Definition



Definition

Cerebral Palsy (CP) is a syndrome or group of disorders, or a category of disability, not a disease, which affects the central nervous system (CNS) and arises in the prenatal or early infancy periods. It is typically a non-progressive entity. CP is often associated with other neurologic difficulties, including mental retardation.

Classifications

Monoplegia: involvement of one extremity Quadriplegia: equal involvement of upper and lower extremities

Hemiplegia: upper and lower extremity involvement on one side Diplegia: quadriplegia w/ mild involvement of the upper extremities

Paraplegia: involvement of both lower extremities

Other Descriptive Terms Used in CP

Hypertonia: (d muscle tension Rigidity: persistent stiffness of muscle on movement

Hypotonia:(d muscle tension Remor: rhythmical purposeless movements

Spasticity: hyperactivity of muscle stretch reflex Monoplegia: involvement of one limb

Associated Problems

Eye Problems

Strabismus (highest incidence is in the diplegic and quadriplegic populations)

Esotropia (deviation of the eyes toward the midline, is more prevalent than exotropia)

Homonymous hemianopsia (occurs in 25% of children with hemiplegia)

Nystagmus (most common in children with ataxia)

Mental Retardation

40 to 60% of children with CP have some degree of retardation with the highest proportion of severe deficits seen in children with quadriplegia, rigidity, and atonia.

Seizure Disorders

Occurs in as many as 50% of children with CP

Communication Disorders

May be secondary to poor oral-motor control of speech, central language dysfunction, hearing impairment, or cognitive deficits

Growth Disturbances: (hemiplegia) Sensory Deficits: (hemiplegia)

Limb Muscle Atrophy: Increases with age Causes, which may include neurotrophic and vascular changes, are obscure

Physical Problems of the Child with Ataxia

Cerebellar Lesion

Problems

• Usually hypotonic, but some have increased tone Poor co-contraction and sustained holding of postures

• Dysmetria Poorly coordinated righting reflexes, equilibrium reactions, and protective responses

Goals of Treatment

• Balanced postural tone Midline and sustained holding throughout range of movement Smoothly coordinated automatic reactions

Physical Problems of the Child with Hypotonia

Problems

|Poor head control |Very poor trunk stability and control |

|Shallow breathing |Joint hypermobility |

|Absent or slow righting reflexes, equilibrium reactions, and protective responses |

Focus of Treatment

• Increased postural tone Improved head and trunk control against gravity Improve automatic reactions Smooth coordinated movement of extremities in gravity-eliminated positions and in positions against gravity with trunk stabilized Permit child to react to imposed movement Stabilization of joints in neutral alignment

Physical Problems of the Child with Spasticity (most common)

Fixed Lesion in the Motorportion of the Cerebral Cortex

Problems

|Low tone in trunk musculature |Extremities maintained in midrange |

|Spasticity in extremity musculature |Stereotypical (patterned) movement |

|Slow, laborious movement |Fearful of movement |

|Incomplete righting reflexes, equilibrium reactions, and protective responses |

|Associated reactions present at risk for orthopedic deformities secondary to muscle and joint tightness |

Focus of Treatment

|Increased tone in trunk musculature |More varied and differentiated movement patterns |

|Reduced tone throughout the extremities |Inhibition of associated reactions |

|Full range of motion in extremities |Avoidance of static postures |

|Increased spinal mobility |Child to initiate movement |

|Provision of weight-bearing experience with movement |

|Provision of different movement experiences-varying positions, speed and direction, and equipment while ensuring safety |

|Anticipate sites of muscle shortening and joint immobility. Work for muscle elongation, joint mobility, proximal stabilization, and active |

|function of muscles around the joint. |

Physical Problems of the Child with Athetosis

Involvement with the Basal Ganglia

Problems

|Fluctuating level of muscle tone (hypotonia) |Asymmetry in both posture and movement |

|Involuntary movement |Movement of head affecting trunk and limbs |

|Lack of co-contraction of muscles |Incomplete righting reflexes, equilibrium reactions, and protective responses |

|Lack of grading of movement Inability to hold segment at various points within the range of motion |

|Greater involvement of head, trunk, and upper extremities than lower extremities |

Focus of Treatment

|Balance postural muscle tone |Develop increased muscle control in ranges away from midline position |

|Develop midline and symmetric muscle action |Develop smoothly coordinated automatic reactions |

|Hold posture or motion at various points within the range during movement transitions |

|Smooth grading of movement Aim for independent movements of the head on a stable trunk |

Therapeutic Exercises

|NDT theoretical assumptions (TECKLIN) |Develop increased muscle control in ranges away from midline position |

|Sensory system affect motor function including sensory modalities: proprioceptive, visual, tactile & vestibular) |

|Assumption that clients with CNS disfunction may have abnormal ability to receive and interpret sensory information |

|Handling and self-directed movement depends on client's specific impairments and capabilities |

|Abnormal tone affects movement with reflexive alterations of muscle tension and voluntary alterations of muscle tension |

|Treatment is aimed at reaching functional, age-appropriate goals, not at following or mimicking developmental sequence |

Equipment Considerations and Uses

|Mats: Proprioceptive and tactile feedback |Benches: 90/90 sitting, table top activities, stepping & climbing |

|Balls & Bolsters: Mobile surfaces to aid in facilitating autonamic reactions |

|Tilt & Equilibrium Boards: various maintained positions during rocking in anteroposterior or mediolateral direction. Slow rocking will elicit |

|righting reaction and more rapid rocking will elicit equilibrium reaction |

LE Orthosis

|Bivalved Short-Leg Cast |Articulating AFO |

|KAFO |Anterior Shell AFO |

|Molded AFO |Supramalleolar Molded Orthosis |

|Shoe Inserts & Hip-Top Orthopedic Shoe/Phelps Short-Leg Brace |

Neurosurgical Interventions

|Selective Dorsal Rhizotomy |Implanted Spinal Chord Stimulator |Baclofen Pump |Botox & Phenol Shot |

Home Management

|Essential part of tx plan |Incorporate in ADL's |Consider daily routine |Consider hobbies |

|Consider hobbies |

Consult with School

|Recognize teacher's role in therapy |Check sitting position at desk, use of splints, orthotics and other ADs |

Other Disciplines

|Family centered care |Team approach with coordinated effort |Treatment program MUST CONSIDER CHILD as a "WHOLE" person |

Additional Terms & Considerations in CP

Decerabrate: extensor problem within midbrain or pons

Decorticate: flexor problems with cervical spinal tract or cerebral hemisphere

Look at tone in rest and during movement to consider pts tone and responses.

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