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BENEFITS OF EARLY INTERVENTION
PHYSICAL THERAPY IN CEREBRAL PALSY
TWO CASES REPORT
Presented By
IROGUE. EGHOSA . KENNEDYIntern Physical Therapist
Department of Physical Therapy
Pediatrics Physical Therapy UnitUniversity of Port Harcourt Teaching Hospital
Port Harcourt, South-South Region, Nigeria
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PRESENTATION OBJECTIVES
To inform our knowledge of evidence basedPhysical therapy in cerebral palsy.
To enumerate physiotherapeutic interventions inchildren with cerebral palsy.
To inform the design of larger studies thatexamines the efficacy of early intervention in
children with CP.
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OUTLINE History
Definition and pathological findings Brief Anatomy
Classification
Etiology, Risk factors
Epidemiology
Physical examination, early signs and Diagnosis, Differentials
Clinical findings and Associated problems
prognosis
Outcome measures
Treatment Team
Physical Therapy Interventions
Cases Report
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HISTORY OF CEREBRAL PALSY
In 1861 William Little
described a paralytic
condition of children that
is recognizable as spastic
diplegia.
Sigmund Freud challenged
Littles opinion on the
association between CP and
birth trauma
In his paper, Dr. Little
showed a child with
adductor spasm ,crouch
gait and in toeing.
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DEFINITION OF CEREBRAL PALSY
Cerebral palsy (CP) describes a group of permanentdisorders of the development of movement and posture,causing activity limitation, that are attributed to non-progressive disturbances that occurred in the immature or
developing fetal or infant brain. problems.Rosenbaum etal, 2007
The International Classification of Functioning, Disabilityand Health (ICF) defines activit y asthe executionof a task
or action by an individual and activity limitations asdifficulties an individual may experience in executingactivities. For the child with CP, this can include taskssuch as rolling, , running, and climbing stairs. (WHO,2001)
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PATHOLOGICAL FINDINGS IN CP
Specific brain lesions related to CP can be identified inmost of the cases.
These lesions occur in regions that are particularly
sensitive to disturbances in blood supply and are groupedunder the term hypoxic ischemic encephalopathy.(HIE)
Five types of hypoxic ischemic encephalopathy exists.They are
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FIVE TYPES OF H.I.E
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PATHOLOGICAL FINDINGS IN CP
The lesion in the brain may occur during the prenatal,perinatal, or postnatal periods.
CP is not a single disease but a name given to a wide
variety of static neuromotor impairment syndromesoccurring secondary to a lesion in the developing brain.
Any non progressive central nervous system (CNS) injuryoccurring during the first 2 years of life is considered to beCP.
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DEFINITION OF CEREBRAL PALSY
Time of brain injury
Prenatal period : Conception to the onset of labor Perinatal period : 28 weeks intrauterine to 7 days postnatal
Postnatal period : First two years of life
The motor disorders of cerebral palsy are oftenaccompanied by disturbances of sensation, perception,cognition, communication, and behaviour, by epilepsy, and
by secondary musculoskeletal problems.Rosenbaum et al,2007
Although CP is non- progressive But the clinicalmanifestation is said to change over time.
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BRIEF ANATOMY
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BRIEF ANATOMY
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BRIEF ANATOMY
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BRIEF ANATOMY
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CLASSIFICATION OF CEREBRAL PALSY
CP can be broadly classified into two: Clinical and Anatomical
These are based on Muscle tone, Anatomical
distribution and severity of the problem(s).Clinical classification
Tonus Lesion site
Spastic Cortex Dyskinetic Basal ganglia - extra pyramidal system
Hypotonic / Ataxic Cerebellum
Mixed Diffuse
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CLASSIFICATION OF CEREBRAL PALSYAnatomical classification
Location Description
Hemiplegia: Upper and lower extremity on one side of body
Diplegia: Four extremities, legs more affected than the arms
Quadriplegia: Four extremities plus the trunk, neck and face
Triplegia: Both lower extremities and one upper extremity
Monoplegia: One extremity (rare)
Double hemiplegia: Four extremities, arms more affected than the legs
Clinicians classify patients to describe the specific problem, to predictprognosis and to guide treatment. Classification provides a clearerunderstanding of the specific patient and directs management. Eventhough some of these types are clinically imprecise and may lack
reliability among observers ,these terms are conceptually useful.
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CLASSIFICATION OF CEREBRAL PALSY
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CLASSIFICATION OF CEREBRAL PALSY
Spastic CP
Spasticity is defined as an increase in thephysiological resistance of muscle to passivemotion. It is part of the upper motor neuron
syndrome characterized by hyperreflexia, clonus,extensor plantar responses and primitive reflexes.Spastic CP is the most common form of CP.
Approximately 70% to 80%of children with CP arespastic. Spastic CP is predominantly anatomicallydistributed into three types namely
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CLASSIFICATION OF CEREBRAL PALSYSpastic hemiplegia
Seizure disorders, visual field deficits, astereognosis, andproprioceptive loss are likely. Twenty percent of children with spastic CP have hemiplegia. A focal traumatic,vascular, or infectious lesion is the cause in many cases. A
unilateral brain infarct with post hemorrhagic porencephalycan be seen on magnetic resonance imaging (MRI). Allhemiplegic children become independent walkers by theage of 3. Sensory deficit and learning disability add to the
movement problem in hemiplegia. Prognosis forindependent living is good.
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CLASSIFICATION OF CEREBRAL PALSY
Spastic diplegia
Intelligence usually is normal, and epilepsy is less common. Fiftypercent of children with spastic CP have diplegia. A history ofprematurity is usual. Diplegia is becoming more common as morelow- birth-weight babies survive. MRI reveals mild periventricular
leukomalacia(PVL).Most diplegic children need various treatments to be able to walkindependently. Problems in maintaining balance and spasticityinterfere with walking. Children who can sit by the age of 2 can
usually walk by the age of 4 to 7. Hand dexterity is impaired.Children have difficulty writing or other tasks that need fine motorcontrol. Almost all diplegic children need surgery for contractures
and deformities Especially when physical therapy is not early.
Many use walking aids.
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CLASSIFICATION OF CEREBRAL PALSY
Spastic Quadriplegia (Total body involvementtetraplegia)
The trunk and muscles that control the mouth,
tongue, and pharynx are also involved .When one
upper extremity is less involved, the term Triplegiais used. Thirty percent of children with spastic CPhave quadriplegia. More serious involvement of
lower extremities is common in premature babies.Some have perinatal hypoxic ischemicencephalopathy. MRI reveals PVL.
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CLASSIFICATION OF CEREBRAL PALSY Dyskinetic CP
Abnormal movements that occur when the patient initiatesmovement are termed dyskinesias (Dyskinetic syndromes).Dysarthria, dysphagia, and drooling accompany the movementproblem. Mental status is generally normal, however severe
dysarthria makes communication difficult and leads the clinician tothink that the child has intellectual impairment. Sensorineuralhearing dysfunction also impairs communication. Dyskinetic CPaccounts for approximately 10% to 15 % of all cases of CP.Hyperbilirubinemia or severe anoxia causes basal gangliadysfunction and results in dyskinetic CP. It is divided into Athetiodand Dystonia
Dystonia is the term used for sustained muscle contractions thatfrequently cause twisting or repetitive movements, or abnormal
postures
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CLASSIFICATION OF CEREBRAL PALSY Dyskinetic CP
Abnormal movements that occur when the patient initiatesmovement are termed dyskinesias (Dyskinetic syndromes).Dysarthria, dysphagia, and drooling accompany the movementproblem. Mental status is generally normal, however severe
dysarthria makes communication difficult and leads the clinician tothink that the child has intellectual impairment. Sensorineuralhearing dysfunction also impairs communication. Dyskinetic CPaccounts for approximately 10% to 15 % of all cases of CP.Hyperbilirubinemia or severe anoxia causes basal gangliadysfunction and results in dyskinetic CP. It is divided into Athetiodand Dystonia
Dystonia is the term used for sustained muscle contractions thatfrequently cause twisting or repetitive movements, or abnormal
postures
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CLASSIFICATION OF CEREBRAL PALSY
Athetosis are uncontrolled extra movements that occur particularly
in the arms, hands and feet, and around the mouth. The lack ofcontrol is often most noticeable when the child starts to move forexample, when the child attempts to grasp toy or a spoon. Inaddition, children with athetoid cerebral palsy often feel floppy
when carried. Types of athetoid dyskinesia arei. Non tension athetoid: Involuntary movements without
increased tone
ii. Dystonic athetoid: Abnormal positioning of limbs, head and
trunk, with unpredictable increased toneiii. Choreoathetoid :Involuntary, unpredictable, small movements of
the distal parts of the extremities
iv. Tension athetoid: Increased muscle tone that usually blocks
involuntary movement
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CLASSIFICATION OF CEREBRAL PALSY
Ataxic CP
Ataxia is loss of balance, coordination, and finemotor control. Ataxic children cannot coordinatetheir movements. They are hypotonic during the
first 2 years of life. Muscle tone becomes normaland ataxia becomes apparent toward the age of 2to 3 years. Children who can walk have a wide-
based gait and a mild intention tremor (dysmetria).Dexterity and fine motor control is poor. Ataxia isassociated with cerebellar lesions.
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CLASSIFICATION OF CEREBRAL PALSY
Mixed CP
Children with a mixed type of CP commonly havemild spasticity, dystonia, and/or athetoid
movements. Ataxic may be a component of themotor dysfunction in patients in this group. Ataxia
and spasticity often occur together. Spastic ataxic
diplegia is a common mixed type that often isassociated with hydrocephalus.
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ETIOLOGY
The etiology can be identified only in 50% ofthe cases. Certain factors in the history of the
child increase the risk of CP. The incidence of
CP among babies who have one or more ofthese risk factors is higher than among the
normal population. We should therefore be
alerted to the possibility of the presence ofCP in a patient with these factors. Risk factorsassociated with CP are grouped into prenatal,
perinatal, and postnatal factors.
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PRENATAL RISK FACTORS
Prematurity (gestational age less than 36 weeks)
Low birth weight (less than 2500 g)
Maternal epilepsy
Hyperthyroidism
Infections (TORCH)
Bleeding in the third trimester
Incompetent cervix
Severe toxemia, eclampsia
HyperthyroidismDrug abuse
Trauma
Multiple pregnancies
Placental insufficiency
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PERINATAL RISK FACTORS
Prolonged and difficult labor
Premature rupture of membranes
Presentation anomalies
Vaginal bleeding at the time of admission for laborBradycardia
Hypoxia
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POSTNATAL RISK FACTORS(0-2YEARS)
CNS infection (encephalitis, meningitis)
Hypoxia
Seizures
CoagulopathiesNeonatal hyperbilirubinemia
Head trauma
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EPIDEMIOLOGY
CP is the most common congenital neurologic disorder
(Gandhi, 2007) and also most common cause of childhooddisability in Western societies. The incidence is 2-2.5/1000live births. The incidence is higher in males than infemales; the Surveillance of Cerebral Palsy in Europe
(SCPE) reports a M:F ratio of 1.33:1(Johnson andAnn,2002).
Data emanating from Nigeria shows that the spastic CP isthe most common type with birth asphyxia being thecommonest etiology.
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EPIDEMIOLOGY
In a research conducted in physiotherapy
department by the paediatric team in UPTH; CPincidence was 35% next to Erbs palsy producing a
higher Male to female incidence rate M:F ratio of
I.82:1( UPTH physiotherapy medical records andarchive 2006-2010).
Some CP children do not survive hence the
prevalence varies between 1-5/1000 babies indifferent countries. In the past it was thought tooccur as a result of acute intrapartum hypoxicevents.
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EPIDEMIOLOGY
Recent epidemiological studies suggest that in only
10% of cases this is true, and 90% of cases are due tochronic events or congenital factors (Blair and
Stanley,1988; Nelson, 1986; Yadkin et al.,1994)
It was also previously thought that improvements inperinatal and obstetric care would decrease theincidence of CP. However, the incidence has not
declined and the overall prevalence increased duringthe 1980s and 1990s. This is explained by increasedsurvival of premature and very-low birth-weightinfants and by a rise in the number of multiple births
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EPIDEMIOLOGY
Approximately 11% of premature babies who survive inneonatal intensive care units develop CP.
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EPIDEMIOLOGY
In vitro fertilization results in multiple pregnanciesand increases the risk of CP.
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EPIDEMIOLOGY
Multiple births have a substantially higher risk ofdeveloping CP. The reported prevalence rate perpregnancy for singles is 0.2%, for twins 1.5%, for
triplets 8.0%, and for quadruplets 43%.(Yokoyama
et al.,1995). Even at centers where optimal conditions exist for
perinatal care and birth asphyxia is relatively
uncommon, the incidence of CP in term babies hasremained the same. This has led researchers toconsider unknown prenatal causative factors.
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PHYSICAL EXAMINATIONS AND MAKING DIAGNOSIS
Physical examination of a child with movementproblem has two basic purposes.
First, physical examination accompanying a
detailed history enables an accurate diagnosis. Second, it allows the physical therapist to define
the impairments and disabilities, determine the
functional prognosis and set treatment goals inchildren with CP.
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Goals of physical examination in a child with
movement disorder
Establish an accurate diagnosis
Differentiate CP from progressive causes of childhood neuromotordisability
Classify the type and severity of involvement
Define the musculoskeletal impairment (spasticity, balance,
weakness, contractures and deformities) and decide on ways oftreatment
Evaluate associated impairments and get appropriate treatment
Determine functional prognosis
Set treatment goals
Devise a treatment plan
Evaluate the outcome of previous treatment procedures
Assess the changes that occur with treatment as well as with growth& develo ment
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HISTORY TAKING
History is a key component in evaluating the child.It provides valuable information for diagnosis. Inchildren with a definite diagnosis, the timing of
achievement of developmental milestones and the
presence of associated impairments help to decide afunctional prognosis.
A detailed history provides knowledge about
Risk factors
Timing of achievement of developmental milestones
The presence of associated impairments
Progression of childs capabilities
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KEY POINTS OF HISTORY
Health of parents
Hereditary factors
Siblings
Pregnancy
Labor and delivery Rh factor
Birth weight
Condition at birth
Neonatal history
Age disability recognized and symptoms noted
Development and present status of Head balance & control
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KEY POINTS OF HISTORY
Sitting Crawling
Walking
Feeding
Dressing
Toilet care
Speech
Mental status
Hearing
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KEY POINTS IN HISTORY
Vision
Handedness
Drooling
Convulsions
Emotional development
Social and recreational activities
School placement
Parental attitude
Braces Medication
Previous treatment
Reason for referral
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CLINICAL EXAMINATION
Examination begins with observation. Do not touchthe child before you watch her move.
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CLINICAL EXAMINATION
Examine the young and frightened child in his mothers lap.
Evaluate tonus abnormalities when the child is comfortable.
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CLINICAL EXAMINATION
Guide the parents to help you during the clinical examination
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CLINICAL EXAMINATION
Start the examination by giving the child something to playwith. A ball or a balloon will help to test upper extremity
function.
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CLINICAL EXAMINATION
Examination outlineNeurological examination
Skull, head circumference
Spine
Mental status
Cranial nerves
Vision - hearing - speech
Motor system
Muscle tone
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CLINICAL EXAMINATION
Muscle power
Muscle bulk
Degree of voluntary control
Reflexes Involuntary movements
Sensory examination
Sphincters Developmental milestones
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CLINICAL EXAMINATION
Musculoskeletal examination
Range of motion
Deformities, contractures
PostureFunctional examination
Sitting
Balance Gait
Hand function
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NEUROLOGICAL EXAMINATION
Neurological evaluation of the infant and the child
requires adequate knowledge of neurological
developmental stages.
Also the evaluation of persistent primitive reflexes
and the absence of advanced postural reactions
Evaluate muscle tone and involuntary movements
Muscle strength and selective motor control
.
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NEUROLOGICAL EXAMINATION
NEUROLOGICAL EXAMINATION
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NEUROLOGICAL EXAMINATION
This 8 month old baby has difficulty maintaining head control ontraction response indicating developmental delay.
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NEUROLOGICAL EXAMINATION
This spastic quadriplegic child still has not developedprotective extension and is severely delayed.
PRIMITIVE REFLEXES
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PRIMITIVE REFLEXES
SOME EXAMPLES OF PRIMITIVE REFLEXES
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SOME EXAMPLES OF PRIMITIVE REFLEXES
Asymmetrical tonic neck reflex (ASTNR): The child lies supine.Turn the head to one side and then the other. The extremities onthe face side extend and the ones on the occiput side flex. This iscalled the fencing position. The reflex is present at birth and
disappears at 6 months.
FOOT PLACEMENT REACTION
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FOOT PLACEMENT REACTION
Foot placement reaction: Hold the child by the axilla and bring thedorsum of the foot against the edge of the table. The child willautomatically place his foot on the table top. This is a normal responsein all children and is inhibited b a e 3 to 4.
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Tone labyrinthine reflex
Tonic labyrinthine reflex: Put the baby in the prone position, bring the neckto 45o flexion. The response is flexion of the arms, trunk and legs. Put thebaby in the supine position and bring the neck to 45o extension. Extensor
tone will increase. This reflex is present at birth and disappears at 4 months
Landau Reflex
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Landau Reflex
Landau reflex: Suspend the baby horizontally. The neck, trunk and armsextend, legs partially flex. This is an advanced postural reaction which
appears at 6 months.
PARACHUTE RESPONSE
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PARACHUTE RESPONSE
Parachute response: The child lies prone on the table. Lift the childvertically and suddenly tilt forward towards the table. The arms and thelegs extend as a protective reaction. This is an advanced postural reactionthat a ears at 8 months.
SIGNS SUGGESTIVE OF CP IN AN INFANTS
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SIGNS SUGGESTIVE OF CP IN AN INFANTS
Absent Landau reflex at 11months is a
sign of developmental delay.
Si n ti f CP in n Inf nt
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Signs suggestive of CP in an Infants
Absent traction responseindicating poor head control in a10month old baby.
Increased tone in the limbs andtruncal hypotonia is common inspastic quadriplegia.
ABNORMAL MUSCLE TONE AND INVOLUNTORY
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ABNORMAL MUSCLE TONE AND INVOLUNTORY
MOVEMENT
SELECTIVE MOTOR CONTROL
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SELECTIVE MOTOR CONTROL
Children who do not have selective motor control are unable todorsiflex the ankle without moving the hip or knee; but they canproduce this response in a gross flexion movement of the lowerextremity. This is called pattern response. When the child flexes the
hip against resistance, ankle dorsiflexion becomes apparent.
EXAMINE THE MUSCULOSKELETAL
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EXAMINE THE MUSCULOSKELETAL
FUNCTIONAL EXAMINATION
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FUNCTIONAL EXAMINATION
FUNCTIONAL EXAMINATION
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FUNCTIONAL EXAMINATION
FUNCTIONAL EXAMINATION
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FUNCTIONAL EXAMINATION
Hands-free sitter Hand-dependent sitter
Propped sitters needs external support to sit.
EARLY SIGNS SUGGESTIVE OF CP
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EARLY SIGNS SUGGESTIVE OF CP
DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
CLINICAL FINDINGS
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CLINICAL FINDINGS CONTS
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CLINICAL FINDINGS CONTS
GROUP OF MUSCLES OFTEN AFFECTED
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GROUP OF MUSCLES OFTEN AFFECTED
ASSOCIATED PROBLEMS
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ASSOCIATED PROBLEMS
ASSOCIATED PROBLEMS
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ASSOCIATED PROBLEMS
ASSOCIATED PROBLEMS CONTS
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ASSOCIATED PROBLEMS CONT S
ASSOCIATED PROBLEMS CONTS
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ASSOCIATED PROBLEMS CONT S
PREDICTING FUNCTIONAL PROGNOSIS IN CP
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PREDICTING FUNCTIONAL PROGNOSIS IN CP
Clinical findings established over time helpdetermine prognosis.
Potential ambulators usually begin to walk between
2 to 7years of age. Approximately 85% of partiallyinvolved children have the potential to becomeindependent ambulators compared to only 15% of
severely involved.
He must be able to hold his head before he can sit, and hemust be able to sit independently before he can walk onhis own. In children between 5 to 7 years of age
PREDICTING FUNCTIONAL PROGNOSIS IN CP
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FUNCTIONAL PROGNOSIS
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FUNCTIONAL PROGNOSIS
OUTCOME MEASURES IN CP
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OUTCOME MEASURES IN CP
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MANUAL ABILITY CLASSIFICATION SYSTEM (MACS)
MODIFIED ASHWORTH SCALE FOR SPASTICITY (MAS)
TARDIEU SCALE FOR SPASTICITY
CANADIAN OCCUPATIONAL PERFORMANCE MEASURE(COPM)
DENVER DEVELOPMENT SCREEN TEST
BAYLEY SCALE OF INFANT DEVELOPMENT
OUTCOME MEASURES
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Many outcome measure tools are available for use
in children with CP. Some of these assess activity
or activity limitations; some quantify activity levelsin conjunction with participation which is definedby the ICF as involvement in a life situation
(WHO, 2001).
This study is focused on evaluative measures usedto quantify the magnitude of change over time in
an individual or groups (kirschner and Guyatt,1985).
OUTCOME MEASURES
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To be robust, an outcome measures need to be
reliable (consistent and free from error) and Valid(measures what it is intended to) (Streiner andNorman, 2003).
The evaluative outcome tools is also required to showresponsiveness to change, which means that theydetect minimal clinically important differences(MCID).
The MCID is the smallest change on an objectivemeasurement tool in which the patient detects asignificant change in their health (Jaeschke, Singer,
and Gu att, 1989 .
OUTCOME MEASURES
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In a detailed systematic review by Harvey et al
(2008) they critically appraise literatures on
psychometric properties and clinical utility ofevaluative activity limitation of eight evaluativeoutcome measures ASK, CHQ, FAQ, FMS,
GMFM, PEDI, PODCI, and WeeFIM used inchildren with CP.
They reported that ASK and GMFM showed the
most robust psychometric properties with othertools requiring further confirmation of validity and
responsiveness.
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They advised clinicians to select tools based on
established psychometric properties and thepurpose of measurement. Since no single measureadequately addresses all aspects of the ICF
The GMFCS is now the preferred means ofclassifying motor impairment in children with CP.For this reason, discriminative validity of toolsshould be examined using GMFCS level rather
than mild, moderate, or severe, and topographicaldistribution. This has been addressed more recently(Ottenbacher et al., 1997).
OUTCOME MEASURES
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The GMFM is a valid and reliable tool for
measuring changes in motor function of children with CP consisting of 88 items across fivedimensions:(A) lying and rolling; (B) sitting; (C)
crawling and kneeling; (D) standing; and (E)
walking, running, and jumping (Palisano et al, 2000;Vos-Vromans, Ketelaar, and Gorter, 2005).
For each item, the child is asked to perform a gross
motor task. The test administrator observes thechild and assigns a score of 0 to 3 based on thechilds performance of this task.
OUTCOME MEASURES
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A score of 0 indicates that the child is unable to
initiate the task; 1 indicates that the child initiates
but performs less than 10% of the task; 2 indicatesthat the child can perform more than 10% of thetask but does not fully complete the task; and 3
indicates that the child is able to complete the task.
Each dimension is scored as a percentage of the
maximum score for that section and eachdimension contributes equally to the total GMFM
score.
TREATMENT TEAM
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PHYSICAL THERAPY INTERVENTIONS
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Importance of proper positioning the neonate,
Lyingsupine and prone positions and theirimplications,
Rolling
Head controlTrunk control
Sitting
CrawlingWalking
Upper extremity function
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Respiration and Speech
Feeding
Visual perception
Social development
Cognitive development
Parents involvement in early intervention
programmes.
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Proper positioning is important as numerous
benefits have been found from systematicreview which include
a greater awareness of external stimuli, enhanced
development, a calming effect, and quicker
acquisition of developmental skills such as headand ocular control, upper and lower extremityfunction and decreased extensor patterns of the
neonate (Brown 1985,Anderson & Anderson
1986, Monterosso et al 2003, Schoger 2005)
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Correct positioning of the neonate is very
important in the control of posture of thosewho are at risk of developing fixed deformities,therefore is of importance to physical therapists
in early intervention (Monterosso et al 2003,
Brown 1985).
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Lying Supine Versus Prone Positions and
Its Implications An infants primary sleeping position has been
suggested to affect the age range in which
developmental milestones occur (Jantz et al1997).
Early Intervention should include prone play for theinfant at 2-4 months as it has been reported to
maximize the development of the childs upper bodystrength; shoulder girdle strength and extensionmovements in infants (Davis et al 1998, Bridgewater&Sullivan 1999, Liao et al 2005).
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It is suggested that instead of emphasizing a
single position during awake and sleep time, i.e.prone and supine respectively, the use ofchanging positions (Back-to-side) during
sleeping in early infancy may be beneficial for
the child to attain the whole range of skills in theaverage normal development (Vaivre-Douret et
al 2004, Vaivre-Douret et al 2005).
PHYSICAL THERAPY INTERVENTIONS
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Early Intervention should include prone play for the
infant at 2-4 months as it has been reported tomaximize the development of the childs upper bodystrength; shoulder girdle strength and extension
movements in infants (Davis et al 1998, Bridgewater&
Sullivan 1999, Liao et al 2005). The physicaltherapists role should include educating parents of
the importance of prone positioning in playtime as many parents
may misinterpret the intent of Sudden Infant Death Syndrome(SIDS) prevention programmes and avoid placing their child inprone whilst awake and/or asleep (Salls et al 2002, Monson et al2003, Liao et al 2005, Vaivre-Douret et al 2005)
PHYSICAL THERAPY INTERVENTIONS
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Rolling
Early Intervention however one study bySmither (1991) reports that facilitationtechniques used by the therapist are shown to
increase quantity and quality of a childs rollingability. A beneficial outcome is reported as aresult of facilitation techniques; diminishment ofrocking from side to side and rolling over of the
pelvis followed by the shoulder girdle, howeverthis study has limited creditability, as thetechniques used are not detailed.
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Head control is considered as constituting the
beginning of body equilibrium development andsubsequent locomotor development (Assaiante1998)
The importance of head control can be drawnfrom the published literature.
Head control is found to improve reaching andhead eye stabilizations in order to relate to a stable
frame of reference for reaching in infants (Thelen
1984, Bertenthal&Von Hofsten 1998).
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This is supported by Thelen & Spencer (1998)
study which found head control to be importantin the onset of successful reaching, with eachinfant showing good head control several weeks
prior to reaching.
Stabilization of the head appears to be moresensitive to the dynamic characteristics of theactivity being performed than the pelvis e.g. in
walking there is a higher degree of stability ofthe head in space (Ledebt& Wiener-Vacher1996, Assaiante 1998).
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Development of head control is very importantas the head position of a child significantlyimpacts their ability to access and function
within the environment and in meeting their
educational needs (Doherty 1998).
Therefore Early Intervention is required in orderto facilitate maximum functioning of the child
within their environment and increased
opportunities from an early onset of typicalnormal development.
PHYSICAL THERAPY INTERVENTIONS
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Head control may be promoted by the physicaltherapist by placing a wedge with a shallow,bevelled surface attached on to a tray, and
placed at a comfortable height in positioning the
head in an upright position relieving stress on
the spinal structure(Pope et al 1994).
Numerous studies have found sensory feedback
used by physical therapists very successful in
improving head control (Wooldridge& Russell1976, Bishop 1977,Walmsley et al 1981,Catanese& Sanford 1984, Hallum
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Support in prone facilitates visual orientation, headcontrol, development of postural extension and activecontrol of weight shift
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Trunk Control
Trunk extension is reported to be a componentof overall trunk control and is important to theattainment of independent sitting, trunk mobility
and functional activity therefore it is animportant area considered in Early Intervention(Miedaner 1990, Barks 2004, McDonald et al2004).
Like head control, trunk control is important asa foundation to executive function anddevelopment of a child (Kangas,2002)
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Vision is thought to influence trunk control inconjunction with sitting experience(Hempel1993, Bertenthal & Von Hofsten 1998)
Although reaching is dependent on eye and head
co-ordination, reaching requires a nestedhierarchy of stabilized systems in which the eyesand head are supported by the trunk in either asitting or standing posture (Bertenthal & Von
Hofsten 1998).
PHYSICAL THERAPY INTERVENTIONS
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Adaptive seating is identified within EarlyIntervention as an important treatmentapproach to facilitate sitting of a child who does
not have the adequate head, trunk or pelvic
control to maintain this position independently
(McDonald et al 2004, Washington et al 2002). Prescription of adaptive seating is found within this
review as early as six months due to a childs lack of
ability to initiate sitting upright and presentation ofdeficits at this stage of development (Pain et al 2000).Green et al (1995) reported that when adaptive seating
was provided to children with cerebral palsy, immediate
improvements in sitting ability was observed.
PHYSICAL THERAPY INTERVENTIONS
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Conductive education
Vojta therapy Bobath therapy
Vibration therapy
Suit therapy Hippotherapy
Patterning
Body weight support treadmill training
Constraint induced therapy
Hyperbaric therapy
PHYSICAL THERAPY INTERVENTIONS
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Sensory integration
Electrical Stimulation- functional or ThresholdConventional exercises
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PHYSICAL THERAPY INTERVENTIONS
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PHYSICAL THERAPY INTERVENTIONS
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PHYSICAL THERAPY INTERVENTIONS
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PHYSICAL THERAPY INTERVENTIONS
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PHYSICAL THERAPY INTERVENTIONS
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PHYSICAL THERAPY INTERVENTIONS
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PHYSICAL THERAPY INTERVENTIONS
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EARLY INTERVENTION
Early Intervention is defined by Stephens &
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Early Intervention is defined by Stephens &
Tauber (2001) in two parts,
earlyrefers to the most critical period of a childsdevelopment between birth and three years of age.
Interventionrefers to programme implementationdesigned to maintain or enhance the childs
development in natural environments and as a
member of a family
Numerous studies have identified the importanceof early intervention and many benefits have beenreported (Ayres 1979, Gulnerick 1998, Farel et al
2003 These are identified in the table below
BENEFITS OF EARLY INTERVENTION
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BENEFITS OF EARLY INTERVENTION
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GOAL OF EARLY INTERVENTIONS
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Goals of Early Intervention include -
Strengthen childs skills Provide parents with information, social and
emotional support
Strengthen parents coping abilities and childrearing skills
Instructing parents in providing their children
emotional support and intellectual stimulation(Benasich et al 1992, Guralnick 1997, Meisels& Shonkoff 1990).
EARLY INTERVENTIONS
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Early intervention programmes that combine a
child and parent focus are reported to have agreater impact on the developmental outcomes of
the child (Lekskulchai &Cole 2001).
Children are deemed eligible for early interventionservices if they are delayed in one or more of thefollowing areas: physical, cognitive, language and
speech, psychosocial and self-help, or if they havea diagnosis of a physical or mental condition which
will result in developmental del(Hanft1988,Pelchat et al 2004).
SUMMARY OF PHYSICAL THERAPY INTERVENTION
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SUMMARY OF PHYSICAL THERAPY INTERVENTION
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SUMMARY OF PHYSICAL THERAPY INTERVENTION
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SUMMARY OF PHYSICAL THERAPY INTERVENTION
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SUMMARY OF PHYSICAL THERAPY INTERVENTION
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BENEFIT OF IMPROVING THE TRUNK CONTROL
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BENEFIT OF ADAPTIVE SEATING
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CASE REPORTS
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CONCLUSION AND RECOMMENDATION
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Cerebral palsy treatment has to be tailored
according to the patients age, clinical form, severityof the diseases and it involves a multitasking teamincluding the patients family. At this moment there
are available a large number of treatments optionsto chose from. Identifying the right approach needs
an evidence based evaluation to prove theusefulness and superiority of a method over the
other and a skilled physical therapist,
CONLUSION AND RECOMMENDATION
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There is currently very little clinical evidence with
regards to the physical therapy Early Interventionin CP, and in relation to the efficacy and
effectiveness of Early Intervention. It would appear
that Early Intervention programmes are based uponindividual physical therapists knowledge, skills andclinical opinion.
THANKS FOR LISTENING
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HELP US DEVELOP MOTOR SKILLS