1. Rehabilitation Approach of Children with Cerebral Palsy
Presented by Amal AlShamlan Head of Rehabilitation Section AlWasl Hospital Dubai Health Authority
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2. outline Definitions Model of care Classification Outcome measures
Intervention strategies & philosophies
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3. What is Cerebral Palsy?
It is a group of conditions results in permanent disorders of movement & posture due to damage in fetal or infant brain Features: 1.epilepsy. 2. involuntary movement 3. abnormal sensation & cognition 4- abnormal vision , hearing & speech. 5- mental retardation. 6. abnormal movement / behaviour.
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4. What is Rehabilitation ?
Rehabilitation is combined and coordinated use of medical , therapeutic , social , educational and vocational measures for training or retraining the individual to highest possible level of function
Holistic Approach
QOL
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5. Aims Improve functional status
Prevent secondary impairments & functional limitations
Efficiently use resources when there is reasonable prognosis for improvement
Facilitate integration into the community
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6. Model of care Functional & social vs disease-based
Growth & development
Child-focused & family centered.
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7. Environmental Factors
International Classification of Functioning, disability and Health (ICF)
condition
Body Function &
structure
Activities
Participation
Environmental Factors
Personal Factors
World Health Organization , 2001
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8. Environmental Factors
International Classification of Functioning, disability and Health (ICF)
C.P.
Activity Limitation
Walking on slopes
Walking in crowds
Climbing on equipment
Impairments
Muscle weakness
Muscle hypoextensibility
Poor balance
Poor endurance
Participation
Walking to class room
Play during recess
P.E class
Environmental Factors
Teachers’ concern
Distance to play ground
Children crowded in equipment
Personal Factors
Child’s attitude toward:
being transported
Adult assistance
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9. Multidisciplinary Team
client
Social worker
psychologist
Physician
Orthotists
Speech /language
therapists
Occupational
Therapists
Physiotherapists
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10. Care Pathway AlWasl Hospital - Rehabilitation Section referral
screening
Initiate therapy
Cross referral - therapy
Interdisciplinary clinic
Discharge / long term follow up
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11. Interdisciplinary Approach
Working for common goals
Pooling of expertise
Opportunity for personal growth & development
Forum for problem solving
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12. Classification of CP Etiology Body involvement Movement disorder
impairment
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13. GMFCS for children with CP
Description
Level I
Walks without restrictions; limitation in more advanced gross motor skills
Level II
Walks without assistive devices; limitations are walking outdoors and in the community
Level III
Walks with assistive mobility devices; limitations are walking outdoors and in the community
Level IV
Self-mobility with limitations; children are transported or use powered mobility outdoors or in the community
Level V
Self-mobility is severely limited even with the use of assistive technology
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14. Outcome measures Validate progress
Provides accountability to child/family/third-party payers for intervention used
Aides in plan of care
Provides normative data to obtain developmental levels e.g. age equivalent , standard score
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15. Tests Measuring Developmental Age , Activity , or participation Abilities
Function/Activity
Participation
AIMS X
GMFM
PDMS II
TIMP
Quest
LAPI
PEDI
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16. PDMS AIMS TIMP LAPI QUEST GMFM
Assesses normative performance of gross/fine motor function for children from birth to 72 months of age
Assess gross motor function including maturation of skills and postural alignment of of infants from birth to 18 mths of age
Assess postural control & alignment needed for age appropriate functional activities in early infancy
34 wks gestational age to 4 mths post full term delivery date
PDMS
AIMS
TIMP
Used to evaluate quality of UE functions in 4 domains: dissociated movement, grasping, protective extension & weight bearing
Assessment of motor tone & oromotor function for preterm babies
More than 33 wks corrected age – 1 mths post term
Specifically designed for CP , developed to measure change over time . Consists of activities in 5 dimensions: lying & rolling, sitting, creeping & kneeling, standing & walking, running & jumping.
LAPI
QUEST
GMFM

17. communication rating scale
skill %
Pointing
0 – 10
Gestures
11- 20
Gestures with speech sounds
21- 30
Speech sounds
31- 40
Single words
41 – 50
Phrases
51 – 60
Short sentences
61 – 70
Complete sentences
71 – 80
Complex sentences
81 – 90
paragraphes
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18. Spasticity
Spasticity is one of the most common UMN lesion problem seen in children with CP resulting in postural control & movement disorder thereby limitting, delaying or arresting the sensory motor development.(also other areas like communication, cognition, social , perception etc).
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19. What is spasticity?
Spasticity is a motor disorder characterized by a velocity dependent increase in stretch reflexes(muscle tone) with
exaggerated tendon jerks resulting from hyper excitability of the stretch reflex as one component of the UMN syndrome (Lance, 1980).
Spasticity is a movement disorder affecting both the neural & non-neural characteristics of postural tone and can be described by the positive & negative UMN symptoms” (D. Burke, 1988).
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20. Neural components of UMN symptoms
Positive symptoms
Spasticity.
Spasms (flexor & extensor).
Exaggerated tendon reflexes.
Clonus.
Babinski response.
Negative symptoms
Weakness.
Loss of dexterity.
Fatigability.
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21. Non-neural component of UMN symptoms
Altered muscle length (elasticity): muscle fibres shorten (hypoextensible).
Altered muscle structure (viscosity): filaments become sticky affecting muscle glide(stiffness).
Abnormal co- contraction (reciprocal innervation) : due to bio- mechanical effects of abnormal position. (too much stability & not enough mobility).
Changes in visco-elastic properties leads to stiffness, tightness & contracture.
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22. Normal functional Skills achievements
Normal postural tone
Normal patterns of movement
Success in normal patterns of movement
repetitions
Normal functional Skills achievements
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23. CP? Abnormal postural tone repetition
Abnormal patterns of movement
Success in abnormal patterns of movement/ stereotyped
repetition
Deformity/ less functional skills acheivments
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24. Intervention Philosophies & strategies
Evidence based?
There is no evidence that any one treatment method is superior to another.
Therapists select from the variety of treatments available those that best meet the child’s and family’s need.
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25. Analyzing Analysing the postural tone & patterns of movement.
What the child can do? How? /can’t do ? why?
Choosing appropriate intervention/frequency depends on:
Age (infant, toddlers, preschool, adolescent etc)
Distribution of postural tone (diplegic, hemiplegic, quadriplegic etc)
Quality of postural tone (mild, moderate or severe).
Associated problems.(vision, hearing, cognitive, seizure, SPD etc)
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26. Early intervention
Studies focused on child and family reported favorable outcomes.
The analysis also suggested that parent participation might have a greater impact on child’s outcomes for children younger than 3 yrs.
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27. Neonatal Developmental screening
Neonatal physiotherapy is an advanced practice subspecialty area of paediatric physiotherapy and involves a highly complex set of skills in observation, examination and intervention procedures for the extremely fragile NICU population.
Main objective to identify developmental delay in 1st year of life
Early intervention can change abnormal movement pattern in mild to moderate cerebral palsy
Those whom deemed to be delay remain delay if no intervention started.
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28. All high risk preterm infants with meeting criteria:
Gestation 32 weeks and below
Birth weight < 1.5 kg
IVH GR.3&4, PVL
Chronic lung disease or O2 dependency
Ventilated for RSD
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29. Neonatal Developmental screening
NICU : LAPI
Outpatient : TIMP , AIMS , PDMS
detected
detected
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30. Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit
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31. Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit
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32. Intervention Philosophies & strategies
Neurodevelopmental Therapy ( NDT)
Moving through normal movement patterns to experience normal movement
Major components : reflex-inhibiting posture, inhibition of abnormal reflexes, normalization of muscle tone, and adherence to normal developmental sequence of motor progression
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33. NDT Inhibiting abnormal movement patterns.
Facilitating normal movement patterns.
No strong evidence that supports the effectiveness of NDT for children with CP with respect to normalizing muscle tone , increasing rate of attaining motor skills, and improving functional motor skills
Butler C, Darrah J: Effects of Neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence report. Dev Med Child Neurol 2001 ; 43:
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34. AlWasl Hospital - Rehabilitation Section

35. Intervention Philosophies & strategies
Sensory Integration Therapy
Principle: a neurobiological process organizes sensation from one’s own body and from environment and makes it possible to use the body effectively within environment
Emphasis on importance of three body centered sensory systems : tactile , proprioceptive & vestibular
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36. SI Therapy
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37. Intervention Philosophies & strategies
Constrained - Induced Movement Therapy
Constraining non-affected arm to encourage performance of therapeutic task with the affected arm, which children normally tend to disregard.
Systematic review has found the effectiveness of CIMT for children with hemiplegic CP.
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38. Serial casting
Serial casting may serve to reduce spasticity in muscles by decreasing the strength of abnormally strong tonic foot reflexes.(Bertoli 1996).
Serial casting in the CP population has been shown to improve ROM.( Brouwer 2000)
Casting provides stability and prolonged stretch of a muscle which is immobilized in a lengthened position(Mosley 1997).
At least 6 hrs of prolonged stretch is needed for effectiveness(Tardieu 1987).
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39. Botox + serial casting
Botox reduces spasticity and improves ambulatory status.(Flett 1999)
When used in combination with serial casting it has shown to help maintain and improve muscle length and passive ROM.(Kay 2004)
Without conservative interventions such as serial casting, (with & without botox injection) more expensive procedures may be necessary. (Flett 1999)
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40. Intervention Philosophies & strategies
Body Weight Supported Treadmill Training
Uses theories of motor learning & importance of early task –specific training
Theory : activate spinal & supraspinal pattern generators for gait
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41. Intervention Philosophies & strategies
Strengthening
Progressive resisted exercise improves muscle performance & functional outcomes in CP children
Research had supported effectiveness on increasing force production in CP
Dodd et.al. systematic review of strengthening for individuals with cerebral palsy . Arch Phys Med Reh,83: , 2002
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42. Intervention Philosophies & strategies
NMES
Multiple studies have demonstrated the effectiveness of NMES,
Reduce spasticity.
Increase ROM & strength.
Increase force production.
Promote initial learning of selective motor control.
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43. Intervention Philosophies & strategies
Orthotic devices , splints , cast
Goals :
Maintenance or increase ROM
Protection or stabilization of a joint
Promotion of joint alignment
Promotion of function
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44. AlWasl Hospital - Rehabilitation Section

45. Ankle Foot Orthosis
Compared with barefoot gait, AFO’s enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature PF and improved progression of foot contact during stance.
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46. Intervention Philosophies & strategies
Assistive Technology & Adaptive Equipment
Optimizes alignment, posture & function.
Inhibits spasticity patterns.
Facilitates more normal movement.

47. Adjunct therapies Hippotherapy. Aquathearpy. suits. Theratogs.
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48. Intervention Philosophies & strategies
Speech & Language Therapy
Oralmotor function using strengthening / Intraoral stimulation
verbal ( PROMPT) & non-verbal communication skills ( AAC & PECS , macatone)
auditory training for HI
audiometry screening
swallowing function
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49. Intervention Philosophies & strategies
Psychological Assessment & Management Social support
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50. Out of 32 patients received botox 69% attended PT & 31% did not attend
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51. Out of 22 patients, 91% fully attended PT Mx.
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52. % of patients who improved in ROM post botox 3-6 weeks & 3-6 months.
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53. Benefits of communication
Case selection.
Goal setting.
Educating parents/caregiver in active participation
Compliance
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54. Thank you
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