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Physiotherapy


Cerebral Palsy

It is a neurological disorder of childhood with non-progressive broad spectrum motor disorder and neurological signs with brain damage which may be static and occurs in early life.

A persistent but not unchanged disorder of Posture, Movement, Muscle tone and Motor activity caused by damage to developing nervous system before/during birth and early months of infancy.

Incidence rate is 1.3 per 1000 births. Both sexes are equally affected. CP infants are usually slow in developmental milestones such as rolling over, sitting, crawling and walking.



Causes

• Premature babies (Pre-term infants show brain damage mostly)

  - Due to trauma during delivery

  - Due to immature respiratory and cardiovascular system causing hypoxia and low BP after delivery.

  - Infant with low blood sugar and Jaundice.

  - Due to immature liver.

• Asphyxia

  - Accidents in infants

  - Accidental birth

  - Knotting at umbilical cord at birth

  - Umbilical cord around neck at birth

  - Prolapsed cord

  - Antepaturum hemorrhage

• Trauma (complications during labour)

  - Disproportion of babies head and shoulders to pass through birth canal.

  - Inappropriate forceps delivery

  - Inappropriate breech delivery

  - Rapid delivery may lead to rupture of skull and brain damage in soft skulled babies.

• Severe Jaundice after birth (High level unconjugated bilirubin in blood damages basal ganglia of brain leading to athetoid syndrome.

• Hypoglycemia (Leads to epilepsy and cerebellum damage and vision problems)

• Intra-uterine virus infections like Rubella, Cytomegalo etc

• Neonatal meningitis

• Multiple births (Twins, Triplets)

• Hereditary and genetic conditions.

• Thyroid disorder

• Low birth weight infants

• Rh factor incompatibility (Difference in blood between mother and fetus lead to brain damage in fetus).

Classification

This is based on the areas of brain damage and movement impairments in the child.

Spastic tetraplegia

  - All four limbs affected more/less equally. Most common type.

  - Lying abnormalities, Sitting and Standing affected.

  - May also have hemiparetic tremors, Mask faces, Shaking of limbs and impairment of one side of body.

  - Fixed knee and joint deformities seen.

  - Difficulty in Speech, Visual abnormalities, Difficulty in eating etc.

Spastic triplegia (3 limbs affected)

Spastic diplegia

  - Lower body is affected with little/no upper body involvement.

  - Occurs due to hemorrhagic infarct of periventricular areas of brain.

  - Bilateral symmetrical weakness seen within one year of life.

  - Sitting and Walking movements delayed.

  - Intelligence, Speech, Feeding, Social functions not affected.

  - Lower limb abnormality – Ankle plantar flexion

                                        Knee extension

                                        Hip adduction and internal rotation

  - Scissors gait seen. Near sighted vision occurs.

Spastic monoplegia (only one single limb is affected)

Spastic hemiplegia

  - Only one side of body affected and they are self-sufficient.

  - Most ambulatory and can be trained within 2 yrs.

  - Lean towards one side i.e. unaffected side.

  - Balance, Co-ordination and Symmetry is affected.

  - Face and hands affected. Dynamic equines prevented by using Ankle-foot orthotics

Ataxic

  - Occurs due to cerebellum (UMNL).

  - Hypotonic (Decreased muscle tone)

  - Visual symptoms affected.

  - Hearing impairments

  - Speech altered

  - Mental defects

Athetoid/Dyskinetic/Dystonic

  - Occurs due to basal ganglia damage, Asphyxia.

Symptoms

• Abnormal muscle tone/ Hypotonic/ Spastic.

• Infantile/primitive reflexes (may disappear within 3-6 months after birth).

• Bone and Joint deformities along with contractures.

• Abnormal movements –  jerky/abrupt slow

• Unsteady gait.

• Balance problems.

• Decreased muscle mass.

• Scissors walking.

• Improper posture.

• Mental retardation.

• Learning disabilities.

• Behavioral disorders.

• Speech and language disorders.

• Breathing problems.

• Digestive problems.

• Skeletal deformities.

• Eating difficulties.

• Hearing and Vision problems.

• Bladder and Bowel incontinence problems.

• Dental problems.

• Delayed development of milestones like Head movements, Rolling over, Reaching objects, Sitting, Crawling and Walking.

• Motor skills like Writing, Typing, Using scissors, Balancing, Walking etc affected

• Fine movements need much concentration.

• Sleep disorders.

• May develop arthritis at younger age due to pressure on the joints (excessively stiff and toned muscles)

Diagnosis

• Through physical and mental capabilities are evaluated as diagnostic tests are based on child’s health care provider feedback.

  - Detailed Medical interview, Medical history of parents and family, Mother’s health condition during pregnancy and delivery, Neonatal period.

  - Co-relate child’s medical, mental and physical problems.

• Lab studies - Urine tests, DNA testing done if health care provider suspects child’s difficulties due to hormonal, genetic or metabolic problems.

• Imaging studies

  - Ultrasound of brain – may help in revealing bleeding, brain damage.

  - CT scan (shows cortical atrophy, Ventricular dilation, Intracerebral hemorrhage)

  - X-ray

  - MRI of brain and spinal cord

• Electroencephalography (EEG) (help in diagnosing seizure disorders)

• Electromyography (EMG) and Nerve conduction tests help in determining CP and nerve disorders differences.

Treatment

When to Seek Medical Care (In premature babies, Low birth weight babies, Complicated delivery conditions)

• If child has Seizure.

• If child’s limbs are inappropriate (limping leg, Floppy muscles).

• If child is not responding to loud noises at 1month age.

• If he/she is not moving/turning head properly at 4months age.

• If child is not sitting unsupported by 12 months age.

• If child moves his eye inward and outward (strabismus)

• If your child is not walking properly, change while standing, abnormal gait and walking patterns.

• If the child is not uttering words at 12 months.

• If the child’s movements are unusual (Jerky, Abrupt, Uncoordinated, Slow and Writhing)

Medical

Drug therapy helps in reducing spasticity, abnormal movements and prevent seizures.

• Dopaminergic drugs – Levodopa, Sinemet (carbidopa) and Artane (trihexyphenidyl). Decrease Rigidity and Abnormal movements.

• Muscle relaxants – Baclofen (lioresal). Can be taken as a pill/ Administered via implantable pump. Reduces spasticity initiating muscle relaxation.

• Benzodiazepines – Diazepam (valium). Act on brain to relax muscles.

• Botulinum toxin type A – Helps in reducing spasticity and increases range of motion.

• Anticonvulsants – Helps in stopping seizures and prevents seizure repeatetion.

Surgical (one or combination of surgeries are done)

• Tight muscles are loosened and fixed joints are released. (Mostly done on hips, knees, hamstrings and ankles. Most rarely done to elbows, wrists, hands and fingers).

• Baclofen pump is connected to the spinal cord in left abdomen. Helps in muscle relaxing and reducing spasticity.

• Femoral anteversion/antetorsion (straightening abnormal twists of the leg bones.

• Tibial torsion

• Rhizotomy (cutting nerves on the limbs which effect movement)

Rehabilitation

The rehabilitation program starts in early infancy and continues throughout adolescence. CP treatment if started in childhood may show good prognosis. Repetition of exercises also help.

They include:

• Physiotherapy – Improve muscle strength, Prevent deformities.

• Occupational therapy – Speech therapy, Teaching daily activities

• Bracing – Helps in support, Prevent contractures.

• Assistive devices – Help in supporting while mobility.

Aims

• Educating the parents about the problems in CP and importance regarding exercises.

• To improve mobility/Help start ambulation.

• To prevent deformities.

• To decrease spasticity

• To improve posture

• To improve muscle strength and decrease muscle weakness.

• Make the child to do daily activities independently.

• Helping child in maintaining healthy social life.

Physical therapy

Range Of Motion Exercises

  - Improves flexibility and helps in performing daily activities easily.

  - All the muscles of the joints like Neck, Shoulders, Elbow, Wrist, Fingers, Spine, Hip, Knee, Ankle and Toes are to be moved without causing any further problem.

Stretching Exercises

  - Educate the parent/caretaker the stretches done by the physiotherapist.

  - While stretching, care must be taken to avoid overstretching which may lead to tear of muscle and pain in part.

  - All the exercises done in children and in adults to reduce the CP. In children can  do the

  - Neck stretch

   1. Put the child chin to her/his chest and let gravity pull the head forward stretching back muscles of neck.

   2. Move the head right and again allow gravity to pull the head which stretches left side neck muscles.

   3. Move head left and again allow gravity to pull the head which stretches right side neck muscles.

   4. Slowly and gently move head back as looking up which stretches front neck muscles.

  - Shoulder stretch

   1. Slowly raise the child’s hand over the shoulder and gently push back of elbow stretching shoulder and repeat to other side.

   2. Cross one arm across the chest keeping elbow straight. This helps in stretching front of upper arm.

   3. Clasp your hands together in front of your chest with elbows straight and palms outward. Slowly move the hands away from your body stretches upper back of arm.

  - Chest stretch - Clasp hands behind back with palms together and elbows straight. Lift hands till comfort level stretches chest area.

  - Abdominal stretch - Clasping hands together over the head, slowly straight the child’s arms up and pull away as much as possible.

  - Spine stretch

   1. Clasping hands together over the head with bent arms and bend the body to one side stretching other side. Repeat the same to other side.

   2. Make the child to sit comfortably with legs in front. Cross the right knee on the left bending the right knee to 90 degree. Keep left leg straight. Bend forward keeping left elbow on the outer side of right knee. Repeat to left side.

  - Groin stretch

   1. Sit with bottoms of feet together and knees fall to the sides. Hold ankles and slightly pull them towards the child.

   2. Knees should be pushed down with inside of the elbows.

  - Hamstrings stretch

   1. Make the child to stand as straight as possible with feet apart and slowly bend him over his waist hanging the upper body down.

   2. If possible touch the child’s hands to ground mostly with slight bend of  knee

 - Thigh stretch

  1. Make child stand with feet apart and bend his right feet back up towards the buttocks.

  2. Hold the ankle of right feet with right hand and slightly pull foot up. To maintain balance hold a chair for support.

  3. Repeat with other leg.

 - Calf stretch

  1. Stand straight and put right leg behind and bend child left leg putting his body weight

  2. Push heel of right foot to ground and shift some weight of body towards the right with straight spine.

Strengthening Exercises


  - The muscles groups are to be exercised. Children may play sports for strengthening muscles.

  - Teenagers and adults in wheel chairs should focus on specific muscles to improve the motor function and ambulation.

  - Parent should encourage and help the child to participate in daily activities with his functional skills and the techniques learned during therapy.

  - Sports activities help in decreasing contractures, Stiffness and helps in decreasing use of wheel chairs.

Activities for a Child with Cerebral Palsy

  - Help child to move on the floor and change positions often exploring the positions.

  - Take the child to Parks, Gardens, Zoos, Playgrounds, Supermarkets, and Parties to help him in sensory system development.

  - Help child encouraging Crawling movements, Weight transferring on hands and legs to improve muscle tone.

  - Keep nice stimulating, colorful toys away from the child and encourage him to Crawl over to pick and play with them.

  - Help the child to replace the toys by himself which helps in improving ambulation and daily activities.

  - Allow child for Gym classes, Swimming, Bicycle rides etc.

  - Walking, Jogging, Dancing and Climbing stairs.

  - Encourage child to make friends and include them while playing. Ball games develop good coordination and motor skills.

  - Keep a strong plank of certain height and make the child walk on it without falling which improves balance.

  - Encourage child in indoor and outdoor sports as this helps the child in learning and improving motor skills and fine movements.

   1. Painting

   2. Making clay toys.

   3. Reading and identifying objects improves concentration.

   4. Give picture boards and tell him in communicating with us

Fitness Exercises

  - Help in keeping the child active

  - Reduce risk of obesity and Osteoporosis

  - Cardiovascular health maintenance

  - Improve ambulation.

Hydrotherapy

  - Using of water to relieve pain and treat illness. The water buoyancy minimizes the gravity force on the weight bearing joints and ligaments and improves balance and coordination.

  - Exercises in water help in decreased weight bearing onto joints. Exercises in warm water increase the buoyancy effect of water inducing great relief of pain and relaxation.

  - Pool therapy puts less stress on the joints and muscles reducing pain.

  - Slight minimal weight bearing exercises can also be done.

  - Swimming in cold water help in increasing muscle tone.

  - Swimming in warm water help in relaxing muscles.

Special equipments

  - Splints

   1. Night splints usage help in preventing contractures inducing stretch.

   2. Movable splints help in inducing functional movement of the particular part.

  - Walkers

  - Positioning devices/Braces

  - Customized wheel chairs

  - Customized Scooters

  - Customized tricycles

Manual therapy

  - Massage – Aid in improving Range of motion, Relaxes muscle tension and Circulation

  - Mobilization – Helps in relieving Stiffness, soft tissue stretching.

Leg control in child with CP

Hold the child legs above his/her feet and rotate them as if the child is walking/running/cycling. This helps in instancing walking ability in child.
Encourage the child mentally and physically.

Arm control in child with CP

Make the child lie on his/her back and hold fingers/hands. Slowly rotate the shoulders, move the arms, move the fingers, press fingers on the computer key board etc. This helps in encouraging the patient.

Occupational therapy

- It is another element of physiotherapy which helps in teaching physical skills, fine motor skills like using smaller muscles while feeding, grooming, dressing, writing, speaking etc.

- Occupational therapy starts at 2 yrs of age and may take many days/ months/years depending on the condition.

- Speech therapy – Helps in communication which is necessary to express thoughts, feelings and needs.

Prevention 

• Good prenatal care I.e. pre-pregnancy and pregnancy health visits.

• Get vaccination (For infections like Rubella, German measles). Rh incompatibility tests are to be checked. These are dangerous during pregnancy.

• Routine vaccinations of babies prevent infections and meningitis which lead to CP.

• Folic acid supplementation (400 micrograms of folic acid) before conception, and throughout pregnancy. It helps in preventing CP and other major neural tube defects.

• Avoid using cigarettes, alcohol, drugs and exposure to chemical during pregnancy which reduces premature delivery.

• Use car seat belts and helmet to the child while travelling in vehicles.

• Good balanced diet is to be given to the child. Appropriate care should be taken to the new born child.

• Keep the child away from people with serious diseases as this may affect child’s health.

• Screen your home for any chemicals which may affect child’s health.

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