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REHABILITATION OF CEREBRAL PALSY

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Scleroderma & Pregnancy Author: Muhammad Asim Iqbal Qureshi Last modified by: NABIL Created Date: 8/27/1999 5:56:36 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: REHABILITATION OF CEREBRAL PALSY


1


REHABILITATION OF CEREBRAL PALSY MOTOR DELAY

2
REHABILITATION OF C.P
  • CEREBRAL PALSY
  • Static encephalopathy(non progressive)
    caused by an insult to the immature brain
  • REHABILITATION
  • The process of making the child w/ disability
    maximally able again through the application of
    rehab principles techniques.

3
REHABILITATION OF C.P
  • Principles of proper rehabilitation
  • 1. Proper evaluation ( individual treatment )
  • - to plan a therapy program.to assess
    progress.
  • - to add observation to the diagnostic
    picture.
  • 2. Early treatment( increasing functional
    deficits w/ age as secondary effects of
    spasticity other primary problems
  • 3. Team work ( global dysfunction )

4
(A) Clinical evaluation 1. Functional
Postural control Mobility

Primitive reflexes Motor exam 2.
Swallowing dysphagia 3. Communication
Speech/ language Visual
Auditory
Mentality 4. Chest 5. Urinary bladder 6.
Bowel 7. Self -care activities (ADL) 8.
psychosocial
EVALUATION OF CP CHILD
5
EVALUATION OF CHILD WITH CP.
  • (B) Imaging
  • 1. Serial X-rays
  • Hips (dislocation spastic adductors)
  • Th-L-Spine (scoliosis, hyperlordosis in
    spastic CP
  • kyphoscoliosis in floppy CP)
  • 2. MRI or CT brain (progressive motor
    deficits ?
  • tumors, hydrocephalus

6
ASSESSMENT OF MILESTONES POSTURAL CONTROL
  • Understanding normal development allows to
    adaptive equipment to assist child in gaining
    increase the interaction with the environment.
  • Sitting balance at age 2 yrs. is an indicator of
    future walking.
  • Observe how much parental support given to child.
  • child own ability in postural
    stabilization.
  • collapse on one side of his
    body, twist to one
  • side, tilt turn to one side.

7
EVALUATION OF PRIMITIVE REFLEXES
  • Can be used as indicator of ambulation
  • Abnormal response for two of the following seven
    reflexes by age 12 month has a poor prognosis for
    walking this are
  • Should be absent Should be present
  • ATNR parachute
    reaction
  • STNR foot
    placement
  • Moro response
  • Neck righting reflex
  • Extensory thrust
  • Presence of Moro or ATNR, seizures, ability to
    sit at 12 month indicate ambulation by age of 6
    yrs.

8
MOTOR EXAMINATION
  • GAIT
  • Hemiplegia Toe walk
  • Diplegia Bilateral equinovaras,
  • Knee flexed in valgus
  • Scissoring
  • Cerebellar Ataxic

9
MOTOR EXAMINATION
  • DEFORMITIES
  • Hemiplegia adducted arm, flexed elbow, wrist
    fingers
  • equinus foot.
  • Diplegia adducted hip, flexed knee in
    valgus, bilateral EV
  • knee height discrepancy
    indicates hip dislocation.
  • Quadriplegia combination
  • scoliosis
    hyperlordosis in spastic CP
  • kyphoscoliosis in
    hypotonic CP

10
MOTOR EXAMINATION
  • R.O.M.
  • Degree by goniometry
  • Limited ( fixed deformity ms. Contracture)
  • Not limited ( deformity threatening deformity

  • muscles imbalance)
  • ABNORMAL MOVEMENT
  • Dystonia, ( cervical spasmodic torticollis )
  • Chorea Athetosis
  • Tremors

11
MOTOR EXAMINATION
  • MUSCLE TONE
  • Spasticity ( clasp knife )
  • - generalized or focal
  • - grade 0 (non) - 4 (severe) Ashworth
    scale
  • Rigidity ( lead pipe )
  • Hypotonia ( cerebellar )
  • Combination the predominant symptoms will
    contribute to diagnostic type referred for
    treatment

12
MOTOR EXAMINATION
  • MUSCLE STRENGTH
  • Grade 0 No contraction detected
  • 1 Flicker of contraction w/ no
    movement.
  • 2 Joint movement possible only with
  • gravity eliminated.
  • 3 Muscle contraction possible
    against
  • gravity without resistance.
  • 4 Muscle contraction against
    gravity
  • less than normal amount of
    resistance.
  • 5 Normal power against gravity and
  • resistance.

13
MOTOR EXAMINATION
  • MUSCLE STRENGTH
  • Values of muscles grading
  • - To determine ambulation with or without brace
  • ( grade 3 antigravity muscles can ambulate
    without brace
  • - Topographic classification for treatment plan
  • ( strengthening exercise for weak muscles )
  • - Ex. must be low grade and non-fatiguing in
    ms.lt3/5
  • -N.B (I) grade drops form muscle power
    following tendon lengthening.

14
SWALLOWING STUDY
  • Values - To facilitate appropriate position
    for safe, effective feeding
  • - To increase ability to self
    feed.
  • Methods
  • 1. Video fluoroscopic swallowing study
  • - Requires speech - pathologist
    radiologist
  • - Patient is given liquid various
    consistency of solid food
  • impregnated w/ baruim folowed by X-ray
    until be sure safe
  • effective swallowing
  • 2.Fiberoptic evaluation of swallowing ( FEES
    )
  • Transnasal endoscopy of hypopharynx to
    observe foodway
  • airway before after( but not during )
    the moment of swallowing.
  • 3. EMG, manometry, scintigraphy U.S less
    commonly use.

15
Assessment of speech
  • Speech problems
  • Dysarthria (oral motor control problems )
  • Spastic
  • Hypokinetic (ataxic )
  • Hyperkinetic (dystonia,chorea)
  • Aphasia
  • Language delay (brain pathology, MR, hearing
    impairment )

16
VISUAL ASSESSMENT
  • Problems Strabismus ( imbalance in eye ms. )
  • Hemianopsia(in dense
    hemiplegi w/ MCA occlusion)
  • Blindness ( anoxic cortical
    vision loss )
  • Effects 1. More motor delay 2.
    Language delay
  • 3. Abnormal movements (
    blindism )
  • 4. More delayed postural
    mechanism
  • especially hypotonic CP

17
AUDIOLOGICAL EVALUATION
  • Must be early so that important speech
    development period not lost.
  • In infant (1-2 d. of birth)

    Brain stem auditory evoked response
    (BAER)
    Electrodes placed on the child presenting a
    stimulus picked up from a computerized system.
  • A specific wave form response is recorded
    from the brain stem if stimulus is heard.
  • Otoacoustic emission testing (OAE)

    Echo from hair cell of normally functioning
    cochlea picked by a microphone placed in the
    middle ear connected to micro computer.(middle
    ear pathology is ruled out)

18
AUDIOLOGICAL EVALUATION
  • 6 months children
  • Behavioral testing in sound treated room
  • 2-3 years children
  • Play audiometry done by presenting auditory
    stimulus through loud speaker and associate the
    sound with light or toy

19
CHEST EVALUATION
  • Vital Capacity is measured by spirometry
  • Ventilatory impairment may be caused by
  • 1. Rib cage abnormalities 2ry. to scoliosis
    hyperlordosis (spastic) or kyphoscoliosis
    (floppy)
  • 2. Respiratory muscle dysfunction (spasticity
    or hypotonic)

20
ASSESSMENT OF BLADDER DYSFUNCTION
  • Problems
  • -incontinence,urgency,hesitancy (brain
    damage,motor disability, impaired cognition )
  • -small capacity hypereflexic bladder
  • -detrusor sphincter dyssynergia
  • Assessment
  • -Renal function with serial determination of
    post-voidal volume
  • -Cytometric evaluation with associated EMG
    monitoring of pelvic floor muscle

21
ASSESSMENT OF BOWEL DYSFUNCTION
  • Problems
  • -Fecal incontinence or defecation stress (
    brain damage, motor disability, impaired
    cognition,incoordination of anal sphincter or
    pelvic floor muscle )
  • -Constipation exaggerated by immobility
    inadequate fluid intake
  • Assessment anorectal manometry

22
SCOPE OF CP REHAB.
  • 1. Neurodevelopmental training.
  • 2. Motor facilitation approach.
  • 3. Treatment of spasticity.
  • 4. Rehab. of swallowing problems.
  • 5. Rehab. of speech problems.
  • 6. Rehab. of auditory problems.
  • 7. Rehab. of visual problems.
  • 8. Rehab. of chest problems.
  • 9. Rehab. of urinary bladder bowel problems.
  • 10.Rehab. Of ADL
  • 11.Psychosocial rehab.

23
NEURODEVELOPMENTAL TRAINING
  • EQUIPMENT TRAINING
  • Criteria for selection
  • 1. to carry out tasks otherwise impossible
    with his ability.
  • 2. appropriate support to participate in social
    educational activities .
  • 3. good alignment correction of abnormal
    postures
  • 4. adjust for child growth, removal of support
    with increasing ability.
  • 5. modification for different children in
    schools clinics
  • 6. provide additional motor experience in
    different posture
  • 7. Comfort and protect joints skin.

24
NEURODEVELOPMENTAL TRAINING
  • Equipments varieties
  • 1. Wedges Abductor W prevent adduction
    deformities
  • 2. Trumble form wedges trumbles.
  • 3. Large inflatable ball set
  • 4.Crawlers
  • -platforms on wheels or wedges on
    wheels
  • -A canavas sling under child abdomen
    supports
  • on casters, straps to hold thighs in
    flexion.
  • 5. Sitters

25
NEURODEVELOPMENTAL TRAINING
  • 6. Apparatus for supporting standing
  • a) Prone or supine standers to encourage weight
    bearing standing
  • b) Standing frames adjusting correct alignment
  • -checked for height so that child does not
    grasp them w/ abnormal shoulder
  • hunching , excessive elbow flexion radial
    deviation of wrist.
  • -supplied w/ strapping to correct flexed hip
    knees
  • -feet held at right angles by a board /or
    foot place.
  • c) Parallel bars

  • d) Mirrors
  • e) Stairs with bannisters very in height.
  • f) Rumps, uneven ground, various floor services
    for gait training.

26
NEURODEVELOPMENTAL TRAINING
  • 7.Walking aids
  • Walkers
  • Crutches
  • Braces Calipers
  • Knee gaiters (polyethylene knee moulds) to
    keep knee straight abduction parts to keep legs
    apart.
  • Elbow gaiters which keep elbow straight for
    correct arm push grasp of walkers.

27
MOTOR FACILITATION APPROACH
  • 1. Bobath Method inhibition of abnormal tone
    posture of released postural reflex while
    facilitating specific automatic motor response
    (by special technique of handling) resulting in
    performance of skilled voluntary movements.
  • 2. Rood Method Use of peripheral input of
    cutaneous sensory stimuli (brushing, tapping,
    icing, heating, pressure, ms. stretch, muscle
    contraction, joint approximation. or retraction)
  • Various nerves sensory receptors are
    described classified into types ,location,
    effect, response, indication.

28
MOTOR FACILITATION APPROACH
  • 3. Propioceptive Neuromuscular facilitation
    (Kabat Knott)
  • Use of such mechanisms as maximum resistance
    , quick stretch spiral diagonal (mass)
    movements, sensory afferent stimuli (touch,
    pressure, traction,compression visual) to
    facilitate normal mov .
  • special techniques irradiation. stim. of
    reflexes,reversal(successive induction),
    relaxation..
  • 4. Brunstrom Method ( hemiplegia) Produces
    motion by provoking primitive movement pattern or
    synergitic pattern as follows
  • -Reflex response used initially later
    voluntary control
  • -Control of head trunk by stim. of TNR,
    tonic labrinythine R
  • -Associated reaction hyperextension of the
    thumb produces relaxation of finger flexors.

29
MOTOR FACILITATION APPROACH
  • 5. Motor relearning program of Carr Shepherd
  • functional training, practice, repitition,
    in the performance of tasks carry over those
    motor skills into functional activities.
  • 6. Forced use paradigm ( constraint - induced
    movements therapy CIMT)
  • Non hemiplegic limb is restrained in a sling
    during 90 of waking hrs. to force the patient to
    use the hemiplegic limb.
  • The minimum amount of motion in the paretic
    limb before being enrolled into CIMT protocol is
    20 of wrist extension and 10 of extension of 2
    fingers at MCP or IPJ.

30
TREATMENT OF SPASTICITY
  • Positioning
  • Avoid prolong sitting (less hip hamstring
    flexion )
  • Prone lying at night (less hip flexion )
  • Abduction wedge at night in wheelchair (less
    hip adduction)
  • AFO splint
  • Standing frame
  • Molded thoracolumbar orthosis for early scoliosis
    or kyphosis
  • Total contact support incorporated into a
    contoured seating system

31
TREATMENT OF SPASTICITY
  • Drugs
  • Indication generalised spacticity to aid
    in mobility
  • Types
  • 1. Dantrolene Sodium (Dantrium)
  • Inhibits Ca release in excitation-contractio
    n coupling
  • Used in cerebral form of spacticity Dose
    25- 200mg
  • 2. Baclofen (Lioresal ) presynaptic
    inhibition
  • Used in spinal form of spasticity Dose
    5-40mg
  • 3. Diazepam (Valium) postsynaptic inhibition
  • Used in spinal form of spasticity Dose
    2-30mg

32
TREATMENT OF SPASTICITY
  • PHYSIOTHERAPY
  • PHYSICAL AGENTS
  • Aim a. Analgesia b. Ms. Relaxation c.
    Collagen extensibility
  • Modalities 1) Ice 20mins.
  • 2) Heat Superficial
    Dry I.R. Moist hot packs
  • Deep
    S.W. U.S
  • ELECTRIC CURRENTS Aim Ms. strengthening
    (galvanic faradic) .

  • Analgesia ( TENS, IF)
  • EXERCISES For spasticity Passive ROM
    Stretch (short ms.)

  • Strengthening (weak ms., antagonist),

  • resistive gt 3/5
  • For hypotonia
    Strengthening ( weak ms) Balance
  • For athetosis
    Training to control simple joint motion

33
TREATMENT OF SPASTICITY
  • Nerve/ Motor Point Block
  • Indications Localized spasticity poorly
    responsive to drugs or PT,
  • interfering w/
    mobility, bracing, hygiene causing pain
  • Contraindication
  • - Absolute Allergy
    Infection Pregnancy
  • - Relative Coagulopathy
  • Problems
  • -Loss of motor function of
    injected ms.
  • -Return of spasticity ( axon
    sprouting )

34
TREATMENT OF SPASTICITY
  • Nerve/ Motor Point Block
  • Agents
  • 1- Botulinum toxin(Botox) inhibits A.C at NMJ
  • Used in motor point block of UL LL
  • Antibodies are formed against it
  • 2- Phenol produce coagulation of axon protein
  • Used in nerve motor point block
  • Produces sensory dysesthesia.
  • 3 - Alcohol produce coagulation of axon protein
  • Used in motor point gt nerve block
  • Produces hyperaemia transiant burning

35
TREATMENT OF SPASTICITY
  • INTRATHECAL BACLOFEN PUMP
  • Indications ambulatory or non ambulatory child gt
    28lbs.w/ spastic diplegia.
  • Method
  • - Baclofen is delivered via pump implanted
    S.C.in abdominal wall surgically placed in
    subarachnoid space (CSF) close to its site
    action ( receptors just 1mm under the surface of
    spinal cord )
  • - Start with intrathecal test dose via lumbar
    puncture to assess baclofen effect over 6-8hs
    (1grade drops of spasticity)
  • . Advantage avoid high dose of oral baclofen.
  • Risk Infections e.g. meningitis, hypotonia
    resp.problem

36
TREATMENT OF SPASTICIRY
  • SERIAL CASTING
  • Indications focal contracture (especially
    elbows,
  • knees, ankles ).
  • Method
  • Limb is stretched then casted in a lengthened
  • position ( can be combined with blocks )
  • Changed every few days or weeks to gradually
  • stretch contracted structures.

37
TREATMENT OF SPASTICITY
  • BRACES ( CALIPERS ORTHOSIS )
  • Aim To correct deformity
  • To control athetosis
  • To obtain upright position
  • Types AFO For ankle instability w
    adequate Q gt 3/5
  • Types solid ( in
    ankle clonus )
  • Klenzak
    ankle joint w/spring(A,P)

  • w/ stop (A,P)
  • Accessories varus
    strap valgus strap
  • KAFO For correction of knee
    deform. instab.
  • HKAFO For ambulation w/ hip
    instability
  • . Shoe modification

38
TREATMENT OF SPASTICITY
  • ORTHOPAEDIC SURGERY
  • 1. Spastic equinovarus foot combination of
  • a. Achillis tendon lengthening ( equinus
    def. )
  • b. Split anterior tibial transfer Splitting
    TA tendon
  • medial half left attached
    to its origin
  • lateral half tunneled into
    3rd cuneiform cuboid
  • 2. Tight hip adductor Adductor tenotomy or
    derotational osteotomy
  • ( surgical
    reduction )
  • 3. Scoliosis surgical correction in ambulatory
    child
  • w/ curvature gt 45 vital
    capacity lt 35

39
TREATMENT OF SPASTICITY
  • NEUROSURGERY
  • Dorsal Rhizotomy
  • - Ideal patient young child (3-8 yrs.) w/
    spastic diplegia
  • ambulatory w/ spastic
    gait.
  • - Method - Surgical cutting of
    posterior (sensory) root to
  • decrease sensory
    input to spinal cord reducing
  • muscle tone (but
    decreases sensation)
  • - Must be followed by
    PT OT
  • - Cutting anterior root
    produces atrophy ? ulcer

40
REHAB OF SWALLOWING PROBLEMS
  • Team speech language specialist, OT, Dietary
    specialist.
  • Items
  • Changes in posture head position during
    feeding.
  • Oral motor exercise for the tongue lips to
    increase strength,
  • ROM, velocity, percision.
  • Use of thickened fluid soft food in small
    boluse
  • Use of alternative feeding routes e.g.
    nasogastric tube, gastrotomy or jejunostomy tubes
    with severe aspiration or caloric need.

41
REHAB OF SPEECH PROBLEMS
  • Team speech -language pathologist nurse
  • Items 1- oral option electrolarynx
  • 2 - non oral options
  • - simple hand writing
  • - gestures
  • - augmentative communication
  • device (simple alphabet
    picture board
  • to sophosticated computer
    systems
  • 3- treatment of hearing visual
    problems

42
REHAB OF AUDITORY PROBLEMS
  • Team audiologist, speech therapist, OT
  • Items
  • Cochlear implants (for profoundly deaf)
  • to stimulate auditory nerve provid
    awareness of sound
  • Hearing aid
    - Do not
    help purely central hearing loss.
    Used for ttt of profound
    sensorineural hearing loss in infancy early
    childhood

43
REHAB OF AUDITORY PROBLEMS
  • Assistive listening device
    Voice amplifiers
    used with or in place of hearing aids.
    Speaker microphone is connected to the listeners
    head set or hearing aid through a wire, FM radio
    waves or IR light. The signal is
    amplified and background noise is not picked.
  • Compensatory strategies
    Hand
    signs, lip reading, gestures, written
    communication, speaking clearly at slow
    speed, visual fire alarms,

    enrichment of visual tactile sensory
    environment,
    protection of
    the childs remaining hearing (use of ear plugs
    in swimming, ototoxic drugs are avoided)

44
REHAB OF VISUAL PROBLEMS
  • Training of postural reaction (large balls,
    rolls)
  • Use of compensatory stimuli (auditory, tactile,
    vestibular, propioceptive) for.
  • -Training of motor function of childs life e.g
    dressing, feeding, bathing, roll over, creeping,
    crawling (listen to sound, reach to sound, move
    to sound).
  • -Training of body image movements enjoyment
    (hand to hand, hand to mouth, hand to body)
  • Mother - child relationship ( kisses, touches,
    stroking, talking to the baby) is important.

45
REHAB OF VISUAL PROBLEMS
  • Use of vibrating toys, bells playthings placed
    for his tummy legs similar ideas.
  • Language development
    Important to
    talk clearly label the body parts to
    encourage the childs language.
  • Visual enhancement (illumination, magnification,
    altered contrast, glare reduction, expanders of
    visual field)
  • Visual substitution Recorded talking books,
  • Computer w/
    vebral output,
  • Braille book.

46
REHAB. OF CHEST PROBLEMS
  • Elimination of air way secretion by
    manually assisted cough OR
    mechanical
    insufflator or exsufflator.
  • Respiratory ms. aid by manual force (breathing
    ex) OR
  • mechanical ventillatory assistance(hypoxia)
  • Mouth intermittent positive pressure ventillation
    (IPPV) in late stages.

47
REHAB. OF U.B. PROBLEMS
  • Timed bladder emptying schedule
  • Regulation of fluid intake.
  • Use of diapers.
  • Adequate cleaning of perineum
  • Family education about transfer dressing
    skill .
  • REHAB. OF BOWEL PROBLEMS
  • A timed toileting schedule for incontinence
  • Use of dietary fibers, adequate fluid intake,
    stool
  • softeners, supp., enema for constipation
  • .

48
REHAB OF ADL
  • Team occupational therapist
  • Items
  • - provision of self help devices
  • - training in activities of ADL
  • - provision of creative interest
  • - training in suitable work

49
PSYCHOSOCIAL REHAB
  • Team psychiatrist social specialist
  • Items - provision of recreational activities
  • e.g.- special olympics, athletic
    competition
  • - horse back riding programs
  • (recreational therapeutic
    )
  • - computers ( for schools
    recreation
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