Cerebral Palsy - Part II

Physical Examination

Types of CP

Classification of CP is related to the type of movement disorder and/or by the number of limbs involved: quadriplegia, in which all four limbs are involved; diplegia, when all four limbs are involved, with both legs more severely affected than the arms; hemiplegia means that only one side of the body is affected, with the arm usually more involved than the leg; triplegia, when three limbs are involved, usually both arms and a leg; and monoplegia, which only one limb is affected, usually an arm. [1]

The location of the brain injury will determine how movement is affected. Therefore, the CP could be Spastic, Athetoid (Dyskinetic), Ataxic, or Mixed-type. [1]

The Spastic type is the most common one, affecting about 75% of the CP population, and it’s caused by an injury to the motor cortex. Spastic muscles are tight and stiff, becoming active together, thus blocking effective movement (co-contraction). Spasticity may also involve difficulty in controlling the mouth and tongue. Spasticity may be very mild and affect only a few movements, or very severe and affect the whole body. The amount of spasticity usually changes with time (e.g. aging), but may also change with environmental condition, such as weather (e.g. cold/heat), lighting (e.g. sunlight, halogen lighting), and stimulants (e.g. pop, coffee). [1]

The Athetoid (Dyskinetic) type affects about 25% of the CP population. It results from damage to the basal ganglia in the midbrain, and leads to difficulty in controlling and coordination movements, which can be fast and jerky, or slow and writhing. People with this type may have trouble sitting, walking, and speaking, due to problems controlling the face and tongue muscles. [1]

The Ataxic type is the last common type, affecting 5-10% of the CP population. It is caused by damage to the cerebellum. They have a disturbed sense of balance and depth perception (difficulty judging how close or far away things are). They may also have difficulty walking, often walking with a limp, and difficulty with tasks requiring small, coordinated movements such as writing or reaching and grasping objects smoothly. [1]

The Mixed-type CP it’s caused when areas of the brain affecting both muscle tone and voluntary movement are affected. Usually the spasticity is more obvious at first, with involuntary movement increasing as the child develops. [1]

Treatment

People suffering from CP can present muscle tightness or spasm, involuntary movement, difficulty with gross motor skills and/or fine motor skills. These motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, behaviour, epilepsy. [2]

Before starting any of the therapeutic methods that I am going to mention, the physical therapist should always first prepare the body, and align the joints and muscles to profit the most of the therapeutic methods and exercises. The physical therapist should begin with a massage and accessory and physiological passive mobilization exercises to improve and maintain joint mobility, and diminish the muscle spasticity. Passive, static, and gentle stretches are also performed to decrease and prevent muscle contractures.

One of the most popular therapeutic interventions for the treatment of children with CP is the Neurodevelopmental Treatment (NDT). The basis of NDT approach is that the motor abnormalities in children with CP are due to failure of normal development of postural control and reflexes because of the underlying dysfunction of the central nervous system. The aim of NDT approach is to facilitate normal motor development and function, and to prevent development of secondary impairments due to muscle contractures and joint and limb deformities. The normal developmental sequence of child development is used as the underlying guiding principle to facilitate normal postural and righting reflexes, and movement patterns. [3]

Many children with learning disabilities, CP and other neurodevelopmental disabilities have associated sensory difficulties. The Sensory Integration (SI) theory is based on the hypothesis that in order to develop and execute a normal adaptive behavioral response, the child must be able to optimally receive, modulate, integrate, and process the sensory information. This theory attempts to facilitate the normal development and improve the child’s ability to process and integrate sensory information (visual, perceptual, proprioceptive, and auditory, etc.). Three classic patterns of SI disorders have been proposed, namely sensory modulation disorders, sensory discrimination disorders, and sensory-based motor disorders. [3]

Stepping movements (or reflex stepping reactions) are normally present in newborns and infants, before the infant starts to bear weight, stand and walk. In treadmill training, the child is supported in a harness on the treadmill in an upright posture limiting weight bearing. The child then attempts to walk on the slowly moving treadmill, eliciting the stepping movements. Treadmill training, thus allows development of stepping movements needed for ambulation. Studies using 3-4 sessions per week lasting for 3-4 months have shown improvement in lower extremity movements and gait patterns in children with CP. [3]

Therapeutic horse-back riding has been shown to improve muscle tone, balance, and postural control in children with CP. They enjoy horse riding and it also provides a setting for increased social interaction and psychosocial development. [3]   

The physical therapist shouldn’t also forget to include in their treatments exercises to improve the ability to transfer (e.g. bed to wheelchair).

Several measurement tests can be used by the physical therapist to assess and evaluate the initial degree of disabilities of the child with CP, and to evaluate future improvements, such as the Gross Motor Function Measure (GMFM), the Gross Motor Performance Measure (GMPM), the Quality of Upper Extremity Skills Test (QUEST), the Peabody Developmental Motor Scales Fine Motor (PDMS-FM), the Bruininks-Oseretsky Test of Motor Proficiency, the Modified Ashworth Scale, and the Pediatric Evaluation of Disability Inventory (PEDI).

[1] A Guide to Cerebral Palsy (2006). Cerebral Palsy Association of British Columbia: The Hamber Foundation

[2] Antilla, H. et al (2008). Effectiveness of physical therapy interventions for children with cerebral palsy: A systematic review. BMC Pediatrics; (8):14

[3] Patel, D.R. (2005). Therapeutic Interventions in Cerebral Palsy. Indian Journal of Pediatrics; 72: 979-983