Cp ppt (kannan)
- 1. Rehabilitation of cerebral palsy children Dr. C. Kannan 1st Year Post Graduate MD Pediatrics MGMCRI
- 2. Cerebral palsy CP has been defined as Non progressive injury to the immature brain Leading to motor dysfunction Lesion is not progressive, but The clinical manifestations change over time.
- 3. Progressive disorders resembling CP Type I Arginase deficiency Sjögren – Larsson syndrome Lesch - Nyhan syndrome Chiari Type I malformation Dandy - Walker syndrome Angelman syndrome Nonprogressive disorders resembling CP Mental retardation Deprivation Malnutrition Non-motor handicaps (blindness) Motor handicaps (spina bifida, myopathies)
- 4. Risk factors Prenatal Prematurity (< 36 weeks) Low birth weight (less than 2500 g) Maternal epilepsy Infections (TORCH) Bleeding in the third trimester Severe toxemia, Eclampsia Multiple pregnancies Placental insufficiency Drug abuse and trauma Perinatal Prolonged and difficult labor Premature rupture of membranes Presentation anomalies Vaginal bleeding at the time of labor Bradycardia and hypoxia Postnatal CNS infection (encephalitis, meningitis) Neonatal hyperbilirubinemia Head trauma Seizures and Coagulopathies
- 5. Clinical classification Tone Lesion site Spastic Cortex Dyskinetic Basal ganglia Hypotonic/Ataxic Cerebellum Mixed Diffuse
- 6. Anatomical 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
- 9. Spastic CP Increase in the physiological resistance of muscle to passive motion. It is part of the upper Motor neuron syndrome characterized with 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 are spastic. Spastic CP is anatomically distributed into Hemiplegia Diplegia Quadriplegia
- 10. Early signs of CP Signs suggestive of CP in an infant Abnormal behaviour Excessive docility or irritability Poor eye contact Poor sleep Oromotor problems Frequent vomiting Poor sucking Tongue retraction Persistent bite Grimacing Poor mobility Poor head control Hand preference before 2 years of age Abnormal tone
- 11. Early differential diagnosis in developmental disability Cerebral palsy Mental retardation Risk factors Often present Mostly absent Complaints Irritable, sleepless baby Easy baby Milestones Delayed Delayed Muscle tone Increased Normal or reduced Primitive reflexes Persist Normal disappearance Postural reflexes Delayed appearance Normal or Delayed appearance Focal signs Appear Absent
- 12. Neuromotor problems in CP Difficulty with flexing and extending the body against gravity Sitting Functional ambulation
- 13. Impairments Primary impairments (due to the brain lesion) Muscle tone (spasticity, dystonia) Balance Strength Selectivity Sensation Secondary impairments Contractures (equinus, adduction) Deformities (scoliosis) Tertiary impairments Adaptive mechanisms (knee hyperextension in stance)
- 14. Contractures and deformity Common sites for contracture Upper extremity Pronator Wrist and finger flexor Thumb adductor Lower extremity Hip adductor-flexor Knee flexor Ankle plantar flexor Common sites for deformity Spine Scoliosis and kyphosis Hip Subluxation, Dislocation Femur & tibia Internal or external torsion Foot Equinus, valgus and varus.
- 15. Associated problems in CP Seizures Visual impairments Intellectual impairment Learning disabilities Hearing problems Communication problems Oromotor dysfunction Gastrointestinal problems and nutrition Teeth problems Respiratory dysfunction Bladder and bowel problems Social and emotional disturbances
- 16. Epileptic seizures Seizures affect about 30 to 50% of CP patients They are most Common in the Quadriplegics and Hemiplegics, Patients with mental retardation Postnatally acquired CP. Seizures most resistant to drug therapy occur in hemiplegics. Seizure frequency increases in the preschool period. Electroencephalograms are necessary for the diagnosis of seizure disorder
- 17. Visual impairments seen in CP Pathology Clinical finding Damage to the visual cortex Cortical blindness Damage to the optic nerve Blindness Loss of oculomotor control Loss of binocular vision Refraction problems Myopia
- 18. Nutritional and oromotor issues Teeth problems Dentin Primary or hyperbilirubinemia Malocclusion Spasticity Tooth decay Feeding, swallowing problems Gingival hyperplasia Antiepileptic drug use Causes of inadequate food intake Difficulty chewing and swallowing Hyperactive gag reflex Spasticity of oropharyngeal muscles Loss of selective control of oropharyngeal muscles Gastroesophageal reflux
- 19. Urinary problems Enuresis Frequency Urgency Urinary tract infections Incontinence Causes of urinary problems Poor cognition Decreased mobility Decreased communication skills Neurogenic dysfunction
- 20. Psychosocial problems Extremely stressful for the family and the child when he grows up. Stress leads from denial to anger, guilt and depression. Coping with the emotional burden of disability is easier if the family has strong relationships, financial security, and supportive members of the community. The child and the family need to find ways to connect to each other. A healthy relationship between the mother and the child forms the basis of future happiness. Prevention or appropriate treatment of associated problems Improves the quality of life of the child and the family.
- 21. Rehabilitation Rehabilitation is the name given to all diagnostic and therapeutic procedures Which aim to develop maximum physical social and vocational function in a diseased or injured person
- 22. Goals of rehabilitationGoals Objectives of rehabilitation Improve mobility Teach the child to use his remaining potential Teach the child functional movement Gain muscle strength Prevent deformity Decrease spasticity Improve joint alignment Educate the parents To set reasonable expectations Do the exercises at home Teach daily living skills Have the child participate in daily living activities Social integration Provide community and social support
- 23. Components of rehabilitation Physiotherapy Occupational therapy Bracing Assistive devices Adaptive technology Sports and recreation Environment modification
- 24. Rehabilitation planning Example: Independent standing State the necessary time period Plan the methods to achieve this goal Evaluate the end state. Revise the treatment program
- 25. Therapy program Age group Program Infant Stimulating Advanced postural equilibrium Balance reactions for head and trunk control Toddler & pre-schooler Stretching the spastic muscles Strengthening the weak ones Promoting mobility Adolescent Improving cardiovascular status
- 26. Principles of therapy methods Support the development of multiple systems such as Cognitive Visual Sensory Musculoskeletal Involve play activities to ensure compliance Enhance social integration Involve the family Have fun
- 27. Gross Motor Function Classification System Class Goal of treatment 1- Walks independently, speed, balance & coordination reduced. Diminish energy expenditure Decrease level of support Improve appearance 2- Walks without assistive devices but limitations present. Diminish energy expenditure Decrease level of support Improve appearance 3- Walks with assistive devices Improve gait Improve standing 4- Transported or uses powered mobility Decrease pain Improve sitting & standing 5- Severely limited, dependent on wheelchair. Better positioning Decrease pain Improve hygiene
- 28. Conventional exercises Active and passive range of motion Stretching Strengthening Fitness
- 29. Neurofacilitation techniques Sensory input to the CNS produces reflex motor output. Various neurofacilitation techniques are based on this basic principle. All of the techniques aim to normalize muscle tone To establish advanced postural reactions and to facilitate normal movement patterns.
- 30. Vojta method of therapy 18 points in the body – crawling and reflex rolling. placing the child in particular positions and stimulation of the key points in the body would enhance CNS development In this way the child is presumed to learn normal movement patterns in place of abnormal motion. Applied by the primary caregiver at home at least 4-5 times daily and stopped after a year if there is no improvement
- 31. Bobath neurodevelopmental therapy This is the most commonly used therapy method in CP worldwide. It aims to Normalize muscle tone Inhibit abnormal primitive reflexes Stimulate normal movement. It uses the idea of reflex inhibitory positions to decrease spasticity and stimulation to promote the development of advanced postural reactions.
- 32. It is believed that through positioning and stimulation a sense of normal movement will develop. To teach the mother how to position the child at home during feeding and other activities. The baby is held in the antispastic position to prevent contracture formation.
- 33. Occupational therapy OT aims to improve hand and upper extremity function in the child through play and purposeful activity . There are defined systematic treatment methods for occupational therapy. Sensory integration therapy aims to enhance the child’s ability to organize and integrate sensory information. In response to sensory feedback, CNS perception and execution functions may improve and the motor planning capacity of the child may increase. .
- 34. Constraint induced movement therapy Where the normal hand is constrained Paralytic hand is forced to function Useful in children with hemiplegia. Begin therapy toward one year of age when the child can feed himself using a spoon and play with toys. Teach the child age appropriate self care activities such as dressing, bathing and brushing teeth. Encourage the child to help with part of these activities even if he is unable to perform them independently
- 35. play Always include play activities in the rehabilitation program. Play improves mental capacity and provides psychological satisfaction. Organized play can address specific gross and fine motor problems This increases the child’s compliance with therapy. Riding a toy horse may improve Weight shift over the pelvis Swinging may improve sensation of movement.
- 36. Advantages of swimming Normalizes muscle tone Decreases rate of contracture Strengthens muscles Improves cardiovascular fitness Improves walking Horseback riding Improves Head control Trunk balance Normalize muscle tone Positive emotions Self esteem
- 37. Recreational programs Arts and crafts Music Dancing Wheelchair dancing Drama, Camping Fishing Scuba diving
- 38. OTHERS Speech therapy Hearing aids and implants Drugs Antispasmodics Baclofen Diazepam Clonidine Thizanidine Dantroline Botulinum injections Neoromuscular blockers Proton pump inhibitors for GERD Analgesics for pain Respiratory physiotherapy
- 39. Goals of brace Increase function Prevent deformity Keep joint in a functional position Stabilize the trunk and extremities Facilitate selective motor control Decrease spasticity Protect extremity from injury in the postoperative phase
- 40. Braces in CP Ankle foot orthoses Knee-ankle foot orthoses Hip abduction orthoses Thoracolumbosacral orthoses Supramalleolar orthoses Foot orthoses Hand splints
- 41. Functions of the AFO Main function Keep the foot in a plantigrade position Stance phase Stable base of support Swing phase Prevent drop foot At night Prevent contracture
- 42. Spinal braces To slow the progression of deformity To delay surgery To allow skeletal growth To assist sitting balance To protect the surgical site from excessive loading after surgery
- 43. Mobility aids Example Standers Walkers Crutches Canes Advantages of mobility aids Develop balance Decrease energy expenditure Decrease loads on joints Improve posture
- 44. Benefits of Standers Support erect posture Enable weight bearing Stretch muscles to prevent contractures Decrease muscle tone Improve head and trunk control
- 45. Goals of orthopaedic surgery Goal Operate to achieve Walking potential Functional ambulation Good hip and knee extension Stable hips Plantigrade stable feet No walking potential Sitting balance Straight spine Horizontal pelvis Stable hips
- 46. Ortho surgeries in CP Types of CP Surgical procedures most often performed Quadriplegic Hip adductor flexor release Osteotomy Spine fusion Diplegic Hamstring-gastrocnemius lengthening Hip adductor-flexor lengthening Derotation osteotomy Rectus femoris transfer Hemiplegic Gastrocnemius lengthening Split tibialis anterior & posterior transfer Tibialis posterior lengthening
- 47. Message Enhance Familial bonding and support Therapy along with peers No aggressive therapy Don’t give false hopes Include sports and recreational activities Successful rehabilitation includes Prevention of additional problems Reduction of disability Community integration. Rehabilitation is successful if Child is happy Parents are well adjusted
- 48. THANK YOU !!