techniques For Mature Postural ReflexFacilitation Techniques For Mature Postural Reflex..

`̀

Key points of control Key points of control Are used to attempt to change the Are used to attempt to change the

patterns of spasticity so the child is patterns of spasticity so the child is prepared for movements.prepared for movements.

The key points are usually head& The key points are usually head& neck,shoulder & pelvic girdles.neck,shoulder & pelvic girdles.

Developmental SequencesDevelopmental Sequences All-day managementAll-day management –should supplement –should supplement

treatment session.parents &others are treatment session.parents &others are advised on daily management & trained advised on daily management & trained to treat the children.to treat the children.

Proprioceptive neuromuscular Proprioceptive neuromuscular Facilitation (PNF)Facilitation (PNF)

Herman Kabat,with Margret Knott & Dorothy Voss-Herman Kabat,with Margret Knott & Dorothy Voss- Developed a system of movement facilitation Developed a system of movement facilitation

techniques &methods for inhibition of hypertonus.techniques &methods for inhibition of hypertonus. The main features areThe main features are : : Movements patternsMovements patterns (called mass movements (called mass movements

patterns)-patterns)- Patterns observed with functional activities as Patterns observed with functional activities as

walking ,feeding, playing sports. These patterns are walking ,feeding, playing sports. These patterns are spiral (rotational)& diagonal.spiral (rotational)& diagonal.

The movements patterns consist of the following The movements patterns consist of the following components-components-

(1) Flexion or Extention(1) Flexion or Extention (2) Abduction or Adduction(2) Abduction or Adduction (3) Internal or External rotation(3) Internal or External rotation Sensory (afferent) stimuliSensory (afferent) stimuli:: Those muscle group working in synergy Those muscle group working in synergy

with rotational& diagonal patterns were with rotational& diagonal patterns were identified & with a combination of touch & identified & with a combination of touch & pressure, traction & compression. stretch , pressure, traction & compression. stretch , proprioception ,auditory& visual stimuli proprioception ,auditory& visual stimuli are given to muscles to contract against are given to muscles to contract against resistance. resistance.

Special TechniquesSpecial Techniques 1. Irradiation-this is the predictable 1. Irradiation-this is the predictable

overflow of action from one muscle group overflow of action from one muscle group to another within a synergy.to another within a synergy.

2. Rhythmic stablizations-which use stimuli 2. Rhythmic stablizations-which use stimuli alternating from the agonist to its alternating from the agonist to its antagonist in isometric muscle work.antagonist in isometric muscle work.

3. Stimulation of reflexes- such as the 3. Stimulation of reflexes- such as the mass flexion or extension.mass flexion or extension.

4. Repeated contractions- of one pattern 4. Repeated contractions- of one pattern using any joint as a pivot.using any joint as a pivot.

5. Reversals-from one pattern to its 5. Reversals-from one pattern to its antagonist.antagonist.

6. Relaxation techniques- such as 6. Relaxation techniques- such as contract-relax & hold-relax. Ice contract-relax & hold-relax. Ice treatment are used for relaxation of treatment are used for relaxation of hypertonus.hypertonus.

Sensory Stimulation for Sensory Stimulation for Activation & InhibitionActivation & Inhibition

It is a sensory approach in which Rood’s It is a sensory approach in which Rood’s technique-By Margret Roodtechnique-By Margret Rood

muscles are classified according to their muscles are classified according to their function & the appropriate stimuli for function & the appropriate stimuli for their action are given.their action are given.

The various nerves & sensory receptors The various nerves & sensory receptors are described & classified into types, are described & classified into types, location, effect, response, distribution & location, effect, response, distribution & indication.indication.

Techniques of stimulation, such as Techniques of stimulation, such as stroking, brushing (tactile) icing, heating stroking, brushing (tactile) icing, heating (temp.) pressure, bone pounding, slow (temp.) pressure, bone pounding, slow & quick muscle stretch, muscles & quick muscle stretch, muscles contractions (proprioception) are used contractions (proprioception) are used to activate, facilitate or inhibit motor to activate, facilitate or inhibit motor response.response.

Sensory motor technique uses a series Sensory motor technique uses a series of eight clearly defined developmental of eight clearly defined developmental patterns which children learn in patterns which children learn in sequence.sequence.

These patterns are spine withdrawal, These patterns are spine withdrawal, rolling over, pivot prone, neck co-rolling over, pivot prone, neck co-contraction, elbow weight bearing, all contraction, elbow weight bearing, all four weight bearing, standing upright four weight bearing, standing upright & walking.& walking.

Vital functions-A developmental Vital functions-A developmental sequence of respiration, sucking, sequence of respiration, sucking, swallowing, phonation, chewing & swallowing, phonation, chewing & speech is followed.speech is followed.

Reflex creeping&Other Reflex Reflex creeping&Other Reflex ReactionsReactions

By Vaclav Vojta-By Vaclav Vojta- Trigger points are points on the body Trigger points are points on the body

which facilitate movement patterns which facilitate movement patterns involving the head,trunk & limbs.involving the head,trunk & limbs.

These reflex zones ( 9 in number) are These reflex zones ( 9 in number) are activated with sensory stimuli & activated with sensory stimuli & creeping is seen as a response to this creeping is seen as a response to this triggering.triggering.

Sensory integration treatment Sensory integration treatment approachapproach

Developed by A.J.AyersDeveloped by A.J.Ayers The goal of this technique is to teach The goal of this technique is to teach

the children how to integrate all their the children how to integrate all their sensory feedback & then produce sensory feedback & then produce useful & purposeful motor response.useful & purposeful motor response.

Activities like catching a ball in Activities like catching a ball in different position uses integration of different position uses integration of visual, vestibular & joint visual, vestibular & joint proprioception feedback system at proprioception feedback system at the same time.the same time.

Theory of this system is that sensory Theory of this system is that sensory input followed by appropriate motor input followed by appropriate motor function will contribute to the function will contribute to the improved development of higher improved development of higher cortical motor sensory function.cortical motor sensory function.

Orthopaedic ManagementOrthopaedic Management For improvement of functional For improvement of functional

mobility and appearance after mobility and appearance after conservative therapy has failedconservative therapy has failed

Correction of contractures – Correction of contractures – TenotomyTenotomy

Correction of deformities from muscle Correction of deformities from muscle imbalance Eg. Tendon transferimbalance Eg. Tendon transfer

Correction of functional handicaps of Correction of functional handicaps of hands and feet – Arthrodesing hands and feet – Arthrodesing operationsoperations

Gentle StretchingGentle StretchingStretching is the activity of gradually applying tensile force to lengthen, strengthen, and lubricate muscles, often performed in anticipation of physical exertion and to increase the range of motion within a joint. Stretching is also believed to help to prevent injury to tendons, ligaments and muscles by improving muscular elasticity and reducing the stretch reflex in greater ranges of motion that might cause injury to tissue.

Strengthening exercisesStrengthening exercises

These exercises are done to increase the power These exercises are done to increase the power & strength of the muscle. They usually done & strength of the muscle. They usually done as Resisted Exercises both Manually and as Resisted Exercises both Manually and Mechanically.Mechanically.

Contd…..Contd…..Rolling Rolling

The patient is made to move from one side to The patient is made to move from one side to another side by his side. This is known as rolling another side by his side. This is known as rolling

CrawlingCrawling

The child is made to move on his four limbs The child is made to move on his four limbs

Standing with supportStanding with support

Posture CorrectionPosture Correction

Gait TrainingGait Training

Speech RehabilitationSpeech Rehabilitation

VERBAL APPROACH-VERBAL APPROACH- Initiating auditory-verbal therapy as Initiating auditory-verbal therapy as

early as possible is essential because early as possible is essential because the child's greatest capacity for the child's greatest capacity for learning language auditorily, occurs learning language auditorily, occurs during the first two to three years of during the first two to three years of life. In order to effectively learn life. In order to effectively learn spoken language, a child's hearing spoken language, a child's hearing and listening skills must be and listening skills must be stimulated during this critical time.stimulated during this critical time.

Parent-Centered ModelingParent-Centered Modeling

Parents are the major influence in a Parents are the major influence in a young child's development, acting as young child's development, acting as primary role models and the most primary role models and the most effective teachers. For this reason, effective teachers. For this reason, the verbal approach is parent-the verbal approach is parent-oriented. The verbal therapist oriented. The verbal therapist develops a working partnership with develops a working partnership with parents to teach speech and parents to teach speech and language to the child at home language to the child at home

Oral Sensory motor facilitation Oral Sensory motor facilitation techniquestechniques

Proper neural development of oral Proper neural development of oral movements and oral sensory movements and oral sensory function is vital for providing the function is vital for providing the foundation for good speech foundation for good speech production and mature feeding production and mature feeding patterns.patterns.

Oral Sensitivity (based on these Oral Sensitivity (based on these domains - Temperatures, Textures, domains - Temperatures, Textures, Tastes) Hypersensitivity - Over-Tastes) Hypersensitivity - Over-sensitivesensitive

Hyposensitivity - Under-sensitiveHyposensitivity - Under-sensitive

Jaw StabilityJaw StabilityPosition of the jaw and presence/absence of stability or Position of the jaw and presence/absence of stability or weakness during oral sensory-motor activities, such as weakness during oral sensory-motor activities, such as chewing.chewing.

Lip FunctionLip FunctionPosition and action/movement of the lips during oral Position and action/movement of the lips during oral sensory-motor activities, such as drinking, sucking, sensory-motor activities, such as drinking, sucking, chewing or blowing.chewing or blowing.

Tongue FunctionTongue FunctionPosition and action/movement of the tongue during oral Position and action/movement of the tongue during oral sensory-motor activities, such as chewing, drinking, sensory-motor activities, such as chewing, drinking, sucking or blowing.sucking or blowing.

TONGUE EXERCISESTONGUE EXERCISES  Range of MotionRange of Motion

  1. Tongue Extension1. Tongue Extension Protrude tongue between lips.Protrude tongue between lips. Sticking out tongue as far as you Sticking out tongue as far as you

can.can. Hold tongue steady and straight for 3 Hold tongue steady and straight for 3

to 5 seconds.to 5 seconds. Relax and Repeat 5 times.Relax and Repeat 5 times.

  2. Tongue Retraction2. Tongue Retraction Retract tongue, touching the back of Retract tongue, touching the back of

your tongue to the roof of your mouth  your tongue to the roof of your mouth  (as if producing the /k/).(as if producing the /k/).

Hold for 1 to 3 seconds.Hold for 1 to 3 seconds. Relax and Repeat 5 times.Relax and Repeat 5 times.   3. Tongue Extension and Retraction3. Tongue Extension and Retraction Combine the two procedures above, Combine the two procedures above,

holding each position for 1 to 3 seconds.holding each position for 1 to 3 seconds. Relax and Repeat 5 times.  .Relax and Repeat 5 times.  .

  4. Tongue Tip Up4. Tongue Tip Up Place tongue on alveolar ridge, (the area Place tongue on alveolar ridge, (the area

behind your top teeth.)behind your top teeth.) If you don't have any teeth, move your If you don't have any teeth, move your

tongue tip up to your gum where your top tongue tip up to your gum where your top teeth would be.teeth would be.

Open mouth as wide as possible Open mouth as wide as possible maintaining tongue contact.maintaining tongue contact.

Hold for 3 to 5 seconds.Hold for 3 to 5 seconds. Relax and Repeat 5 timesRelax and Repeat 5 times

  5. Tongue Elevation Along The Palate5. Tongue Elevation Along The Palate Tongue tip to alveolar ridge,  (The area behind Tongue tip to alveolar ridge,  (The area behind

your top teeth.)your top teeth.) Move tongue front to back along the roof of your Move tongue front to back along the roof of your

mouth.mouth. Relax and Repeat 5 times.Relax and Repeat 5 times.   6. Tongue Side To Side6. Tongue Side To Side Tongue tip to left side of mouth, hold for 3 to 5 Tongue tip to left side of mouth, hold for 3 to 5

seconds.seconds. Tongue tip to right side of mouth, hold for 3 to 5 Tongue tip to right side of mouth, hold for 3 to 5

seconds.seconds. Relax and Repeat 5 to 10 times.Relax and Repeat 5 to 10 times.

Tongue Resistance:Tongue Resistance:   1. Tongue Push Forward 1. Tongue Push Forward

Stick out your tongue as far as you can.Stick out your tongue as far as you can. Put something flat (back of a spoon or a tongue depressor) Put something flat (back of a spoon or a tongue depressor)

against your tongueagainst your tongue Push against your tongue with the flat object at the same Push against your tongue with the flat object at the same

time as you push against the flat object with your tonguetime as you push against the flat object with your tongue Hold for 1 to 2 seconds.Hold for 1 to 2 seconds. Repeat 5 times.Repeat 5 times.   2. Tongue Push Up2. Tongue Push Up Push down on your tongue with the flat object,  while, at Push down on your tongue with the flat object,  while, at

the same time, you push up with your tongue.the same time, you push up with your tongue. Hold 1 second.Hold 1 second. Repeat 5 times.Repeat 5 times.

JAW EXERCISESJAW EXERCISES  Range of MotionRange of Motion

  1. Jaw Opening1. Jaw Opening 2. Side-to-Side Movement2. Side-to-Side Movement 3. Increasing Circular Jaw Movement3. Increasing Circular Jaw Movement

LIP EXERCISESLIP EXERCISES  Range of Motion:Range of Motion:   

  1. Lip Retraction1. Lip Retraction Smile.  Hold for 5 seconds.Smile.  Hold for 5 seconds. Relax and Repeat 5 times.Relax and Repeat 5 times.   2. Lip Protrusion2. Lip Protrusion Pucker your lips as if you were going to give Pucker your lips as if you were going to give

someone a kiss.someone a kiss. Hold for 5 seconds.Hold for 5 seconds. Relax and Repeat 5 times.Relax and Repeat 5 times.   3. Lip Retraction and Protrusion3. Lip Retraction and Protrusion Smile then pucker your lips.  Use exaggerated Smile then pucker your lips.  Use exaggerated

movements.movements. Relax and Repeat 5 times.Relax and Repeat 5 times.

Lip Closure:Lip Closure:   1. Lip Press 1. Lip Press

Press lips tightly together for 5 seconds.Press lips tightly together for 5 seconds. Relax and Repeat 5 times.Relax and Repeat 5 times.   2. Lip Press on Tongue Depressor2. Lip Press on Tongue Depressor Tightly press lips around tongue depressor, Tightly press lips around tongue depressor,

while the clinician tries to remove it.while the clinician tries to remove it. Perform for 3 to 5 seconds.Perform for 3 to 5 seconds. Relax and Repeat 5 times.Relax and Repeat 5 times.

Compensatory TechniquesCompensatory Techniques:: Correction of Respiratory errorsCorrection of Respiratory errors:: Attention should be given to the development of Attention should be given to the development of

speech-breathing patterns before the child is a speech-breathing patterns before the child is a year old.year old.

The following techniques are used for The following techniques are used for improvement of breathing patterns for speech :-improvement of breathing patterns for speech :-

1.Break Up Persistent Tonic Reflex Patterns1.Break Up Persistent Tonic Reflex Patterns Abnormal distribution of muscle tone is found in Abnormal distribution of muscle tone is found in

abdominal, thorax & neck muscles of CP abdominal, thorax & neck muscles of CP Children.When strong tonic reflexes persist they Children.When strong tonic reflexes persist they should be weakened or broken up through should be weakened or broken up through systematic use of such techniques as reflex systematic use of such techniques as reflex inhibition or sensory facilitation. inhibition or sensory facilitation.

2.Facilitate Developmental Sequences 2.Facilitate Developmental Sequences Which Lead To Good Sitting PostureWhich Lead To Good Sitting Posture

Many of the cerebral palsied children seem Many of the cerebral palsied children seem to collapse on sitting because much of the to collapse on sitting because much of the weight of the trunk and head bears down weight of the trunk and head bears down on the abdominal areas, thus interfering on the abdominal areas, thus interfering with function of the diaphragm & with function of the diaphragm & abdominal musculature.abdominal musculature.

The back is rounded & the head is flexed The back is rounded & the head is flexed so that the chin rest on the chest.so that the chin rest on the chest.

In this position elevation of the rib In this position elevation of the rib cage for inhalation is difficult.cage for inhalation is difficult.

Therefore taking the child through Therefore taking the child through the developmental sequences the developmental sequences leading to unsupported sitting with leading to unsupported sitting with good posture is basic fo developing good posture is basic fo developing speech breathing.speech breathing.

3.Maintaining Proper Postural 3.Maintaining Proper Postural Relationships between Abdomen, Relationships between Abdomen, Trunk, Neck & Head.Trunk, Neck & Head.

Seating in a properly fitted & Seating in a properly fitted & adjusted relaxation chair will help the adjusted relaxation chair will help the child maintain a more satisfactory child maintain a more satisfactory postural relationship between head & postural relationship between head & neck, trunk & abdominal areas.neck, trunk & abdominal areas.

In physical therapy ,attention must In physical therapy ,attention must be given to the flexors & extensors be given to the flexors & extensors muscles of the neck & shoulders. muscles of the neck & shoulders.

3.Develop a Breathing Rate of Less 3.Develop a Breathing Rate of Less Than 30 Cycles/minuteThan 30 Cycles/minute

Several procedure are suggested for Several procedure are suggested for imposing a slower rest-breathing rate on imposing a slower rest-breathing rate on child.child.

A) Crossing the child’s forearm across his A) Crossing the child’s forearm across his chest & pressing them tightly enough chest & pressing them tightly enough against his thorax to encourage a deeper against his thorax to encourage a deeper exhalation.For inhalation the pressure is exhalation.For inhalation the pressure is released.released.

The therapist times his movement of The therapist times his movement of pressure & relaxation of pressure to control pressure & relaxation of pressure to control the normal breathing pattern.the normal breathing pattern.

B) With the child lying on his back, flex the B) With the child lying on his back, flex the knees & press the front portion of the upper knees & press the front portion of the upper legs against the abdomen by flexing the legs against the abdomen by flexing the hips.Quickly extend the legs at the hips, hips.Quickly extend the legs at the hips, thus releasing the pressure on the thus releasing the pressure on the abdominal area. This pattern of movements abdominal area. This pattern of movements should be repeated at a rate corresponding should be repeated at a rate corresponding to the normal breathing rate i.e. about 20 to the normal breathing rate i.e. about 20 cycles/ minute. cycles/ minute.

4.Develop a Speech Breathing 4.Develop a Speech Breathing Patterns pf Quick Inhalation & Patterns pf Quick Inhalation & Controlled, Prolonged ExhalationControlled, Prolonged Exhalation

Contd…Contd…

Some CP children seem to have difficulty in Some CP children seem to have difficulty in learning to inhale quickly and then produce learning to inhale quickly and then produce the controlled, prolonged exhalation the controlled, prolonged exhalation required for continuous speech (as in required for continuous speech (as in yawning & crying).It is difficult to modify yawning & crying).It is difficult to modify these breathing patterns for speech these breathing patterns for speech production.production.

Momentary interference with inhalation-by Momentary interference with inhalation-by holding a tissue over the nose & mouth-will holding a tissue over the nose & mouth-will cause the child to breath deeply when the cause the child to breath deeply when the interference is removed.interference is removed.

Producing deep inhalation on a reflex basis Producing deep inhalation on a reflex basis is only a first step.is only a first step.

Next learning is to hold the inhaled air Next learning is to hold the inhaled air until given a signal to exhale.until given a signal to exhale.

At first the exhalation will be rapid & At first the exhalation will be rapid & uncontrolled.uncontrolled.

Having the child imitate a prolonged sigh, Having the child imitate a prolonged sigh, a prolonged phonation, babbling or a prolonged phonation, babbling or sustained blowing will help him develop sustained blowing will help him develop controlled, prolonged phonations.controlled, prolonged phonations.

5.Counteract Abdominal Movements 5.Counteract Abdominal Movements Which are Asynchronous with Thoracic Which are Asynchronous with Thoracic MovementsMovements

Sometimes CP children are unable to Sometimes CP children are unable to produce prolonged exhalations because the produce prolonged exhalations because the abdominal-diaphragmatic movements are abdominal-diaphragmatic movements are antagonistic to the thoracic movements.antagonistic to the thoracic movements.

Because of this asynchrony the child will be Because of this asynchrony the child will be able to produce phonation of short duration.able to produce phonation of short duration.

To overcome this difficulty, a corset To overcome this difficulty, a corset or girdle is wrapped around which or girdle is wrapped around which extends from lower border of extends from lower border of sternum to the ileac crest.sternum to the ileac crest.

This helps in stronger voices & longer This helps in stronger voices & longer exhalations.exhalations.

6.Functional Techniques for 6.Functional Techniques for Developing Control of Developing Control of RespirationRespiration

Many techniques & pieces of Many techniques & pieces of equipments have been developed to equipments have been developed to encourage the child to produce encourage the child to produce prolonged exhalations such as prolonged exhalations such as sustained blowing or sustained sustained blowing or sustained phonations.phonations.

Correction Of Phonatory ErrorsCorrection Of Phonatory Errors

1.Encouraging Vocalization:1.Encouraging Vocalization: Parents should learn not to respond Parents should learn not to respond

to the crying so quickly so that the to the crying so quickly so that the child get sufficient practice to use his child get sufficient practice to use his larynx.larynx.

Laughing also exercises larynx.Laughing also exercises larynx. For “quite babies “ positioning is For “quite babies “ positioning is

useful in facilitating vocalization.useful in facilitating vocalization.

2.Coordinate Phonation with 2.Coordinate Phonation with exhalation exhalation

Audible sigh on the exhalation.Audible sigh on the exhalation. After the child learned to hold a deep After the child learned to hold a deep

inhalation ,he should be taught to phonate inhalation ,he should be taught to phonate a vowel sound on the exhalation.a vowel sound on the exhalation.

If the child has difficulty initiating If the child has difficulty initiating phonation, different techniques for phonation, different techniques for breaking up the laryngeal block should be breaking up the laryngeal block should be tried.tried.

Positioning may also be used to good Positioning may also be used to good advantage.advantage.

3.Develop Prolonged Phonation 3.Develop Prolonged Phonation without Undesirable Tension:without Undesirable Tension:

Before encouraging the child to Before encouraging the child to develop longer phonation, the develop longer phonation, the therapist should be sure that the therapist should be sure that the child inhales sufficiently immediately child inhales sufficiently immediately before beginning phonation.before beginning phonation.

The therapist should be sure that the The therapist should be sure that the child has learned to hold the inhaled air child has learned to hold the inhaled air & to coordinate phonation with & to coordinate phonation with exhalation. exhalation.

4.Develop Variation of Loudness & 4.Develop Variation of Loudness & pitch:pitch:

Practice in producing tones at different Practice in producing tones at different levels of loudness & pitch levels helps the levels of loudness & pitch levels helps the child to increase his laryngeal function child to increase his laryngeal function

Only a little imagination is required Only a little imagination is required to think of many ways to motivate to think of many ways to motivate the child to vary the loudness, pitch the child to vary the loudness, pitch or inflection patterns of his voice.or inflection patterns of his voice.

For example- whispering, ordering like For example- whispering, ordering like police man, cheering at something or police man, cheering at something or singing.singing.

5. Counteract Undesirable postural 5. Counteract Undesirable postural pattern:pattern:

The postural pattern interfere with The postural pattern interfere with laryngeal function. as the child laryngeal function. as the child phonates, he extends the leg, arch the phonates, he extends the leg, arch the back and throw back his head.back and throw back his head.

These can be detected by placing one’s These can be detected by placing one’s hand against the soles of the child’s hand against the soles of the child’s feet, on his shoulders or behind his feet, on his shoulders or behind his headhead

The therapist must learn how to feel The therapist must learn how to feel these changes in flexors and these changes in flexors and extensor tone.extensor tone.

When increase in extensor tone or When increase in extensor tone or associated with phonation, he should associated with phonation, he should use appropriate reflex –inhibiting use appropriate reflex –inhibiting postures or appropriate sensory postures or appropriate sensory stimulation for activation and stimulation for activation and inhibition of selected muscle group. inhibition of selected muscle group.

CORRECTION FOR CORRECTION FOR ARTICULATORY ERRORSARTICULATORY ERRORS

Before going for articulatory Before going for articulatory correction the therapist should be correction the therapist should be sure that the child has sufficient sure that the child has sufficient control over speech breathing and control over speech breathing and phonation.phonation.

The patterns of neural organization The patterns of neural organization as in sucking and swallowing must as in sucking and swallowing must also be developed.also be developed.

1.1.Encourage and facilitate Encourage and facilitate babblingbabbling

While an infant is crying it is possible to While an infant is crying it is possible to produce approximation of the lips by produce approximation of the lips by placing the hand beneath the mandible placing the hand beneath the mandible and gently elevating it.and gently elevating it.

Repetition of this technique enables the Repetition of this technique enables the child to hear and feel the consonantal child to hear and feel the consonantal modification of his vocalization.modification of his vocalization.

Bilabial consonants may be added by Bilabial consonants may be added by rapidly vibrating the lips with the rapidly vibrating the lips with the therapist’s or parent’s fingers.therapist’s or parent’s fingers.

2. develop sucking, swallowing 2. develop sucking, swallowing and chewing patternsand chewing patterns

Attention should be given to the Attention should be given to the develop of sucking, swallowing and develop of sucking, swallowing and chewing patterns in CP children.chewing patterns in CP children.

The mother can use several The mother can use several techniques which facilitate techniques which facilitate maturation of oral activities.maturation of oral activities.

When spooned foods are added to the When spooned foods are added to the child’s diet, it is to be placed in the child’s diet, it is to be placed in the front of the mouth, thus encouraging front of the mouth, thus encouraging the child to develop the tongue the child to develop the tongue movements which are essential for the movements which are essential for the first stage of chewing and swallowing.first stage of chewing and swallowing.

Touching the child’s lips spoon will Touching the child’s lips spoon will make him aware of his lips and thus make him aware of his lips and thus facilitate and maintenance of lip facilitate and maintenance of lip closure. closure.

3. Improving the Function of the 3. Improving the Function of the Lips, Mandible and Tongue as Lips, Mandible and Tongue as articulatorsarticulators

The therapist should help the child The therapist should help the child about his awareness of his about his awareness of his movement of the various movement of the various articulators.articulators.

By using the mirror the child can see By using the mirror the child can see the movement of his mandible the movement of his mandible moves with his tongue movement.moves with his tongue movement.

Stabilization of the mandible with Stabilization of the mandible with small object placed between the small object placed between the molars, aids the child in developing molars, aids the child in developing free tongue movements.free tongue movements.

Team Approach To Team Approach To RehabilitationRehabilitation

A comprehensive management plan A comprehensive management plan will pull in a combination of health will pull in a combination of health professionals with expertise in the professionals with expertise in the following:following:

  physical therapyphysical therapy to improve to improve walking and gait, stretch spastic walking and gait, stretch spastic muscles, and prevent deformities;  muscles, and prevent deformities; 

occupational therapyoccupational therapy to develop to develop compensating tactics for everyday compensating tactics for everyday activities such as dressing, going to activities such as dressing, going to school, and participating in day-to-school, and participating in day-to-day activities;  day activities; 

speech therapyspeech therapy to address to address swallowing disorders, speech swallowing disorders, speech impediments, and other obstacles to impediments, and other obstacles to communication;  communication; 

counseling and behavioral therapycounseling and behavioral therapy to address emotional and psychological to address emotional and psychological needs and help children cope needs and help children cope emotionally with their disabilities; emotionally with their disabilities;

drugsdrugs to control seizures, relax muscle to control seizures, relax muscle spasms, and alleviate pain; spasms, and alleviate pain;

surgerysurgery to correct anatomical to correct anatomical abnormalities or release tight muscles abnormalities or release tight muscles

braces and other orthotic braces and other orthotic devicesdevices to compensate for muscle to compensate for muscle imbalance, improve posture and imbalance, improve posture and walking, and increase independent walking, and increase independent mobility; mobility;

mechanical aidsmechanical aids such as such as wheelchairs and rolling walkers for wheelchairs and rolling walkers for individuals who are not individuals who are not independently mobile; and independently mobile; and

communication aidscommunication aids such as such as computers, voice synthesizers, or computers, voice synthesizers, or symbol boards to allow severely symbol boards to allow severely impaired individuals to communicate impaired individuals to communicate with others.   with others.  

The members of the treatment team The members of the treatment team for a child with cerebral palsy will for a child with cerebral palsy will most likely include the following:   most likely include the following:  

  A A physicianphysician, such as a pediatrician, , such as a pediatrician, pediatric neurologist, or pediatric pediatric neurologist, or pediatric psychiatrist, who is trained to help psychiatrist, who is trained to help developmentally disabled children developmentally disabled children

An An orthopedistorthopedist, a surgeon who , a surgeon who specializes in treating the bones, muscles, specializes in treating the bones, muscles, tendons, and other parts of the skeletal tendons, and other parts of the skeletal system. An orthopedist is often brought in system. An orthopedist is often brought in to diagnose and treat muscle problems to diagnose and treat muscle problems associated with cerebral palsy.associated with cerebral palsy.

A A physical therapistphysical therapist, who designs and , who designs and puts into practice special exercise puts into practice special exercise programs to improve strength and programs to improve strength and functional mobility. functional mobility.

An An occupational therapist,occupational therapist, who who teaches the skills necessary for day-teaches the skills necessary for day-to-day living, school, and work. to-day living, school, and work.

A A speech and language speech and language pathologist,pathologist, who specializes in who specializes in diagnosing and treating disabilities diagnosing and treating disabilities relating to difficulties with swallowing relating to difficulties with swallowing and communication.    and communication.   

A A social worker,social worker, who helps individuals who helps individuals and their families locate community and their families locate community assistance and education programs. assistance and education programs.

A A psychologist,psychologist, who helps individuals who helps individuals and their families cope with the special and their families cope with the special stresses and demands of cerebral palsy. In stresses and demands of cerebral palsy. In some cases, psychologists may also some cases, psychologists may also oversee therapy to modify unhelpful or oversee therapy to modify unhelpful or destructive behaviors. destructive behaviors.

An An educator,educator, who may play an especially who may play an especially important role when mental retardation or important role when mental retardation or learning disabilities present a challenge to learning disabilities present a challenge to education. education.

Surgical options in CPSurgical options in CP

Intrathecal baclofenIntrathecal baclofen therapy uses an therapy uses an implantable pump to deliver baclofen, a implantable pump to deliver baclofen, a muscle relaxant, into the fluid surrounding muscle relaxant, into the fluid surrounding the spinal cord. Baclofen works by the spinal cord. Baclofen works by decreasing the excitability of nerve cells in decreasing the excitability of nerve cells in the spinal cord, which then reduces muscle the spinal cord, which then reduces muscle spasticity throughout the body. Because it spasticity throughout the body. Because it is delivered directly into the nervous is delivered directly into the nervous system, the intrathecal dose of baclofen can system, the intrathecal dose of baclofen can be as low as one one-hundredth of the oral be as low as one one-hundredth of the oral dose. Studies have shown it reduces dose. Studies have shown it reduces spasticity and pain and improves sleep. spasticity and pain and improves sleep.

Orthopedic surgeryOrthopedic surgery is often is often recommended when spasticity and recommended when spasticity and stiffness are severe enough to make stiffness are severe enough to make walking and moving about difficult or walking and moving about difficult or painful. For many people with painful. For many people with cerebral palsy, improving the cerebral palsy, improving the appearance of how they walk – their appearance of how they walk – their gait – is also important. gait – is also important.

Selective dorsal rhizotomySelective dorsal rhizotomy (SDR) is (SDR) is a surgical procedure recommended a surgical procedure recommended only for cases of severe spasticity when only for cases of severe spasticity when all of the more conservative treatments all of the more conservative treatments – physical therapy, oral medications, – physical therapy, oral medications, and intrathecal baclofen -- have failed and intrathecal baclofen -- have failed to reduce spasticity or chronic pain. In to reduce spasticity or chronic pain. In the procedure, a surgeon locates and the procedure, a surgeon locates and selectively severs overactivated nerves selectively severs overactivated nerves at the base of the spinal column. at the base of the spinal column.

THANK YOUTHANK YOU