CHILD WITH CEREBRAL PALSY

1. What Is Cerebral Palsy (CP)? – Definition

 Definition:
Cerebral palsy (CP) is a non-progressive, heterogeneous group of disorders caused by
brain damage or maldevelopment that occurs during fetal development, infancy, or early
childhood. This condition primarily affects movement, posture, and motor function, often
accompanied by disturbances in sensation, perception, cognition, communication, and
behavior.

2. Impairments – Primary, Secondary, and Associated

 Primary Impairments:
Direct results of the initial brain lesion, including:
o Abnormal muscle tone (e.g., spasticity, hypotonia)
o Impaired motor control and coordination
o Deficits in postural control
 Secondary Impairments:
Consequences that develop over time because of the primary impairments, such as:
o Muscle contractures
o Joint deformities
o Bone deformities and reduced bone density
 Associated Impairments:
Additional challenges that may co-occur with CP:
o Cognitive deficits
o Seizure disorders
o Sensory impairments (vision, hearing)
o Communication and feeding difficulties
3. Classification Systems

a. Gross Motor Function Classification System (GMFCS)

 Overview:
A five-level scale that describes a child’s self-initiated movement abilities—particularly
sitting, walking, and mobility.
 Levels:
o Level I: Walks without limitations.
o Level II: Walks with some limitations.
o Level III: Walks using a hand-held mobility device.
o Level IV: Self-mobility with limitations; may use powered mobility.
o Level V: Severe limitations; transported in a manual wheelchair.

b. Manual Ability Classification System (MACS)

 Purpose:
Evaluates how children with CP handle objects in daily activities.
 Scale:
Ranges from Level I (handles objects easily and successfully) to Level V (severe
difficulty or inability to handle objects).

c. Clinical Presentation

 Subtypes by Motor Abnormalities:

o Spastic CP: Characterized by increased muscle tone and stiffness (most common,
~80% of cases).
o Dyskinetic CP: Involuntary, uncontrolled movements (includes dystonia and
choreoathetosis).
o Ataxic CP: Poor coordination and balance, leading to a shaky gait.
o Mixed CP: Features of more than one type without a clear dominant pattern.

4. Activity Limitations in Children with CP

 Gross Motor Skills:

Difficulties with tasks such as:
o Sitting and standing
o Walking, running, and balance
 Fine Motor Skills:
Challenges in:
o Grasping, writing, and manipulating objects
 Communication & Self-Care:
Impairments may affect:
o Speech, language, and social interactions
o Daily activities like dressing, feeding, and toileting
5. Screening

 Early Identification:
Focus on monitoring developmental milestones and motor skills in infancy.
 Tools & Methods:
o Standard developmental checklists
o Observation for abnormal muscle tone, reflex persistence, and delayed motor
milestones

6. Examination – GMFM and GMPM

 Gross Motor Function Measure (GMFM):

A standardized, observational tool to assess changes in gross motor function over time.
 Gross Motor Performance Measure (GMPM):
Complements GMFM by evaluating the quality of movement—examining aspects like
alignment, stability, coordination, and weight shift.

7. Diagnosis

 Clinical Diagnosis:
Primarily based on:
o History (prenatal, perinatal, and postnatal factors)
o Detailed physical and neurological examinations
 Supporting Investigations:
o Neuroimaging (MRI, CT) to visualize brain structure and identify lesions
o Developmental assessments to correlate clinical findings with motor milestones

8. Prognosis – Motor Growth Curves & Milestone Determination

 Prognostic Indicators:
o Motor Growth Curves: Track the progression of motor abilities over time.
o Milestones: Early achievements (e.g., sitting independently by 24 months) can
predict future walking ability and independent function.
 Outcome Variability:
Dependent on CP subtype, severity, and the presence of comorbidities.
9. Management of Impairments and Activity Limitations – Evidence Summary

 Multidisciplinary Approach:
Combines therapies tailored to individual needs, including:
o Physical Therapy: Enhances mobility, strength, and balance.
o Occupational Therapy: Focuses on improving fine motor skills and
independence in daily activities.
o Speech and Language Therapy: Addresses communication and swallowing
difficulties.
 Assistive Technologies:
Usage of devices (braces, walkers, wheelchairs) to support mobility and function.
 Evidence-Based Practices:
Ongoing research supports early intervention, task-specific training, and family-centered
care to optimize outcomes.

10. Medical Management – Overview of Spasticity and Its Treatment

 Spasticity:
A key feature in CP marked by increased muscle tone leading to stiffness and movement
limitations.
 Management Options:
o Medications: Muscle relaxants (e.g., baclofen, diazepam), and botulinum toxin
injections to reduce tone.
o Intrathecal Baclofen Therapy (ITB): Delivery of baclofen directly into the
spinal fluid for severe cases.
o Selective Dorsal Rhizotomy (SDR): A neurosurgical intervention to reduce
spasticity by selectively cutting nerve root fibers.

11. Orthopedic Surgical Management Techniques

 Goals:
To improve alignment, balance, and function by addressing musculoskeletal deformities.
 Techniques Include:
o Muscle Lengthening: Procedures to relieve contractures.
o Tendon Transfers: Re-routing tendons to improve joint mechanics.
o Osteotomies: Surgical realignment of bones to correct deformities.
 Post-Surgical Rehabilitation:
Critical to maximize functional gains and improve gait and mobility.
12. Gait Deviations in Spastic CP

 Common Patterns:
o Toe Walking: Often due to spasticity in the calf muscles.
o Crouch Gait: Characterized by excessive knee and hip flexion.
o Scissoring Gait: Medial thigh crossing due to abnormal hip adductor activity.
 Assessment and Correction:
o Detailed gait analysis is used to tailor interventions.
o Orthotic devices and targeted therapies can help address these deviations.