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12/1/11

Dr. Ahmad RIFAI SARRAJ

12/1/11

Cerebral palsy (CP)


A childhood condition Motor disability (palsy) caused by a static, non-progressive lesion in the brain (cerebral). The causative event has to occur in early childhood, usually defined as less than 2 years of age. Normal children with special needs. Understanding the medical and anatomic problems in individuals with CP is important; Objectives : To grow and develop to the maximum capabilities so that they may succeed as contributing members of society.

Etiology of Cerebral Palsy


Bleeding in the immature brain occurs primarily around the ventricles, which have many fragile vessels. Intraventricular hemorrhage (IVH) means bleeding into the ventricles. Germinal matrix hemorrhage (GMH) means bleeding into the tissue around the ventricles. Periventricular intraventricular hemorrhage (PIVH) means bleeding into both areas. Periventricular cysts (PVC) form in these same areas as the acute hemorrhage resolves.

Dr. Ahmad RIFAI SARRAJ

12/1/11

Cerebral palsy (CP)


Cerebral hemorrhages evolving from GMH and IVH Develop in the first 72 hours after birth. Bleeding then resolving peri- ventricular leukomalacia (PVL) develops 1 to 3 weeks after birth in some children. More severe bleeds have a worse prognosis for survival and a higher risk for developing CP; No specific parameters that fully predict risk of developing CP or, much less, predict the severity of CP in an individual child.

Etiology of CP
Hypoxic events occurring around delivery, usually in full-term infants, also lead to disability. Termed hypoxic-ischemic encephalopathy (HIE) Severe cases of HIE subcortical cyst formation ( multicystic encephalomalacia) prognosis for good function is poor, severe quadriplegic pattern involvement with severe mental retardation. Some of these children develop cysts in the thalamus and basal ganglia, which may lead to dystonia.

Dr. Ahmad RIFAI SARRAJ

12/1/11

Etiology of CP
Neonatal stroke occurring in the preterm or full-term infant Middle cerebral artery presents as a wedge-shaped defect in one hemisphere.

Anatomic Classification
Anatomic pattern of involvement Hemiplegia = one half of the body. Diplegia = primarily the lower extremities with mild upper extremity involvement; Quadriplegia, which involves all four limbs, is most useful. Double hemiplegia = much more severe on one side than the other. Monoplegia = one limb is primarily involved

Dr. Ahmad RIFAI SARRAJ

12/1/11

Spastic Diplegia
The most common type
Speech / intellect: normal slightly impaired UL : gross motor OK

Cerebral palsy

minor incoordination of fine motor skills LL : spastic : hip: flexion, adduction, int. rotation knee: flexor / extensor spasticity /or equal ankle: equinus foot: pes valgus

Most walk independently by 4 years

Spastic Diplegia

Cerebral palsy

Dr. Ahmad RIFAI SARRAJ

12/1/11

Spastic Hemiplegia

Cerebral palsy

30 % of all CP

One side affection upper > lower extremity 50 % mentally retarded 33 % seizures

Spastic Quadriplegia

Cerebral palsy

All four limbs involved and trunk Often mentally retarded With seizures Most ( 80 % ) non walkers

Dr. Ahmad RIFAI SARRAJ

12/1/11

Evaluation

Motor Development Birth - 1 month


Apgar Scale (1st rating of developmental status) rating scale of newborn's functional status scored 1 min. & 5 mins. after birth max score is 10 5 characteristics rated (0/1/2)
heart rate efforts to breathe muscle tone skin colour reflex irritability

Dr. Ahmad RIFAI SARRAJ

12/1/11

Reflexes/Primary Motor Patterns


Reflex response: "motor output that predictably follows some specific sensory input

Abnormal Response patterns


Unvarying, obligatory responses to specific stimuli weakness/ excessive strength absence/ undue persistence asymmetry of response

Dr. Ahmad RIFAI SARRAJ

12/1/11

The most primitive reflex is the sucking reflex, which is stimulated by contact of the infants perioral area (A)The hand (B) and toe grip (C) grasp reflexes are also present at birth and are stimulated by stroking the palm or plantar surfaces.

Grasp Reflex
Tactile stimulus to palm. Fingers flex and grasp. Response strongest 1-2 months weakens by 3 months. (Burns 1992)

UniSA 2004

Dr. Ahmad RIFAI SARRAJ

12/1/11

Plantar Grasp
UniSA 2004

Apply pressure under foot at MTP joints. Response is toe flexion with some PF & Knee ext. Fades as weight-bearing starts 6- 9 months. (Burns 1992)

The tonic labyrinth reflex shows the baby with abducted shoulders, flexed elbows, adducted extended hips, and extended knees and ankles. This posture primarily occurs with the baby in the supine position.

Dr. Ahmad RIFAI SARRAJ

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12/1/11

The asymmetric tonic neck reflex


is activated by turning the childs head. The side to which the face turns shoulder to abduct elbow and hand extension. The leg in full extension. On the opposite side shoulder is also abducted elbow and hand are fully flexed leg is flexed at the hip, knee, and ankle. By turning the head to the opposite side, the pattern reverses.

The Moro reflex


initiated with a loud noise, such as a hand clap, full extension of the head, neck, and back. shoulders abduct and elbows extend. legs also have full extension. After a short time, the pattern reverses and the head, neck, and spine flex; the arms are brought to the midline; and the legs flex.

Dr. Ahmad RIFAI SARRAJ

11

12/1/11

The parachute reaction


Initiated by holding the child at the pelvis and tipping him head down. Reaction : extend the arms as if he were going to catch himself with his arms. Present by 11 months of age.

The foot placement reaction or step reflex is initiated with the child held under the arms or by the chest. When the dorsum of the foot is stimulated at the edge of a table, the child will flex the hip and knee, simulating a stepping action.

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Developmental reflexes evolution Reference Tool Bobath center - London


Mois
Moro Galant RTAC Station debout + + primaire Marche automatique Grasping Griff Succion Landau
1 2 3 4 5 6 7 8 9 10 11 1an 2ans

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Normal developmental milestones Gross motor skill Lifts head when prone Supports chest in prone position Rolls prone to supine Sits independently when placed Pulls to stand, cruises Walks independently Walks up stair steps Kicks a ball Jumps with both feet off the floor Hops on one foot with holding on Mean age of development 1 month 3 months 4 months 6 months 9 months 12 months 18 months 24 months 30 months 36 months Abnormal if not present by 3 months 4 months 6 months 9 months 12 months 18 months 24 months 30 months 36 months 42 months

Sources : Adapted from Standards in Pediatric Orthopedics by R.N.Hensinger

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Posture of Neonate

(0-4 weeks)

Characterised by physiological flexion (due to intra-uterine packaging) in all positions Gravity & active use of antagonists gradually reduces physiological flexion Healthy premature infant less tightly "packaged" so looks "more flattened into gravity" than full-term neonate

Neonate in prone
Flexed, unable to extend against gravity Prone Lying (1) (Piper & Darrah 1994)

UniSA 2004

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Neonate: Supine
Head rotated to one side. Limbs flexed. Pulled into abduction by gravity in supine. Supine (1) (Piper & Darrah 1994)

UniSA 2004

Neonate: Held sitting

Total Ccurve spine in sitting

UniSA 2004

Dr. Ahmad RIFAI SARRAJ

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12/1/11

2 - 4 months
Prone: symmetry with control, extension head and upper trunk against gravity

UniSA 2004

2 - 4 months
Supine: midline orientation of head, hands and feet

UniSA 2004

Dr. Ahmad RIFAI SARRAJ

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12/1/11

2 - 4 months
Sitting : head midline Upper Tx ext and Lx flexion (sitting with propped arms, not yet independent)

UniSA 2004

3 - 5 months
Pulled to sit with chin tuck Head in line with or in front of trunk Arms flexed
UniSA 2006

Dr. Ahmad RIFAI SARRAJ

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12/1/11

4- 6 months
Prone: weight on hands elbows extended, chin tuck

UniSA 2007

4 - 6 months
Supine: balance flexion and extension Hands to feet

UniSA 2004

Dr. Ahmad RIFAI SARRAJ

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12/1/11

5 - 7 months: Reaching from forearm support

Weight on one forearm, hand and abdomen Controlled reach with free arm

UniSA 2006

4 - 7 months:

Held standing hips in line with shoulders.

UniSA 2006

Dr. Ahmad RIFAI SARRAJ

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12/1/11

6 - 8 months
Sitting: Able to sit unsupported, balance between flexion and extension. Hands free to play.

UniSA 2004

5 - 9 months
Rolling supine to prone without rotation Lateral head righting Beginning of dissociation between shoulders and pelvis.

UniSA 2006

Dr. Ahmad RIFAI SARRAJ

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12/1/11

7 - 9 months: 4 point Kneel

UniSA 2006

9 months: Propped lying on side

Prone, asymmetry with control

UniSA 2004

Dr. Ahmad RIFAI SARRAJ

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12/1/11

8 - 10 months: Sitting to 4 point kneel and vice versa


This slide is similar but not true sit to 4 point as has more points of contact. UniSA 2006

9-13 months
Cruises furniture Begins with 2 hand support and progresses to one Trunk rotation develops

UniSA 2004

Dr. Ahmad RIFAI SARRAJ

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12/1/11

11 - 14 months
Walks alone Arms in mid to low guard Legs slightly abducted or neutral

UniSA 2004

12 - 15 months:
Squats to play Lowering towards squat. Needs control of quads eccentrically to achieve position

UniSA 2006

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Physical Examination
Child is using a wheelchair
Evaluation of the fit of the wheel and the support it is providing. Evaluation of orthotics for fit and function. Childs functional ability how she can stand, how much support she needs to sit, and how she crawls.

Physical Examination
Child is ambulatory
Assessment of the gait Assessing muscle tone and motor control often is best accomplished by holding and handling the child if this is age appropriate.

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Physical Examination
Specific region evaluation
Spinal assessment flexibility and deformity. child sitting, with side bending for the flexibility evaluation

Physical Examination
Specific region evaluation
Spinal assessment flexibility and deformity. child sitting, with side bending for the flexibility evaluation

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Physical Examination
Specific region evaluation
Hip Abduction This is the most important screening evaluation of the hip in the prevention of hip dysplasia.

Physical Examination
Specific region evaluation
Hip External Rotation Child prone and the hip extended

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Physical Examination
Specific region evaluation
Hip Internal Rotation Child prone and the hip extended

Physical Examination
Specific region evaluation
Hip flexion Hip flexion is measured with the contralateral hip in extension and lordosis reduced to normal range. Total flexion without forceful further push toward flexion.

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Physical Examination
Specific region evaluation
Hip flexion Hip extension can be measured several ways, but the technique of dropping the contralateral leg off the end of the table works well for many children.

Physical Examination
Specific region evaluation
Popliteal Angle with the contralateral hip and knee in full extension. The hip on the side to be measured is then flexed to 90 and the knee slowly extended until the pelvis starts to move.

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Physical Examination
Specific region evaluation
Leg rotational profile child in the prone position and the knee flexed 90. The thighfoot alignment gives a measurement of the overall alignment of the leg and foot. Normal should be 0 to 15 external. A more specific measurement of tibial torsion is measuring the transmalleolar to thigh angle.

Physical Examination
Specific region evaluation
Feeding, Growth, and Weight Problems
A major problem for many children with CP is poor nutrition. Measure the height and weight. routine dental care

Dr. Ahmad RIFAI SARRAJ

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Disorders of Muscle Tone


Stiffness of the muscles or the limb as one tries to passively move the limb. Spring characteristic, Nonlinear response to movement. Studies using the leg drop test, a difference has been seen between an awake and alert child compared with the same child under neuro-motor blockade anesthesia. In normal individuals there is less muscle tone under anesthesia than when they are awake.

Disorders of Muscle Tone


Stiffness of the muscles or the limb as one tries to passively move the limb. Spring characteristic, Nonlinear response to movement. Studies using the leg drop test, a difference has been seen between an awake and alert child compared with the same child under neuro-motor blockade anesthesia. In normal individuals there is less muscle tone under anesthesia than when they are awake.

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Motor tone
High tone = spasticity or hypertonicity Low tone = hypotonia

Movement patterns, especially dystonia, may be difficult to differentiate from spasticity

Ashworth scale and modified Ashworth scale


Ashworth Scale : Score 1 2 3 4 5 Description of the muscle tone No increase in normal tone Slight increased tone with a catch with rapid joint motion Increased tone but the joint is still easy to move Considerable increase in tone making passive movement difficult Limb is rigid, movement is difficult

Modified Ashworth scale 00 0 1 1+ 2 3 4 Hypotonia Normal tone, no increase in tone Slight increase in tone manifested by a slight catch and release or minimal increased resistance to joint range of motion Slight increase in tone manifested by a slight catch and minimal increased resistance to joint range of motion for more than half the joint range More marked increase of tone through most of the whole joint range, but the affected joint is easily moved Considerable increase in muscle tone, passive movement difficult but possible Affected joint is stiff and cannot be moved

Dr. Ahmad RIFAI SARRAJ

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Muscle extensibility

Dr. Ahmad RIFAI SARRAJ

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Hip Flexors : extensibility


Ilio-psoas ( the main and most powerful ) Sartorius Tensor fascia lata Rectus femoris Adductors

Muscle extensibility Hip Flexors


With fixed knee flexion, Thomas test should be performed with knee outside at table edge to prevent false positive results

Cerebral palsy

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Hip Flexors : extensibility


Staheli Test

Prone position

Pelvis over table edge More accurate

Hip Flexors : extensibility

Ely / Rectus Femoris Test

Well known Significance ?

Dr. Ahmad RIFAI SARRAJ

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Knee Flexors : extensibility ( Hamstring Tightness )

Ankle Plantoflexors : extensibility


Silfverskiold 1923 Gastroc. Vs T. Achilles ( Soleus )

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Upper Limb : Position


Elbow flexion Forearm pronation Wrist flexion Finger flexion Thumb in palm

Upper Limb : Posture

Wrist dorsi-flexed

Wrist palmar-flexed

Dr. Ahmad RIFAI SARRAJ

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Equilibrium reactions

Dr. Ahmad RIFAI SARRAJ

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Effects of lower limb alignment on Gait


1.

Base of support (spatial)


The base gradually narrows due to bony changes combined with increasing postural control abilities to maintain the centre of gravity over increasingly smaller bases of support.
Age BOS as % of Pelvic Width

1 year 3 years 4 years

70% 45% Close to adult values


Whittle 2002

Effects of lower limb alignment on gait


3. Velocity (temporal)
Age 1 year 7 years Adult females Adult males Velocity m/sec 0.64 1.14 1.30 1.46

4. Proportion of time in swing phase


Less for young children to reduce time in unstable SLS
(Whittle 2002)

Dr. Ahmad RIFAI SARRAJ

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Effects of lower limb alignment on Gait


5. Cadence (temporal)
Age 1 year 7 years Adult females Adult males Steps/minute 171 141 118 113 Cycle time (secs) 0.7 0.85 1.02 1.06

Whittle 2006

Dr. Ahmad RIFAI SARRAJ

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12/1/11

Timing For Orthop Surgery


Surgery should not be unduly staged one by one ( with each birthday )
?ETA ? Hams ? Psoas ? Rectus Femoris

Equinus

Crouch

Flexion

Stiff Knee

Ok

Dr. Ahmad RIFAI SARRAJ

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