Management of Cerebral palsy

(rough outline)
Developing a plan of care is a complex problem solving activity, which requires integration of
examination and evaluation findings and child and family goals. Functional outcomes for
individuals with CP will vary greatly depending on the severity and age. Severity may be
influenced by the childs muscle strength, sensory systems compromise, spasticity, cognitive
abilities, and medical status. Selection of aims and methods for management by a therapist is
based on the assessment framework.
This assessment framework varies with individuals with CP in different age group. The main aim
of management in infants with development delay are reinforcing milestones for that particular
age group such that it helps in development of gross motor functions, fine motor functions which
would later aid in acquisition of activities of daily living.
In infancy and early childhood
The focus is on developing skill, learning to control body and limbs to produce effective and
efficient movements. Change in body position (rolling, weight bearing on limbs for transitioning
from one position to other), stability in assumed position, sitting with and without support,
grasping, bi-manual coordination, reaching, releasing objects, movement exploration by going in
variety of positions prior to pull to stand are the main objectives in infancy and child with CP.
There is a need to identify the neurological and biomechanical limitations which may prevent the
acquisition of above goals and age related milestones. One such neurological limitation is
hypertonia. Together with abnormal movement patterns, influence of primitive reflexes,
tightness of muscles and low power in muscles prevent normal movement patterns. Hypertonia
leads to altered weight bearing in upper extremity and increases the intensity of grasp reflexes.
Inability to bear body weight prevents balancing the body over the base, prevents development
of fundamental skills and adequate hand opening respectively.
Hypertonia and extensor thrusts may lead to difficulty in feeding. Hence hypertonia is largely
managed by positioning. Appropriate handling of individuals with CP needs to be taught for the
same. In children with severe spasticity, possible positions in which the child can be managed
are:
1.
2.
3.
4.

Supine, head down on mothers legs (if the child is small enough).
Side lying on mothers knee on side that is more flexed
Carrying in sideline position
Predominantly extended children are very difficult for mothers to
handle. They push backwards with their heads, and sometimes their
whole bodies, against the mothers arm when she is trying to hold or
carry them. One way is to have the mother tuck him under her arm,
holding his legs in flexion, abduction and outward rotation.

Written/compiled for BPT III yr.

The principles of management also included reduction of tone by countering the patterns of
spasticity and by avoiding too much stimulation and effort. Avoid using stereotyped patterns of
movement for functionfind ways to break them up. Facilitate sequences of movement.
Facilitate wide ranges of movement in tone-influencing patterns. The hypertonic tight muscles
which restrict functions should be stretched judiciously. The muscles which show propensity to
become tight in lower limb are hip flexors, knee flexors, dorsiflexors (some children) and
plantarflexors. In the upper limb shoulder adductors, internal rotators, elbow flexors, pronators,
wrist flexors and small muscles of hand might go for tightness and eventually contracture. This
may decrease the chances of gaining function if not managed early.
In children with movement disorders like choreo-athetosis, the aims are
1. Stabilising of posture through controlled stimulation and small ranges of movement
2. Weight-bearing and compression to facilitate co-contraction and reduce involuntary
movements
3. Work for symmetry and midline orientation
4. Facilitation of head and trunk control and proximal fixation to give child possibility to
control distal movements
5. Use of placing and holding to facilitate sustained tone and lead to better grading of
movement
6. Facilitation of reach and grasp
In children with ataxia, the aims are:
1. Control postural tone by weight-bearing and joint compression
2. Place and hold child in positions to facilitate co-contraction. Encourage child to take over
so that you can release hold
3. Use mobile weight-bearing and graded movements to change from one position to
another
4. Get selectivity of movement and independence of limbs from trunk
5. Work for rotation around body axis
6. Facilitate balance and protective reactions
Normal movement patterns are facilitated to gain maximum proprioceptive along with visual,
vestibular and auditory feedback for integration and development of movement. This patterns are
repeated over and over until the child is able to develop antigravity control over the limitations
imposed. Adequate stimulation of brain during this period helps the child to consolidate the
processing of all these sensory stimuli to produce functional movement. Sensory stimulation,
maintenance of muscle length and facilitation of hypo active muscles (using principles of
developmental therapies like NDT) which are necessary for transition in movements form part of
early intervention. Normal alignment of body structure is crucial during this period to facilitate
the developing control in muscles and bone growth as the child grows.
In childhood
Usually this period extends form 24 months of age to 4 to 6 years. Teaching mobility and
manipulation skills form important part of this programme. Cognitive development plays an

Written/compiled for BPT III yr.

important role along with motor development to achieve above mentioned goals. Management is
based on gross motor function categories (GMFCS).
During this period the child may be immobile (GMFCS V and VI category) or belong to more
developed categories (GMFCS I to GMFCS III) where the child may be able to perform ADL
and movements with or without assistance. Management is mostly directed to facilitate control,
strengthening of muscles and maintaining biomechanical alignment of the body. Hypertonia is
managed through variety of approaches including strengthening of agonist muscles, hippo
therapy and use of developmental therapies like NDT.
Play therapy is included to incorporate the exercise regimen to make therapy sessions more fun
so that child and their parents adhere to rehabilitation programme which they may require over a
long period of time. The programme may consist of task-oriented exercises and activities that are
focused on muscle activation, contractility and strength, and on developing co-ordination or
motor control of the lower limbs as they flex and extend, support, balance and move the body
mass in actions such as standing up and sitting down, squatting to pick up an object on the floor
and standing up again, walking up and down stairs and slopes (Carr and Shepherd, 2003, 2010).
The focus is on developing skill, learning to control body and limbs to produce effective and
efficient movements. Gait training is performed to overcome obstacles without tripping. Some
children with deformed, supple or spastic foot may require foot orthosis for stability during
standing and bi-pedal weight bearing. Some children who lack control in the trunk and head may
benefit from assistive technology like standing frames. Hip surveillance forms a part of
rehabilitation programme to monitor dislocation and development of painful hip. Regular weight
bearing programmes are devised in frames for development of acetabulum. Similarly,
customized seating arrangements where adequate support to the trunk and head is available.
Stable base with good posture helps in improved upper extremity control and thus facilitate
independent self-care, feeding, play and academic activity. This also prevents or delay
development of scoliosis and pulmonary function limitation. The main aim in this age group is to
delay development of contractures, deformity and hence the need of surgery.
Ambulatory CPs are trained to walk with assistive devices like AFO, posterior walkers, elbow
crutches as per the need. Balance training programmes are usually incorporated along with
activity based tasks in therapy sessions. Walking over treadmill is considered. The children are
encouraged to participate in community mobility, social life, personal care and education. These
patients are also trained for endurance, so that their functional capacity is raised through
conditioning of cardio vascular system. This prevent frequent fatigue in these children. Children
with CP who demonstrate tightness contracture and deformity are either managed conservatively
through muscle denervation blocks or referred for surgery following slow motion video gait
analysis. The surgical intervention and post-operative physiotherapy management depends on the
type surgery performed. The common deformities seen in this age group are the bony changes
and joint subluxations and dislocations. They may have scoliosis, hyperextension of the knee,
kyphosis, patella displacement (alta or baja), lordosis, subluxation of the hip, claw toes, shoulder
and elbow dislocation
Adolescents and adult with cerebral palsy
The aim of physiotherapy is this group is to maintain ambulation, prevention of deterioration of
orthopedic alignment. Participation in rehabilitation is maintained through regular family visit to
Written/compiled for BPT III yr.

therapist or pediatric orthopedician. The neurophysiological and biomechanical limitations to

movement are managed through appropriate neurological approaches like task oriented exercises
strengthening and maintenance of endurance. Emphasis is placed on protection of joints to delay
degeneration. Use of activity pacing and use of appropriate assistive devices help in achieving
this goal. Wheel ambulation is considered for longer distances.
Family education is given at all the stages to let the caregivers and family know about
prophylaxis, progression of deformity and growing health care needs according to the severity.
Family counselling is must at all ages to prevent burn out. Appropriate handling of individuals
with CP needs to be taught to prevent burden on caregivers.

Written/compiled for BPT III yr.