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Cerebral palsy is a disorder of movement. The term relates to the physical

condition of a person who has difficulty either producing movement, preventing
movement or controlling movement following injury or the brain before or
during birth or in the first five years of life. The physical problems presented by
cerebral palsy are often referred to as motor problems. A child with CP may also
have a additional disabilities, caused by damaged to parts of the brain other
than those controlling motor function, such as visual or hearing problems, other
sensory problems, perceptual difficulties or language delay. There is no cure for
cerebral palsy. Damaged brain cells cannot regenerate. However, many believe
that there are ways in which the effects of brain damage may be brought under
control so that the individual can live a more fulfilling life than might otherwise
have been the case. Doctors can be reluctant to diagnose cerebral palsy when a
child is showing signs which lead them to suspect it. There may be a number of
reason for this:

It is not always easy to identify (especially in the very young baby) and
doctors are wary of misinforming parents.
Even when a child has clearly sustained damage to the brain or starts to
show signs of having cerebral palsy, there are numerous instances of
symptoms disappearing. Leaving the child free of any motor problems or
other impairments
There are wide variations in the severity of the condition so parents may
misinterpret minor problems as being very severe.
Doctors may exercise caution in informing parents of their suspicions
because they fear that the parent will be unable to cope with the
Early symptoms of CP might give way to other problems which are mre of
an issue than the motor problems

Cerebral palsy (CP) has constantly evolved since the 1800s and has involved
some of the most influential medical minds in history, including William Little, Sir
William Osler, and Sigmund Freud. Advances in medicine and world-wide
communication have led to the current definition: Cerebral palsy describes a group of
permanent disorders of the development of movement and posture, causing activity
limitation, that are attributed to non-progressive disturbances that occurred in the
developing fetal or infant brain. The motor disorders of CP are often accompanied by
disturbances of sensation, perception, cognition, communication, and behavior, by
epilepsy, and by secondary musculoskeletal problems.53 This definition excludes a
number of disease processes that may present similarly, but either progress (i.e.,
genetic or metabolic diseases), have a primarily peripheral etiology (i.e., neuromuscular
or peripheral nerve injury), or occur after the central nervous system has fully
developed (i.e., traumatic injuries or oncologic manifestations). It serves to remind us
that the term CP reflects much more than a musculoskeletal process; it reaches to the
function of a person.

Spastic cerebral palsy (pyramidal)
Spastic CP is caused by damage to the cortex. The child will be stiff in one
or more limbs and possibly all over.

Athetoid cerebral palsy (extra-pyramidal)

Althetoid CP is caused by damage to the basal ganglia and/or cerebellum.
The child may be floppy in one or more limbs, possibly all over whilst
many may have high or flunctuating tone with accompanying constant
uncontrolled movements.

Ataxic cerebral palsy

Ataxic CP is caused by damaged to the cerebellum. The child will be
unsteady. Although movement is present it may appear random and
bringing these random movements under control may be difficult

Mixed cerebral palsy

Mixed CP is a term used for types of cerebral palsy which do not fit neatly
into one of the other three classifications. The child may show signs of
more than one type of cerebral palsy

Topographical classification
Cerebral palsy is most commonly classified topographically (in terms of
the parts of the body affected and the extent of the disability), as detailed

- All four limbs are affected

- All four limbs are affected but the legs more so than the arms. This
is common if CP occurs due to premature birth

- Both legs are affected.

- Three limbs are affected

- Other side of the body is affected. This is a type of CP that can be
the result of a bleed on the brain prior to birth

- One limb is affecte

- Motor delay means that the child is behind the average in
developing normal movement in limbs and body. This will be
assessed by noting where a child fails to achieve a motor
milestone - such as sitting up by six months or walking by
12-18 months
- Developmental delay means that the child is behind the
average in her motor, vision and fine speech, language and
social development
- Global delay has a similar meaning to developmental delay
but tends to be used where a consultant believes that all
aspects of a childs development are affected.
- Intellectual impairment means that the consultant believes
the childs understanding is affected, to an extent which will
cause learning difficulties.
- Sensory impairment means that one or more of the childs
senses touch, taste, sight, hearing and smell are affected.
There are other sensory areas, such as proprioception (the
ability to have a sense of yourself in space) and the vestibular
system (affecting balance), which might also be affected.
- Cortical blindness is caused by damaged to cerebral cortex.
This means that the child has difficulty making sense of what
he sees but it does not necessarily mean than he is blind in
the conventional sense. He may be clinically able to see but

unable to organize what he sees. There is evidence that sight

can improve with visual stimulation.
- Multiply handicapped is a general term for children who have
several problems of which cerebral palsy may be one.
- Epilepsy is used to
describe fits or seizures
caused by sudden
electrical activity in the





varies but is approximately 2-3 per

1000 live birth
One of the most common
disabilities affecting children.
Common in children who are born
very prematurely or at term
Most patients are identified by 2
years of age due to delayed motor
slightly higher prevalence in the
male population, with a male:female
, ration of 1.5:1
higher prevalence among black nonHispanic children compared with
white non-Hispanic children
Poor prenatal care may increase the
incidence of cerebral palsy
Living in substandard housing with
lead paint may increase the
incidence of cerebral palsy


Lies in the cranial cavity and is continuous with the spinal cord through the foramen
magnum. It is surrounded by three meninges: the dura, the arachnoid mater, and the
pia mater; these are continuous with the corresponding meninges of the spinal cord.
Functions of the Brain
interprets sensations
determines perception
stores memory
makes decisions
coordinatesmuscular movements
regulates visceral activities
determines personality

The cerebrum is the largest part of the brain. It is divided into 2 parts (halves)
called the left and right cerebral hemispheres.
The 2 hemispheres are connected by a bridge of nerve fibres called the corpus
The outer surface of the cerebrum is called the cerebral cortex or grey matter.
It is the area of the brain where nerve cells make connections, called synapses,
that control brain activity.
The inner area of the cerebrum contains the insulated (myelinated) bodies of the
nerve cells (axons) that relay information between the brain and spinal cord.
This inner area is called the white matter because the insulation around the
axons gives it a whitish appearance.






Perform high level cognitive functions, such as

reasoning, abstraction, concentration, and
executive control.
Provide for information storage, or memory
Control voluntary eye movement.
Influence somatic motor control of activities
such as respiration, GI activity, and blood
Perform motor control of speech in the dominant
hemisphere, usually the left.
Contain the motor cortex that controls voluntary
motor function.
Contain the premotor cortex or motor
association areas that are involved with
generalized movement.
Interpret sensory information to define size,
shape, weight, texture, consistency, and
awareness of body parts. The non-dominant
parietal lobe processes visual-spatial information
and controls spatial orientation. The dominant
lobe is involved with the ideomotor apraxis.
Contain the primary auditory receptive areas,
the auditory association area, and the
interpretive area
Involved with auditory, visual, olfactory, and
somatic perception and integration, which
extend to learning, memory, emotional effect,
and intellectual ability that involve these senses.
contain the primary visual cortex and visual
association areas, the primary functions of
which are visual perception, some visual reflexes
such as fixation, and involuntary smooth eye
movements (smooth pursuit system).

Dura Mater
Most superior of the layers
It is tough and inflexible and forms several structures that separate the cranial
cavity into compartments and protect the brain from displacement.

Arachnoid Mater
Middle layer of the meninges
makes arachnoid villi, small protrusions through the dura mater into the venous
sinuses of the brain, which allow CSF to exit the sub-arachnoid space and enter
the blood stream.
Cerebrospinal fluid (CSF) flows under the arachnoid in the subarachnoid space.

Pia Mater
The delicate innermost layer of the meninges .
A thin fibrous tissue that is impermeable to fluid which allows it to enclose CSF
(cerebrospinal fluid). By containing CSF.
Pia works with the other meningeal layers to protect and cushion the brain.
Allows blood vessels to pass through and nourish the brain.

- The brain receives it arterial supply from two pairs of vessels, the vertebral and
internal carotid arteries, which are interconnected in the cranial cavity to
produce an arterial circle (of Willis).
- The two vertebral arteries enter the cranial cavity through the foramen magnum
and just inferior to the pons fuse to form the basilar artery.
- The two internal carotid arteries enter the cranial cavity through the carotid
canals on either side.

Each vertebral artery arises from
the first part of each subclavian
artery in the lower part of the neck,
and passes superiorly through the
transverse foramina of the upper six
cervical vertebrae. On entering the
cranial cavity through the foramen
magnum each vertebral artery gives
off a small meningeal branch.
Continuing forward, the vertebral
artery gives rise to three additional
branches before joining with its
companion vessel to form the
basilar artery:
one branch joins with its companion
from the other side to form the
single anterior spinal artery, which
then descends in the anterior
median fissure of the spinal cord;
a second branch is the posterior
spinal artery, which passes
posteriorly around the medulla then
descends on the posterior surface of
the spinal cord in the area of the
attachment of the posterior roots-


The two internal carotid arteries
arise as one of the two terminal
branches of the common carotid
arteries. They proceed superiorly to
the base of the skull where they
enter the carotid canal.
Entering the cranial cavity each
internal carotid artery gives off the
ophthalmic artery, the posterior
communicating artery, the middle
cerebral artery, and the anterior
cerebral artery.

there are two posterior spinal

arteries, one on each side;
just before the two vertebral
arteries join, each gives off a
posterior inferior cerebellar artery.
The basilar artery travels in a rostral
direction along the anterior aspect
of the pons. Its branches in a caudal
to rostral direction include the
anterior inferior cerebellar arteries,
several small pontine arteries, and
the superior cerebellar arteries. The
basilar artery ends as a bifurcation,
giving rise to two posterior cerebral

arteriosus cerebri)


is an anastomotic system of
arteries that sits at the base of
the brain. The circle was named
after Thomas Willis by his student
Richard Lower. Willis was the
author of Cerebri Anatome, a book that described and depicted this vascular
ring. Although such a vascular ring had been described earlier, the name Willis
has been eponymously propagated.

The circle of Willis encircles the stalk of the pituitary gland and provides
important communications between the blood supply of the forebrain and
hindbrain (ie, between the internal carotid and vertebrobasilar systems following
obliteration of primitive embryonic connections). A complete circle of Willis is
present in most individuals, although a well-developed communication between
each of its parts is identified in less than half of the population.

The circle of Willis is formed when the internal carotid artery (ICA) enters the
cranial cavity bilaterally and divides into the anterior cerebral artery (ACA)
andmiddle cerebral artery (MCA). The anterior cerebral arteries are then united
by an anterior communicating (ACOM) artery. These connections form the
anterior half (anterior circulation) of the circle of Willis. Posteriorly, the basilar
artery, formed by the left and right vertebral arteries, branches into a left and
right posterior cerebral artery (PCA), forming the posterior circulation. The PCAs
complete the circle of Willis by joining the internal carotid system anteriorly via
the posterior communicating (PCOM) arteries.


- The cerebral cortex has been divided by KORBINIAN BRODMANN into 47
distinct regions, each having a Brodmanns number
Functional Areas:
The Brodmanns areas
- divided into 47 cytoarchitectural areas
Area 4
Area 6


Frontal eye field

movement area



Area 44

Brocas area

Area 5, 7
Area 43
Area 39, 40
Area 39:
Area 40:

Area 41, 42


FRONTAL LOBE (Motor Function)

motor Voluntary movement
of skeletal muscles
Premotor cortex/ Appropriate response
of movement
association area

Area 8

Area 3, 1, 2


Primary sensory

Immediate paresis if
Complex defects of
movements in the
Movement of the Defective scanning
of opposite side, no
Insight, emotion
judgment, no insight
Speech production
Brocas/nonfluent/nonexpressive, anterior
(Somatosensory Function)
tactile Impaired 2 pointstimulus
tactile -sensations
Taste sensation
Loss of taste

association area
gustatory area
Gnostic/Commo Memory,
behavior, Area 39: Angular
integration sexual desires
combined acalculia,
Area 40: Ideomotor
Primary auditory Hearing

Area 21, 22

Area 17

Area 18, 19

Wernickes area

Speech integration/
visual Sight
visual stimulus




- Modulation of motor flow
- Smoothing voluntary actions
- Initiating/ directing voluntary motor activities





Lateral to the thalamus

Almost completely divided by nerve fibers the
internal capsule
It is called striatum because of its striated
appearance produced by strands of gray
matter passing through the internal capsule.
Connecting the caudate nucleus and putamen
Larged C shaped gray matter.
Closely related to lateral ventricle.
Lies lateral to thalamus.
Vertical plate of white matter




Divides nucleus into a larger, darker lateral

Inner lighter portion
Contains higher portion of inner myelinated
Center for coordination of impulses of skilled
Large motor nucleus situated between the
tegmentum and the crus cerebri
Found throughout the midbrain
Has shape of biconvex lens
The nucleus has important important
connections with the corpus striatum

located in posterior cranial fossa tentorium cerebelli (cerebrum), 4th ventricle
(brain stem)
communicate with other structure via uperior, middle, and inferior cerebellar

- Simple reflexes such as stretch reflex require coordinated contraction and
relaxation of different muscle groups.

Small encapsulated sensory receptors that have spindle-like shape and are
located within the fleshy part of a muscle.

In parallel with the muscle fibers.

Does not contribute to the overall contractile force
. Nuclear bag fibers (2-3)
Nuclear chain fibers (approximately 5)


Maternal seizures
Intellectual disability
Thyroid disease
History of stillbirth or neonatal death
Maternal age > 40 years
Low socioeconomic status


Birth defcts
Small for gestation age
Low birth weight
Placental abnormalities
Maternal disease, during pregnancy
Abnormalities in fluid volume
Maternal bleeding in 2nd and 3rd trimesters

Birth hypoxia
Meconium staining
Meconium aspiration
Abnormal duration
Abnormal duration of labor
Fetal presentation
Respiratory distress


Abusive head trauma
Bacterial meningitis
Motor vehicle crashes



Gestational age <32 wks

Birth weight <2.5 kg

Mental retardation

Seizure disorder


Two or more previous fetal deaths

Sibling with more deficits

Twin gestation

Fetal growth retardation

Third trimester bleeding

Increased urine protein excretion


Premature placenta separation

Low placenta weight

Abnormal fetal presentation

Fetal malformations

Fetal bradycardia

Neonatal seizures

Except for severe CP, life expectancy same as unaffected


May need to repeat previous surgeries or new surgery for

during adulthood

Associated CP problems of dysphagia, GI reflex,urinary

incontinence, constipation and painful contractures usually
worsen with aging

Adult CP frequently more motivated and able to

participate in therapy than a child

Communication, ADL and mobility are the priorities

expressed by adult CP, whereas ambulation is the priority of
children with CP


Fetus Rh + blood

Mother ( -) blood

RH antibodies form in
mothers blood
Fetus in subsequent

Destroy RBC

Hemolysis of RBC

Production of
immature RBC

Enlarged liver and



bilirubin pass to the

Erythroblastosis fetalis

Athetoid CP


The most noticeable sign of cerebral palsy is impairment of muscle tone
the ability of muscles to work together by maintaining proper resistance. Muscles
coordinate with other muscles, oftentimes in pairs. As some muscles contract,
others must relax. Even something as simple as sitting requires coordination of
many muscles; some flexing while others relax. The brain injury or malformation
that caused cerebral palsy impairs the ability of the central nervous system to
coordinate muscle movement.

Hypotonia decreased muscle tone or tension (flaccid, relaxed, or floppy

Hypertonia increased muscle tone or tension (stiff or rigid limbs)
Dystonia fluctuating muscle tone or tension (too loose at times and too
tight at others)
Mixed the trunk of the body may be hypotonic while the arms and legs
are hypertonic
Muscle spasms sometimes painful, involuntary muscular contraction
Fixed joints joints that are effectively fused together preventing proper
Abnormal neck or truncal tone decreased hypotonic or increased
hypertonic, depending on age and cerebral palsy type
Clonus muscular spasms with regular contractions
o Ankle/foot clonus spasmodic abnormal movement of the foot
o Wrist clonus spasmodic movement of the hand

Sensory integration disorder (SID) is a neurological disorder found
commonly in children with cerebral palsy. An individual with SID experiences an
inability to correctly process information received through one or more of the five
senses sight, hearing, touch, smell, and taste and therefore has difficulty
forming a proper response to external stimuli.



Loss of visual acuity means the child cannot see the object.

Loss of visual field means the child can see the object, but has a limited field
of vision which requires them to move their eyes or turn their head to do so.

A visual integration disorder exists when an individual relies on sight to
perform other tasks and is unsuccessful. An example would be a visual
processing deficit whereby the child has a difficult time describing objects
viewed. The child sees the object, but the brain isnt processing what the eyes
see. Individuals with stereognosia, on the other hand, have difficulty perceiving
and identifying objects through touch.

Auditory integration challenges are similar to visual challenges in that the
child can hear, but his or her brain is unable to process the information in a
meaningful way. In this instance, the child will appear to be listening, but the
information does not seem to click with the child.


It is estimated that 8%-18% of those with cerebral palsy have a form of
hearing loss or impairment, which may or may not coincide with vision
impairment. The two hearing impairment classifications are sensorineural and

Sensorineural impairment
is damage to the auditory nerve which prevents the brain
from receiving the correct signals.

Conductive impairment
is when the middle or outer ear prevents sound from
reaching the healthy auditory nerve which in turn prevents hearing.


Abnormal perceptions
Abnormal sensations
Conductive impairment
Hearing abnormality
Hearing impairment
Hearing loss
Maturational delay (language delay)
Perception impairment
Sensorineural impairment
Sensory integration dysfunction
Sensory impairment
Speech impairment
Vision abnormality
Vision acuity abnormality
Vision field abnormality
Vision impairment
Vision loss
Visual acuity

Hypertonus of the clasp-knife variety

- If the spastic muscles are stretched at a particular speed
they respond in an exaggerated fashion. They contract,
blocking the movement.
- This hyperactive stretch reflex may occur at the
beginning, middle or near the end of movement.
- There are increased tendon jerks, occasional clonus and
other signs of upper motor lesions.


Abnormal postures
Associated with the antigravity muscles which are
extensors in the leg and the flexors in the arm.
Common abnormal postures in supine, prone, sitting,
standing, walking.
Changes in hypertonus and postures
Occur with excitement, fear or anxiety which increases
muscle tension.
Changes in hypertonous are seen with changes of
position in some children, position of the head and neck
ay affect the distribution of hypertonous.
The latter are due to abnormal reflexes which may

sometimes be found in these children. Sudden

movements, rather than slow movements, increase


Voluntary Movement
Voluntary motion is present and may be labored.
There may be weakness in the initiation of motion or
during movement at different parts of its range. If
spasticity is decreased or removed by treatment or
drugs, the spastic muscles may be found to be strong, or
may be weak.
Once spasticity is decreased the antagonists may also be
stronger once they no longer have to overcome the
resistance of tight spastic muscles. However, in time
these antagonists may have become weak with disuse
Involuntary movements-athetosis
- These are bizarre, purposeless movements which
may be ucontrollable.
- The involuntary movements may be slow or fast;
they may be writhing, jerky, tremor, swiping or
rotary patterns or they may be unpatterned. They
are present at rest in some children.
- The involuntary motion is increased by excitement,
any form of insecurity, and the effort to make a
voluntary movement or even to tackle a mental
- Factors which decrease athetosis are fatigue,
drowsiness fever, prone lying or the childs
attention being deeply held.
- Athetosis may be present in all parts of the body
including the face and tongue.
- Athetosis may only appear in hands or feet or in
proximal joints or in both distal and proximal joints.

Voluntary movements
- There are possible but there may be an initial
delay before the movement is begun.
- The involuntary movement may partially or totally
disrupt the willed movement making it
- There is a lack of finer movements and weakness.

Hypertonia or hypotonia
- Either may exist or there may be fluctuations of
- Athethoids are sometimes called tension and nontension types.
- There may be dystonia or twisting of the head,
trunk or limbs. Sudden spasms or flexion or
extension could occur.
- The hypertonia is a rigidity but occasionally

spasticity may be present in the athetoid

quadriplegias. Fluctuating tone sometimes occurs
with fluctuations of mood or emotions.


Athetoid dance
- Some athetiod dance are unable to maintain
weight on their feet and continually withdraw their
feet upwards, or upwards and outwards.
- They may take weight on one foot whilst pawing or
scrapping the ground in a withdrawal motion with
the other leg. This has been attributed to a conflict
between grasp and withdrawal reflexes.

Paralysis of gaze movements

- May occur so that athetoids may find it difficult to
look upwards and sometimes also close to their
eyes voluntarily.

Athetoids change with time

- They may be floppy in babyhood and only exhibit
the involuntary movements when they reach 2 or 3
years of age.
- Adult athetoids do not appear hypotonic but have
muscle tension. Muscle tension seems to increased
in an effort to control involuntary movements.
Disturbances of balance
- There is poor fixation of the head, trunk, shoulder,
and pelvic girdles.
- Some ataxics overcompensate for this instability
by having excessive balance-saving reactions in
the arms. Instability is also found in athetoids and
Voluntary movements
- Is present but clumsy or uncoordinated.
- The child overreaches or underreaches for an
object and is said to have dysmetria.
- This inaccurate limb movement in relation to its
objective may also be accompanied by intention
tremor. Poor fine hand movements occur.
- Is usual. Ataxia may be present in the hypertonic
cases as well.
- may exist.
- Slow, writhing, involuntary movements particularly
in the distal extremitie;
- both agonist and antagonist muscles are active;
intensity may increase with emotions and
purposeful activity



Abrupt, irregular, jerky movements usually

occurring in the head, neck and extremities.

- Combination of athetosis and choreiform
movements; generally large-amplitude-involuntary
movements; dominating pattern is the athetoid
- Slow, rhythmic movements with tone changes
generally found in trunk and extremities; abnormal
- Unsteadiness with uncoordinated movements;
often associated with nystagmus, dysmetria,, and
a wide-based gait.
Mixed types includes both spastic and dyskinetic

- Permanently stiff joints (contractures) and dislocated hips may develop.
- Contracture. Contracture is the shortening of muscle tissue due to severe
tightening of the muscle (spasticity). Contracture can inhibit bone growth, cause
bones to bend, and result in joint deformities, dislocation or partial dislocation.
- Osteoarthritis. Pressure on joints or abnormal alignment of joints from muscle
spasticity may result in the early development of painful degenerative bone
disease (osteoarthritis).
- In addition, some preteens, teens, and young adults develop abnormal curves in
the spine (scoliosis).


is a congenital deformity involving one foot or both. The affected foot appears to
have been rotated internally at the ankle.
Is the combination of ankle plantar flexion and internal rotation.
Growth problems may be caused by poor nutrition or by damage to certain parts
of the brain: babies with CP may not gain weight at the same rate as other
babies their age, young children with CP may be shorter than average, teens'
sexual development may be slower than normal.
Other growth problems may also occur, such as muscles tightening around the
long bones of a leg. This can result in one shorter leg, which makes walking
Many people with cerebral palsy have seizures, most commonly people with
spastic hemiplegic CP (in which the arm and leg on the same side of the body are
affected) and total body CP.
Children with CP usually have their first seizure between the ages of 2 and 6



Amblyopia lazy eye

Esotropia - affected eye turns inwards

Exotropia - affected eye turns outwards
Hypertropia - affected eye turns upwards
Hyoptropia- affected eye turns downwards
a disorder of sight. It involves decreased vision
in an eye that otherwise appears normal, or
out of proportion to associated structural
problems of the eye; there is much more
'damage to' or impact on vision in that eye
than is predicted, even though the eye doesn't
look completely normal.

Nystagmus dancing eye


condition of involuntary eye movement,

acquired in infancy or later in life, that may
result in reduced or limited vision. Due to the
involuntary movement of the eye
seeing distinctly at a short distance only;

Hearing problems are common with cerebral palsy.
They are more likely to occur in people whose CP was caused by viral
infection (such as rubella) before birth or in people who have dyskinetic CP.

Some people with cerebral palsy may have difficulty speaking because of
problems moving their tongues and vocal cords.
They also may have problems expressing themselves with words and/or have
problems reading.

This occurs in some people who have CP.
It is most common in people who have total body CP, which affects the entire
body to some degree, or in people who also have seizures.
Sometimes the disability has a greater impact on a person's life than cerebral
palsy. Mild degrees ofintellectual disability or learning disabilities may be
detected in individuals before the cerebral palsy is noticed.

Swallowing or feeding problems can make it difficult for someone who has
cerebral palsy, particularly an infant, to get enough nutrition. This may cause
impaired growth and weaker bones. The child may need a feeding tube for
adequate nutrition.


People with cerebral palsy may develop lung disease and breathing disorders.
e.g. Pneumonia, Chronic Restricted Pulmonary disease (CRPD)
Respiratory impairment may also occur in CP children. Decreased vital capacity
and aerobic working capacity is seen both in spastic and athetoid types.
Restrictive pulmonary disease accompanies scoliosis.


Bladder dysfunction can also be a serious health problem for children with
cerebral palsy and may require treatment from a physician who specializes in
bladder function.
Incomplete bladder emptying (resulting in urinary tract infections), increased
accidents due to bladder muscle tone abnormalities, bed wetting, stress
incontinence and dribbling are all issues that may occur with increased frequency
in children with cerebral palsy.



- Gross motor function may be impaired by abnormal muscle tone,
especially hypertonia or hypotonia.
- For example, hypertonic limbs can be too tight, or inflexible, to allow
proper flexion and movement; whereas hypotonic limbs may be too
loose to properly support a childs movements.
- As a babys brain and body develop, they are expected to reach
developmental milestones. Reaching the milestone later than
expected, or reaching it but with low quality of movement (such as
favoring one side while crawling), are possible signs of Cerebral

Impaired gross motor functions limited capability of accomplishing

common physical skills such as walking, running, jumping, and maintaining
Delayed gross motor functions physical skills developed later than
expected; often used in conjunction with developmental milestones for
predictable stages of development.


Sitting up

These should be monitored to note when the baby reaches the milestone, and
the quality of movement.

The incidence of associated disabilities in cerebral palsy varies.
The overall incidence of mental retardation is approximately 50%.
Microcephaly, seizures, and severe neuromuscular dysfunction are associated
with increased risk of intellectual deficit.
Spastic quadriplegic type has the highest rate of mental retardation, while
spastic hemiplegic and diplegic types have the lowest.

The impairment of gross motor function can affect a childs ability to

balance. Signs become recognizable as a child learns to sit, rise
from a sitting position, and begins crawling or walking. Infants need
to use their hands often as they learn these skills. They develop the
strength, coordination, and balance to accomplish the task when
mastering it without the use of their hands.

A childs inability to sit without support can be a sign of Cerebral

Palsy. The Gross Motor Function Classification System, or GMFCS, a
five-level system commonly used to classify function levels, uses
balance while sitting as part of its severity level system.


o Requiring both hands for support
o Having difficulty balancing when not using hands for support
o Unable to sit without using hands for support
o Swaying when standing
o Unsteady when walking
o Difficulty making quick movements
o Needing hands for activities that require balance
o Walking with abnormal gait
Balance is often the same whether a childs eyes are open or closed. Balance
impairment is most often associated with ataxic, and to a lesser degree, spastic
Cerebral Palsy.

Disorders of behavior may present with attention deficit, distractibility,
disturbances of impulse control, and overt hyperkinesis.
Behavior disorders also include true emotional lability as part of an organic
pseudobulbar palsy consisting of dysarthria, drooling, and poor chewing.
Poor peer acceptance leading to a negative self-image, school problems,
depression, and anger may be exacerbated during normal periods of transition,
ie, preschool kindergarten, early adolescence.
The more mildly physically involved child may have more difficulty and need
more psychosocial
Cerebral Palsy affects posture and balance. Signs may appear as an infant begins
to sit up and learn to move about. Typically, posture is expected to be
symmetrical. For example, a baby in a sitting position would normally have both
legs in front. When bent, they become mirror images of one another.
Asymmetrical posture means the right and left limbs will not mirror one another.
The hip-joints are one area where this is often prominent in instances of Cerebral
Palsy. One leg will bend inward at the hip, and the other will bend outward.
Much like reflexes, postural responses are expected reactions when putting a
baby in certain positions. They typically appear as the baby develops.
Impairment may be a possibility if the responses do not develop, or if they are
Much like reflexes, postural responses are expected reactions when putting a
baby in certain positions. They typically appear as the baby develops.
Impairment may be a possibility if the responses do not develop, or if they are



Landau reflex when the infant is supported in a lying position, pushing the
head down will cause the legs to drop, and lifting the head will cause them to
rise. This response appears around four or five months of age.
Parachute response when the infant is positioned with his or her head
towards the ground, the infant should instinctively reach as if bracing for impact.
This response appears around eight to 10 months of age.
Head righting when an infant is swayed back and forth, his or her head will
remain straight. This response appears around four months of age.
Trunk righting when a sitting infant is quickly pushed to the side, the infant
will resist the force and use opposite hand and arm to brace against impact. This
response appears around eight months of age.
Certain abnormal reflexes may also indicate Cerebral Palsy. Hyperreflexia are
excessive reflex responses that cause twitching and spasticity. Underdeveloped
or lacking postural and protective reflexes are warning signs for abnormal
development, including Cerebral Palsy
Abnormal primitive reflexes may not function properly in children with Cerebral
Palsy, or they may not disappear at specific points in development as they do
with children with no impairment.



Asymmetrical tonic reflex

when the head turns, the legs on the same side will extend, and the
opposite limbs contract like in a fencing pose. Asymmetrical tonic reflex should
disappear around six months of age.

Symmetrical tonic neck reflex

the infant assumes a crawling position when the head is extended.
Symmetrical tonic neck reflex should disappear between eight and 11 months.

Spinal gallant reflexes

when the infant lies on its stomach, the hips will turn towards the side of
the body that is touched. Spinal gallant reflexes should disappear between three
and nine months.

Tonic labyrinthine reflex

when the head is tilted back, the back arches, the legs straighten, and
the arms bend. Tonic labyrinthine reflex should disappear by three-and-a-half
years of age.

Palmer grasp reflex

when stimulating the palm the hand flexes in a grasping motion. Palmer
grasp reflex should disappear around four to six months.

Placing reflex
when an infant is held upright and the back of a foot touches the surface,
the legs will flex. Placing reflex should disappear by five months.

Moro (startle) reflex

when the infant is tilted so his or her legs are above their head, the arms
will extend. Moro reflex should disappear by six months.

Early hand preference can also indicate possible impairments. A child normally
develops hand preference in his or her second year. As this is a wide timeframe and
rough average, development of hand preference, especially if it is early preference, is
cause for concern. Various sources state that early hand preference falls between 6-18

Brain damage in cerebral palsy may also be responsible for special sense defects
of vision and hearing, abnormalities of speech and language, and aberrations of


Some signs will be more apparent when the child is under stress. Some may be
task related, such as reaching for an object. Sometimes signs will seem to
disappear when the child is asleep and muscles are relaxed.
It is common for a child to experience different types of impaired muscle control
in opposite limbs. Coordination and control can likewise be affected differently in
each limb.


Spastic movements hypertonic movements where the muscles are too tight
resulting in muscle spasms, scissoring of the legs, clonus, contracture, fixed
joints, and over-flexed limbs
Athetoid or dyskinetic movements fluctuating muscle tone causing
uncontrolled, sometimes slow, writhing movements which can worsen with stress
Ataxic movements poor coordination and balance making tasks such as
writing, brushing teeth, buttoning shirts, tying shoes, and putting keys into slots
Mixed movements a mixture of movement impairments, most commonly a
combination of spastic and athetoid types, affecting different limbs
Gait disturbances control impairments affecting the way a child walks
In-toeing toes angle or rotate inward
Out-toeing toes angle or rotate outward
Limping more weight is placed on one foot than the other, causing a
dipping, or wavy stride
Toe walking the weight is unevenly placed on the toes
Propulsive gait a child walks hunched over in a stiff posture with the
head and shoulders bent forward
Spastic and scissor gait the hips flex slightly making it look like the
child is crouching while knees and thighs slide past one another like
Spastic gait one leg drags due to muscle spasticity
Steppage gait toes drag because the foot drags
Waddling gait duck-like walking pattern that can appear later in life

Symptoms are frequent.
Gastroesophageal reflux often requires medical management.
Constipation is exaggerated by immobility and abnormal diet and fluid intake.


Difficulty in using the lips, tongue, and jaw indicate impaired oral motor function;
this is a sign that may be present in up to 90% of preschool-aged children diagnosed
with Cerebral Palsy. Signs of oral motor function impairment include, but are not limited
to difficulty with:


Speech requires proper intellectual and physical development. Cerebral Palsy

impairs the physical aspects of speaking by improperly controlling the muscles required
to speak. Oral motor impairment can affect:

Breathing the lungs, and specifically the muscles controlling inhalation and
exhalation necessary for proper speech patterns. The diaphragm and abdominal
muscles are important for proper air flow and posture.
Articulating muscles controlling the face, throat, mouth, tongue, jaw, and
palate all must work together to form the proper shape necessary for
pronunciation of words and syllables.
Voicing vocal cords are controlled by muscles that essentially stretch the vocal
folds between two regions of cartilage.
Apraxia, an inability of the brain to effectively transmit proper signals to the
muscles used in speaking, is one type of speech impairment common to Cerebral
Palsy. It is divided into two types:
Verbal apraxia affects the articulation muscles, especially regarding the
specific sequence of movements needed to carry out proper pronunciation. It is
common in children with hypotonia.
Oral apraxia affects the ability to make nonspeaking movements of the
mouth, but is not related solely to speaking. Examples of oral apraxia would be
the inability to lick the lips or inflate the cheeks.

Dysarthria is another speech impairment common to Cerebral Palsy. Like apraxia,

it is a neurological impairment, as opposed to a muscular condition. It is often found in
Cerebral Palsy that results in hypertonia and hypotonia. Dysarthria is broken into the
following subgroups:

Ataxic dysarthria slow, erratic, inarticulate speech caused by poor breathing

and muscular coordination
Flaccid dysarthria nasal, whiny, breathy speech caused by the inability of the
vocal chords to open and close properly. There may be difficulty with consonants.
Spastic dysarthria slow, strenuous, monotone speech and difficulty with
Mixed dysarthria all three may be present.

Drooling is another sign of Cerebral Palsy that results from muscles in the face
and mouth not being able to properly control coordination. Some specific factors which
can contribute to drooling are impairments in:

Closing the mouth
Positioning the teeth
Inability to move saliva to back of mouth

Tongue thrusting

Feeding difficulties can be present with Cerebral Palsy. They typically manifest as
decreased ability to chew and swallow, and may also involve choking, coughing,
gagging, and vomiting

Include malocclusion, enamel dysgenesis secondary to palatal distortions, and
abnormal oromotor reflexes.
CP children are also at increased risk for cavities due to poor handling of
secretions and food as well as chronic drooling.
Medications, such as scopolamine patches, can be used to address the problem
of drooling.

Executing precise movements defines the category of fine motor

function. Fine motor control encompasses many activities that are learned,
and involves a combination of both mental (planning and reasoning) and
physical (coordination and sensation) skills to master.
Impaired or delayed fine motor skills are an indicator of possible
Cerebral Palsy. Intention tremors, where a task becomes more difficult as it
gets closer to completion, is one such sign.
Examples of fine motor function development are:
Grasping small objects
Holding objects between thumb and forefinger
Setting objects down gently
Using crayons
Turning pages in a book
Is a degenerative disorder of the central nervous system.
The motor symptoms of Parkinsons disease result from the death of dopaminegenerating cells in the substancia nigra, a region of the midbrain; the cause of
this cell death is unkown.
Four motor symptoms are considered cardinal in PD: tremor, rigidity, slowness of
movement and postural instability

also known as intracranial injury, occurs when an external force traumatically,

injures the brain.
A person with a moderate or severe TBI may have a headache that does not go
away, repeated vomiting or nausea, convulsions, an inability to awaken, dilation
of one or both pupils, slurred speech, aphasia (word-finding difficulties),
dysarthria (muscle weakness that causes disordered speech), weakness or
numbness in the limbs, loss of coordination, confusion, restlessness, or agitation.



abnormal limpness when an infant is prone

unable to maintain flexed ligaments, and are able to extend them beyond normal

the movement of the head is uncontrollable, not in the sense of spasmatic

movement, but chronic ataxia
have difficulty feeding, as their mouth muscles cannot maintain a proper suckswallow pattern, or a good breastfeeding latch.


Initial development can be normal. Presents acutely with headache, raised

intracranial pressure, seizures, and focal neurologic deficits.
Occasionally coexists with CP.


Onset of muscular deformity occurs after several years of normal development.

Presents with sustained periods of muscle contraction and dystonia but without
development of contractures. There may be abrupt and violent movements;
patients may even sit on their limbs.
Positive family history.
No spasticity, but patients can develop contractures. There are various subtypes,
including Duchenne, Becker, and limb girdle.
Child may be weak at birth or may have apparent normal development until
approximately 3 years of age followed by a progressive loss of function and
muscle weakness. There may be a positive family history.


Cerebral computerized
tomography (CT)

1Cranial magnetic resonance

imaging (MRI)


CT is helpful in the diagnosis of

intracranial bleeding in the
newborn, it may be helpful in
evaluating congenital
malformations and PVL but in these
and other lesions MRI is superior.
MRI is the best method for
diagnosing lesions in the white
matter after 2 to 3 weeks of age. At
present, MRI and ultrasonography
are the only methods to show
periventricular leukomalacia in an
infant from 1 week of age. No
biochemical methods are available
to identify high-risk infants at birth.
The primary indication to perform
radiography in cases of CP is to
monitor hip instability. Obtain
baseline spine and hip radiographs
in every child and follow the hip at
risk with hip radiographs. Measure
the Reimers index which is the
percentage of femoral head
coverage by the acetabulum.
Three dimensional CT is useful when
planning hip reconstruction. Clinical
examination is sufficient to
diagnose and follow-up scoliosis.

Cranial ultrasonography (USG)

Electroencephalography (EEG)

Measure the Cobb angle in children

who are candidates for surgery.
Obtain radiographs of the
extremities for patients if you plan
osteotomies. Standing radiographs
of the feet help if there are
varus/valgus deformities.
Cranial USG can help in the
differential diagnosis of the infant
when the fontanelle is open. It is
easy and it does not require
sedation as does MRI. Cranial USG
evaluates the ventricles, basal
ganglia and corpus callosum.
Periventricular white matter
ischemic injury and intraventricular
haemorrhage are apparent on realtime cranial ultrasonograms.
EEG measures electrical activity on
the surface of the brain. It is a
necessary tool in the diagnosis and
follow-up of seizure disorders

Neurological examination
Mental status

Vision and hearing

Observe the childs orientation

and interest in the surroundings.
Watch for eye contact, following
objects, alertness, and ability to
obey simple commands.
The diagnosis of visual and
hearing loss in infants can be
easy. Call the child when he is
not looking. Clap your hands or
deliberately drop an object to
make a noise behind the child
and watch the response. If the
child does not seem to hear, look
in the childs ears for wax or
signs of infection. Considering
the high incidence of visual and
oculomotor problems in cases of
CP, all children with a definite
diagnosis of neurodevelopmental
delay and/or CP should undergo
a detailed ophthalmological and
audiological examination during
early infancy. The examinations
should be repeated at yearly
intervals until school age.

selective motor control






Many children with CP cannot

voluntarily contract or relax their
therefore are unable to move
attempts to extend his elbow, he
involuntarily moves his whole
arm. Lack of selective motor
control makes it impossible to
determine muscle strength using
simple manual muscle testing.
Observe muscle strength by
watching the child perform
certain tasks, such as throwing
or hitting a ball.
Evaluate the persistence of
absence of advanced postural
primitive reflexes beyond 6
months of age is a sign of poor
The child must be calm for
assessment of muscle tone.
Place the head in neutral position
because turning or flexion can
trigger tonic neck reflexes and
interfere with muscle tone.
Spasticity is the resistance felt
while moving the joint through a
passive range of motion. Use the
modified Ashworth or Tardieu
scales to grade spasticity. Also
record tremor, chorea, athetosis,
dystonia and ataxia.

Musculoskeletal examination

- Examine range of motion in a slow and smooth manner because
sudden stretch of the muscle will increase spasticity, creating the
false impression of a fixed joint contracture.
- Most young children do not have fixed deformities.
- The hip and knee joints can be moved through a full range of motion
when the patient is prone or supine. However, the child will
demonstrate hip flexion and adduction, knee flexion or extension
and ankle equino varus or valgus in the erect position when Weight

This is dynamic deformity caused by spasticity, impaired motor

control and weakness of muscles.
Severe dynamic deformity caused by spasticity is difficult to
differentiate from contracture.
Stretch slowly, reassure the child and provide a relaxed and calm
atmosphere in which to assess muscle tone.

- Spinal deformity associated with CP might be postural or structural
and includes scoliosis, hyperkyphosis, and hyperlordosis.
Patients lacking sitting balance often exhibit a long postural
Lumbar hyperlordosis occurs in ambulatory patients with hip flexion
contractures, whereas lumbar kyphosis occurs in patients with
hamstring contractures.
Inspect the back for scoliosis and kyphosis with the patient
standing and in forward flexion.
- Examine the back of the non ambulatory child while he or she sits in
the wheelchair.
- Have the child bend forward as you check for any paramedial
elevations indicating lumbar spine involvement or rib elevations
showing thoracic spine involvement. Note sitting balance and pelvic
obliquity, if present. C
- ontracture and/or limb length discrepancy also contribute to spinal

- Pelvic obliquity is the abnormal inclination of the pelvis in the frontal
plane. It is commonly associated with scoliosis and hip instability in
the nonambulatory child.
- Check for sitting balance in the child with scoliosis and hip

- Measure actual lower limb lengths from the anterior superior iliac
spine to the medial malleolus.
- Measure from the trochanter to the knee joint line and from there to
the medial malleolus if knee flexion contracture is present.

Hip assessment
- Measure passive and active hip range of motion.
- Check for flexion and adduction contractures. Evaluate flexion
contracture with the Thomas test.

The THOMAS TEST is based on the fact that a hip flexion contracture is
compensated by an increase in lumbar lordosis. If the lumbar spine is fixed in
the neutral position, lordosis is prevented and hip f exion contracture
becomes apparent. The child lies supine on the examination table. Bring both
legs up to the chest to stabilize the lumbar spine and decrease the lordosis.
Flex the hip and feel that the pelvis is straight. Then, keep one leg in fl exion
while extending the other until resistance in hip extension is felt or movement
in the pelvis occurs. The extended leg should be fl at with the knee in full
extension. If knee fl exion contracture is present, extend the knee beyond the
table. The angle between the thigh and the examination table gives the
degree of the flexion contracture of the hip.

TEST FOR ADDUCTION CONTRACTURE Evaluate range of abduction with

the hips in flexion and in extension. If abduction is limited when the hips are
extended but better when they are flexed, the adduction contracture is
caused by gracilis and medial hamstring spasticity. If hip abduction is limited
in both extension and flexion, the cause is hip adductor spasticity.

THE ELY TEST shows rectus femoris tightness. The rectus femoris flexes the
hip and extends the knee, crossing both joints so that when the hip is in
extension, it is difficult to fl ex the knee if the rectus is tight. With the child
lying prone, stabilize one hip in extension and bring the lower leg quickly into
flexion [H]. If the buttock rises off the table, it is a sign of spastic or tight
quadriceps muscle. Use the Ely test to demonstrate rectus femoris spasticity
and hidden flexion contracture of the hip. Most children are unhappy in the
prone position so they will have increased muscle tone. Be careful not to
mistake increased tone from actual contracture. If the leg is brought into
flexion swiftly, the Ely test will demonstrate rectus femoris spasticity. Do the
test once more, slowly, in order to differentiate rectus femoris tightness from

TEST FOR HIP ROTATION Test in prone position with the knee in flexion.
Excessive internal rotation suggests persistent femoral Anteversion.


The patella position Evaluate the patella position with the child supine
and sitting. The patella slides up in children with severe quadriceps

Posterior capsule tightness Extend the leg. If it does not extend fully,
slowly force the knees and hips into full extension. Limitation indicates
posterior capsule tightness.

Popliteal angle Measure the popliteal angle to test for hamstring



Evaluate contractures and deformities of the ankle and subtalar joints and
toe deformities.

gastrocnemius muscle is shortened and the soleus is normal in most
children. Use the Silfverskild test to assess triceps surae tightness. 1. Lie
the patient in supine position. 2. Measure ankle dorsiflexion first with the
knee in flexion and then in extension. If the ankle dorsiflexion is greater
when the knee is flexed, the gastrocnemius is shortened and the soleus is
normal. If dorsiflexion is unchanged with the knee in flexion or extension,
then both gastrocnemius and soleus are contracted. Always hold the foot
in slight inversion while performing this test.

Test for tibial torsion Examine tibial torsion with the patient in the prone
position. Evaluate the thigh-foot angle with the knee flexed to 90 degrees.

Evaluation of posterior tibialis, anterior tibialis and peroneal

muscles A spastic posterior tibialis muscle causes hindfoot varus. A

spastic anterior tibialis muscle also causes varus and must be carefully
evaluated in mono- and hemiplegic patients. A spastic peroneus or
gastrocnemius muscle may cause a valgus deformity.

Foot deformities Pes valgus, pes varus and hallux valgus occur in
ambulatory children.

Functional Examination
1. Sitting
Evaluate sitting to decide whether the child needs support. Children with
adequate sitting balance are more functional.
2. Balance
Balance and equilibrium reactions are prerequisites for walking. Evaluate
balance in all children. Push the standing child gently from the front, back,
and side to see whether he or she can promptly regain balance. Assess
deficiency of balance and equilibrium using the Romberg sign, unilateral
standing balance test and the hop test.
o Romberg sign shows whether the child can maintain balance. If the child
sways and cannot keep his balance with feet held together and eyes
closed (positive Rombergs sign), then there is sensory ataxia. If the
Romberg sign is negative in the ataxic child, the ataxia is of cerebellar

Unilateral standing balance test Reveals inability to maintain balance

in less severely involved children. A 5 year old should be able to stand on
one foot for 10 seconds. Failure in the unilateral standing balance test
explains why children sometimes show excessive trunk leaning when

Hop test Boys can hop on one leg for five to 10 times from age 5 years
and girls from age 4 years onwards. Inability to perform single-leg hop is
another sign of poor balance and neuromuscular control.

3. Mobility
A crucial part of the examination is the observation of the childs walking
pattern. Video recordings of the childs movement also guide treatment.
Ask the family to obtain photographs or video recordings of their child to
understand how the child functions at home. Computerized gait analysis is
possible in advanced centers. The non ambulatory child is placed on the
floor to assess his mobility. The child may roll, creep, crawl or walk on all
Classification of Ambulation
Community Ambulators
are free to ambulate in the
community independently with or
without orthotics or assistive
Household Ambulators
Walks independently indoors using
braces and assistive devices. They
need a wheelchair for outdoor
Therapeutic Ambulators
Walk as part of a therapy session

for short distances with a helper.

They need a wheelchair at all other
Use the wheelchair for mobility.

Apgar Score


blue or pale
all over

Pulse rate

no response
to stimulation

blue at
body pink
e cry when

Muscle tone


no cyanosis
body and
cry or pull
away when
flexed arms
and legs that

some flexion



strong, lusty





Functional Scales
Different scales are used to assess the functional status of patients with CP [A].
Some are descriptive and compare the child with normal age-matched peers whereas a
few of them measure change over time that occurs with growth and treatment.
Functional tests identify babies and children who have delayed gross or fi ne motor
development and record the progress of those children under treatment. Quality of life
is measured with scales such as the Child Health Questionnaire and the Care and
Comfort Measure.
1. Gross Motor Function Measure (GMFM)
o The GMFM was developed to measure changes in gross motor function
over time in children with CP. It compares the child with normal children
of the same age. The GMFM is a reliable scale to evaluate gross motor
function. It measures the childs skill in lying, rolling, sitting, crawling,
kneeling, standing, walking, running, and jumping, but it does not
measure the quality of movement. It can be used for children from birth
to 5 years of age.
2. Gross Motor Function Classification System (GMFCS)
o The Gross Motor Function Classification System (GMFCS) was developed to
create a systematic way to describe the functional abilities and limitations
in motor function of children with CP. The emphasis is on sitting and
walking. The purpose is to classify a childs present gross motor function.
Five levels are used in the GMFCS from very mild to very severe. The

levels are based on the functional limitations, the need for assistive
technology and wheeled mobility. The quality of movement is not very
important. Because motor function depends on age, separate scales are
used for different age bands. Classifi cation at 2 years allows one to
predict prognosis at age 20 years.
The GMFCS is an important tool for physicians and therapists treating
children with CP. It is easy to use; classifying a child takes 5 - 15 minutes.
Physicians and therapists from various disciplines can easily use this scale
for their patients. Therefore, it provides a basic understanding of the level
of involvement of a child for all those involved in caring for the child. The
use of the GMFCS is becoming increasingly common in CP clinics as a
universal tool for communication with colleagues, determining the
prognosis and planning treatment.

Gross Motor Function Classification System for Cerebral Palsy (GMFCS)

Before 2nd birthday
Level 1
Infants move in and out of sitting and floor sit with both hands free to
manipulate objects. Infants crawl on hands and knees, pull to stand
and take steps holding on to furniture. Infants walk between 18
months and 2 years of age without the need for any assistive
mobility device.
Level 2
Infants maintain floor sitting but may need to use their hands for
support to maintain balance. Infants creep on their stomach or crawl
on hands and knees. Infants may pull to stand and take steps holding
on to furniture.
Level 3
Infants maintain floor sitting when the low back is supported. Infants
roll and creep forward on their stomachs.
Level 4
Infants have head control but trunk support is required for floor
sitting. Infants can roll to supine and may roll to prone.
Level 5
Physical impairments limit voluntary control of movement. Infants are
unable to maintain antigravity head and trunk postures in prone
and sitting. Infants require adult assistance to roll.
Between 2nd and 4th birthday
Level 1
Children floor sit with both hands free to manipulate objects.
Movements in and out of floor sitting and standing are performed
without adult assistance. Children walk as the preferred method of
mobility without the need for any assistive mobility device.
Level 2
Children floor sit but may have difficulty with balance when both
hands are free to manipulate objects. Movements in and out of sitting
are performed without adult assistance. Children pull to stand on a
stable surface. Children crawl on hands and knees with
a reciprocal pattern, cruise holding onto furniture and walk using an
assistive mobility device as preferred methods of mobility.
Level 3
Children maintain floor sitting often by W-sitting (sitting between
flexed and internally rotated hips and knees) and may require adult
assistance to assume sitting. Children creep on their stomach or
crawl on hands and knees (often without reciprocal leg movements)
as their primary methods of self mobility. Children may pull to stand
on a stable surface and cruise short distances.
Children may walk short distances indoors using an assistive mobility

Level 4

Level 5

device and adult assistance for steering and turning.

Children sit on a chair but need adaptive seating for trunk control
and to maximize hand function. Children move in and out of chair
sitting with assistance from an adult or a stable surface to push or
pull up on with their arms. Children may at best walk short distances
with a walker and adult supervision but have difficulty turning and
maintaining balance on uneven surfaces. Children are transported in
the community. Children may achieve self-mobility using a power
Physical impairments restrict voluntary control of movement and the
ability to maintain antigravity head and trunk postures. All areas of
motor function are limited. Functional limitations in sitting and
standing are not fully compensated for through the use of adaptive
equipment and assistive technology. At Level V, children have no
means of independent mobility and are transported.
Some children achieve self-mobility using a power wheelchair with
extensive adaptations.

Between 4th and 6th birthday

Level 1
Children get into and out of, and sit in, a chair without the need for
hand support. Children move from the floor and from chair sitting to
standing without the need for objects for support. Children walk
indoors and outdoors, and climb stairs. Emerging ability to run and
Level 2
Children sit in a chair with both hands free to manipulate objects.
Children move from the floor to standing and from chair sitting to
standing but often require a stable surface to push or pull up on with
their arms. Children walk without the need for any assistive mobility
device indoors and for short distances on level surfaces outdoors.
Children climb stairs holding onto a railing but are unable to run or
Level 3
Children sit on a regular chair but may require pelvic or trunk support
to maximize hand function. Children move in and out of chair sitting
using a stable surface to push on or pull up with their arms. Children
walk with an assistive mobility device on level surfaces and climb
stairs with assistance from an adult. Children frequently are
transported when travelling for long distances or outdoors on uneven
Level 4
Children sit on a chair but need adaptive seating for trunk control
and to maximize hand function. Children move in and out of chair
sitting with assistance from an adult or a stable surface to push or
pull up on with their arms. Children may at best walk short distances
with a walker and adult supervision but have difficulty turning and
maintaining balance on uneven surfaces. Children are transported in
the community. Children may achieve self-mobility using a power
Level 5
Physical impairments restrict voluntary control of movement and the
ability to maintain antigravity head and trunk postures. All areas of
motor function are limited. Functional limitations in sitting and
standing are not fully compensated for through the use of adaptive

equipment and assistive technology. At Level V, children have no

means of independent mobility and are transported.
Some children achieve self-mobility using a power wheelchair with
extensive adaptations.
Between 6th and 12th birthday
Level 1
Children walk indoors and outdoors, and climb stairs without
limitations. Children perform gross motor skills including running and
jumping but speed, balance, and coordination are reduced.
Level 2
Children walk indoors and outdoors, and climb stairs holding onto a
railing but experience limitations walking on uneven surfaces and
inclines, and walking in crowds or confined spaces. Children have at
best only minimal ability to perform gross motor skills such as
running and jumping.
Level 3
Children walk indoors or outdoors on a level surface with an assistive
mobility device. Children may climb stairs holding onto a railing.
Depending on upper limb function, children propel a wheelchair
manually or are transported when travelling for long distances or
outdoors on uneven terrain.
Level 4
Children may maintain levels of function achieved before age 6 or
rely more on wheeled mobility at home, school, and in the
community. Children may achieve self-mobility using a power
Level 5
Physical impairments restrict voluntary control of movement and the
ability to maintain antigravity head and trunk postures. All areas of
motor function are limited. Functional limitations in sitting and
standing are not fully compensated for through the use of adaptive
equipment and assistive technology. At level V, children have no
means of independent mobility and are transported. Some children
achieve self-mobility using a power wheelchair with extensive
Developmental Tests
These tests describe the development of the child in various functional stages.
- This test evaluates the developmental
deficits in infants and young children from
age 1 month to 6 years in the areas of global
motor function, language, fi ne-motor
adaptation and social contact.
- The Denver Developmental Screening Test
(DDST) II is administered to children between
birth and six years of age. It can screen
children who are apparently normal for
possible problems and monitor children who
have high risk because of past history such
as perinatal difficulties. It is not an IQ test nor
will it predict what the level of the childs
future intelligence and ability will be. Do not
use the Denver II for diagnosis. The Denver II
tests the child on twenty simple tasks and on







4 different domains. Personal social

measures the childs ability to get along with
people and to take care of him / her. Fine
Motor Adaptive test identifies the childs
ability to see and to use his hands to pick up
objects and to draw. Language tests
determine the childs ability to hear, follow
direction and to speak. Gross Motor identifies
the childs ability to sit, walk and jump.
This test evaluates cognition, language,
social behavior and motor functions in
children from 1 to 42 months old. The
purpose of the Bayley Scales of Infant
Development is to diagnose developmental
delay. The test takes approximately 45
minutes. The examiner gives a series of
stimuli to which the child responds. The
Mental Scales assess memory, learning,
communication skills. The Motor Scales
evaluate sitting and standing, gross motor
skills and fine motor skills. The Infant
Behavior Record (IBR) assesses the childs
social and emotional development through a
standardized description of his or her
behavior during the testing session. Scores
are measured against norms for each of the
14 different age groups. The Bayley scales
determine whether a child is developing
normally and provide for early diagnosis and
intervention in cases of developmental delay.
The QUEST is a measure designed to
evaluate movement patterns and hand
function in children with cerebral palsy.
Validation studies have been conducted with
children aged 18 months to 8 years. To
evaluate quality of upper extremity function
in four domains: dissociated movement,
grasp, protective extension, and weight
bearing. It evaluates quality of movement in
administered within a play context. Items are
related to quality of movement, not to
chronological age. There are 36 items
assessing dissociated movements, grasp,
protective extension, and weight bearing. 30
- 45 minutes. Validation studies have been
completed with children with cerebral palsy
The Canadian Occupational Performance







Measure (COPM) is a measurement tool that

assists therapists in using a family-centered
approach to service delivery by indicating the
familys priorities. It assists therapists in
using a client-centered approach to service
delivery by indicating the familys priorities.
It thus enables therapy to be individualized
and targeted to the areas of greatest need
and offers an effective system of measuring
the outcomes of therapy. This measure is
available from the Canadian Association of
Occupational Therapists (CAOT).
The PEDI is developed to measure functional
status and functional change in self care
activities, mobility activities and social
function. Self care consists of feeding,
grooming, dressing and toileting, mobility
consists of car, chair, tub and toilet transfers,
indoor, outdoor walking and stairs; social
function consists of comprehension, speech,
interactions with friends and in the
community. Capability is measured by the
identification of functional skills for which the
child has demonstrated mastery and
competence. Functional performance is
measured by the level of caregiver
assistance needed to accomplish major
functional activities such as eating or outdoor
locomotion. A modifications scale provides a
measure of environmental modifications and
equipment used by the child in routine daily
The WeeFIM is an adaptation of the
Functional Independence Measure for adults.
It was developed to measure the need for
assistance and the severity of disability in
children between the ages of 6 months and 7
years. It may be used with children above the
age of 7 years as long as their functional
abilities are below those expected of children
aged 7 who do not have disabilities. It
measures level of independence in self-care,
sphincter control, mobility, locomotion,
communication and social function.




Mechanism of Action
Binds to receptors
(GABA) in the spinal
cord to inhibit reflexes
that lead to increased
tone. Also binds to
receptors in the brain
leading to sedation.


Facilitates postsynaptic
binding of a
neurotransmitter (GABA)
in the brain stem,
reticular formation, and
spinal cord to inhibit
reflexes that lead to
increased tone.


Alpha2-agonist Acts in
both the brain and
spinal cord to enhance
presynaptic inhibition of
reflexes that lead to
increased tone.


Alpha2-agonist Acts in
both the brain and
spinal cord to enhance
presynaptic inhibition of
reflexes that lead to
increased tone.
Works directly on the
muscle to decrease
muscle force produced
during contraction Little
effect on smooth and
cardiac muscles

Dantrolene sodium

Side Effects and Precautions

Sedation, confusion, nausea,
dizziness, muscle weakness,
hypotonia, ataxia, and
paresthesias Can cause loss
of seizure control. Withdrawal
can produce seizures,
rebound hypertonia, fever,
and death.
Central nervous system
depression causing sedation,
decreased motor
coordination, impaired
attention and memory both
overdoses and withdrawal
occur. The sedative effect
generally limits use to
severely affected children
Bradycardia, hypotension, dry
mouth, drowsiness, dizziness,
constipation, and depression
These side effects are
common and cause half of
patients to discontinue the
Dry mouth, sedation,
dizziness, visual
hallucinations, elevated liver
enzymes, insomnia, and
muscle weakness
Most important side effect is
hepatotoxicity (2%), which
may be severe Liver function
tests must be monitored
monthly initially, and then
several times per year. Other
side effects are mild sedation,
dizziness, diarrhea, and


Feeding, Growth, and Nutrition

Dysphagia is commonly observed in patients with CP. Impaired
oropharyngeal strength and coordination place a child at risk for not
meeting caloric and fluid requirements because of feeding inefficiency.
Serious medical complications such as malnutrition and an increased risk
of aspiration events may occur as well. Caregivers may share that this
aspect of the childs care is burdensome, with stress increasing when the
child needs considerable time to eat and activities revolve around feeding
schedules. Frequently, children will struggle to gain weight only to lose it
quickly during an illness. Indications for swallow studies include impaired

oropharyngeal skills with a wet vocal quality or increased congestion

during feeding. It is important to remember that some individuals have
silent aspiration and may not generate a protective cough; therefore,
workup for aspiration events should include a formal swallow study. Early
on, children should receive nutritional counseling and supplemental caloric
and fluid intake if necessary. Some parents may resist placement of
gastrostomy tubes, especially if the child swallows safely, even though
feedings may require increased time and aggressive positioning strategies.
Oral hygiene may be compromised and children may have excessive
sialorrhea, which can contribute to aspiration events and cause secondary
skin irritation. Growth and nutrition may be compromised because of
limited intake of key nutrients, impaired absorption, and endocrine
abnormalities. When malnourished, children are at risk for growth
disturbances, increased infection rates, skin breakdown, osteopenia, and
ultimately decreased life expectancy.

Lung disease is an important cause of morbidity and mortality in
CP. Cumulative injury to lung architecture may occur as a result of
repeated aspiration events, infections, decreased mucociliary clearance,
kyphoscoliosis, and airway obstruction. Prevention of pulmonary aspiration
may require modified feeding consistencies, treatment of reflux,
alternative means of feeding such as gastrostomy with or without
fundoplication, and control of sialorrhea with anticholinergic medications,
botulinum injections, and sometimes surgery. Chest physiotherapy and
bronchodilators can assist with decreased mucociliary clearance. Children
with infections should be treated with tailored antibiotics based on sputum
cultures, and some will require prophylactic or cyclical antibiotic coverage.
Preventative measures include immunizations since this population is at
higher risk for infections and complications. Upper airway obstruction may
require continuous positive airway pressure and/or surgery. Lower airway
obstruction may respond to a trial of bronchodilators and pressure.
Children with CP frequently have sleep-disordered breathing. A history of
snoring or observed irregular breathing patterns with or without excessive
daytime somnolence should prompt the practitioner to investigate possible
sleep apnea, which if untreated can contribute to further morbidity. Apnea
may be central, peripheral, or a combination of both.

Neurologic Issues
The CP population as a whole is at an increased risk for seizures.
Seizures occur most frequently in children with a quadriparetic or
hemiparetic clinical presentation. Medication use for epilepsy management
may be associated with cognitive dulling or other side effects such as
anorexia. Some children have hyperkinetic movement disorders that
mimic seizure activity and may require prolonged video EEG monitoring to
delineate between the two conditions. Weaning of seizure medications
depends on the severity of the seizures and a time period, usually 2 years,
during which the child has been seizure free.

Voiding dysfunction may result from impaired processing of sensory
feedback and also incoordination of muscular functions responsible for
bladder wall contractions and sphincter relaxation: detrusor sphincter
dyssynergia. Full continence and normal voiding patterns may be difficult
to achieve, and children with CP are frequently delayed in age for

achieving continence. Urinary retention can increase chances of urinary

tract infections and if a high intravesical pressure is generated,
vesicoureteral reflux with resultant hydronephrosis and pelviectasis may
occur. Clean intermittent catheterization is required when children are
experiencing chronic urinary retention with urinary stasis. Anticholinergic
treatments for dystonia or sialorrhea may trigger urinary retention.
Children treated with levetiracetam for epilepsy have an increased risk of
renal calculi formation.

Gastroesophageal reflux disease (GERD) and constipation, which
are commonly observed in CP, may produce discomfort and exacerbate
hypertonicity. In more severe cases, children may have dysmotility with
delayed gastric empting and esophagitis from medically refractory GERD.

Musculoskeletal Pain and Osteopenia

Children who are less mobile are at increased risk for contracture
and bony deformity and associated musculoskeletal pain. Although
exercise has been established as beneficial in CP, children at GMFCS levels
IV or V will not be able to achieve the same benefits as those children who
are more mobile. Common sites of musculoskeletal pain include the hips,
spine, knee, and foot and ankle complex.


Muscle - tendon surgery

Muscle-tendon lengthening is the most commonly used method. It
weakens spastic and shortened muscles, thereby balancing the forces
acting on the joint. Split tibialis anterior and posterior tendon transfers of
the foot help balance the deforming forces. Simple tenotomies may be
performed in selected muscles.

Corrects varus and valgus deformities of the foot and flexion
deformities in the lower extremity. Hip osteotomy stabilizes the subluxated
or dislocated hip. Rotational osteotomies correct the torsional deformities
in the tibia or the femur. Arthrodesis corrects deformity and stabilizes the

Spinal fusion and instrumentation

Corrects spinal deformity

The surgical removal of a nerve segment.


Ankle foot orthosis (AFO) most commonly used

Solid AFO The solid or rigid AFO allows no ankle motion, covers the
back of the leg completely and extends from just below the fibular
head to metatarsal heads. Raise the sides for better varus-valgus
control. The solid AFO enables heel strike in the stance phase and

toe clearance in the swing phase. It can improve knee stability in

ambulatory children. It also provides control of varus/valgus

Posterior leaf spring AFO A PLSO is a rigid AFO trimmed

aggressively posterolaterally and posteromedially at the
supramalleolar area. This provides flexibility at the ankle and
allows passive ankle dorsiflexion during the stance phase


GRAFO or FRO (Ground reaction or floor reaction AFO)

Anti-recurvatum AFO This special AFO is molded in slight
dorsiflexion or has the heel built up slightly to push the tibia
forward to prevent hyperextension during stance phase.
Consider prescribing this AFO for the treatment of genu
recurvatum in hemiplegic or diplegic children.

Hinged AFO - Hinged AFOs have a mechanical ankle joint

preventing plantar flexion, but allowing relatively full dorsiflexion
during the stance phase of gait [B,C]. They pr ovide a more normal
gait because they permit dorsiflexion in stance, thus making it
easier to walk on uneven surfaces and stairs. This is the best AFO
for most ambulatory patients. Adjust the plantar flexion stop in 3-7
dorsiflexion to control knee hyperextension in stance in children
with genu recurvatum

Knee-ankle- foot orthosis (KAFO)

Hip-knee-ankle-foot orthosis
Balance forearm orthosis
Hip abduction orthoses
Thoracolumbosacral orthoses: TLSO
Supramalleolar orthoses: SMO
Foot orthoses: FOs
Hand splints


A wheelchair is a mobility as well as a seating device (positioning
device) in children with severe motor dysfunction, poor sitting balance and no
functional ambulation

- Walkers provide the greatest support during gait but they pose certain
difficulties during stair climbing, among crowds and within narrow corridors

Canes, crutches and gait poles

Gait poles or sticks provide sensory input for gait and facilitate a normal
gait pattern, but sometimes are not cosmetically acceptable to patients.


Stretching is a component of therapy programs; its goal is to
reduce the risk of contracture development as a result of muscle

imbalances and hypertonicity. Sustained stretching can be achieved

through the use of positioning devices, orthoses, and serial casting. A
systematic review examining the effects of casting, either alone or in
combination with botulinum toxin type A (BTX-A), on equinus in children
with CP revealed no strong and consistent evidence that combining
casting and BTX-A is superior to using either intervention alone

Historically, exercise programs that included strengthening were
contraindicated in CP. A systematic review of the effectiveness of
strengthtraining programs in CP reported increased strength without any
negative effects of increased spasticity or reduced range of motion.
Indirectly, some studies have reported increased participation and
improved self-esteem
Aerobic Exercise
Historically, exercise programs that included aerobic exercise were
contraindicated in CP. A systematic review of the evidence suggests
improved physiologic measures of aerobic fitness without adverse effects,
for example, increased spasticity, fatigue, or musculoskeletal trauma.
Improvements in aerobic fitness were noted with 45 minutes four times a
week of high-intensity activities such as wheelchair sports, swimming,
matt exercises, or cycling. This benefit is not maintained if the activity is
not maintained. None of the studies have looked into reporting outcomes
representing the ICF model of increased activity and participation.

Constraint-Induced Movement Therapy (CIMT):

CIMT is a treatment for hemiparesis to improve motor function in
the affected upper limb. In children with hemiplegic CP, the unaffected
limb is restrained with a removable cast, typically for 3 weeks, and the
child undergoes intensive, structured therapy in addition to daily activities
and play. A systematic review of randomized controlled trials involving
CIMT noted a medium beneficial effect in arm function, as well as a
medium effect size in the activity level in the ICF-CY model. The review
further suggests that home CIMT had better improvement than clinic- or
camp-based settings.

Functional Electrical Stimulation:

Neuromuscular electrical stimulation (NMS) is the application of an
electrical current of sufficient intensity to elicit muscle contraction. When
applied during a functional activity, it is referred to as functional electrical
stimulation (FES). In contrast, threshold electrical stimulation (TES) is a
low-intensity, subthreshold electrical stimulus that has been theorized to
increase blood flow and stimulate muscle growth when applied during
sleep to take advantage of heightened trophic hormone secretion.
Evidence to support use of these modalities in children with CP is limited;
however, there is more evidence to support NMS and FES than TES.

Robotic and Partial Body Weight Support Treadmill Training

These forms of therapy involve a repetitive and task-specific
approach to facilitate attainment of stepping and locomotion and to
achieve a more normalized gait pattern based on current theories of motor
learning. The setting includes an overhead harness system used to
support the childs body weight on a treadmill, while the therapist or a

robot facilitate the kinematic, kinetic, and temporal features of walking.

Although evidence of potential benefits from PBWSTT and robotic therapy
is emerging in adults with stroke and spinal cord injury, several recent
systematic reviews showed limited evidence to support the use of PBWSTT
in children with CP. Despite reported improvements in gross motor
function, functional status, walking performance, and gait parameters,
statistical significance was not reached in most of the studies

Play Therapy
Begin therapy toward one year of age when the child can feed
himself using a spoon and play with toys. Teach the child age-appropriate
self-care activities such as dressing, bathing and brushing teeth.
Encourage the child to help with part of these activities even if he is
unable to perform them independently. Always include play activities in
the rehabilitation program. Play improves mental capacity and provides
psychological satisfaction. Organized play can address specific gross and
fine motor problems in the child and take the place of boring exercise
protocols. This increases the childs compliance with therapy. For example,
riding a toy horse may improve weight shift over the pelvis, swinging may
improve sensation of movement.

Bobath Technique (Neurodevelopmental Treatment Approach)

This is the most commonly used therapy method in CP worldwide. It
aims to
normalize muscle tone, inhibit abnormal primitive reflexes
and stimulate normal movement.
It uses the idea of reflex inhibitory
positions to decrease spasticity and stimulation of key
points of control to
promote the development of advanced postural reactions. It is believed
that through positioning and stimulation, a sense of normal movement will
develop. An
important part of therapy of the infant is teaching the
mother how to position the child at
home during feeding and other activities.
The baby is held in the antispastic position to

Rood Technique (Sensory Motor Treatment approach)

This approach uses the same hierarchical understanding of
approximately the same time period, as the NDT
sensory motor technique depends heavily on tactile stimulation to facilitate
movement. The overall goal of sensory motor therapy is to activate the
movements at an
autonomic level similar to how postural responses in
normal individuals are activated. This
activation requires superimposing
mobility as produced by basic muscle responses onto
stability, which
is produced by tonic muscle responses. Sensory motor technique uses a
series of eight clearly defined developmentalpatterns, which children are to learn
sequence. These patterns are supine withdrawal, rolling over, pivot
prone, neck cocontraction, elbow weight bearing, all four weight
bearing, standing, and walking.

Ayers Technique (Sensory Integration Treatment approach)

The basic goal of this therapy technique is to teach children how to
integrate their
sensory feedback and then produce useful and purposeful
motor responses. The sensory
integration approach tries to have these
children access and integrate all their sensory input
to use for functional
gain. Activities such as catching a ball in different positions may be used

a way of stimulating and requiring integration of visual, vestibular, and joint

proprioception feedback systems at the same time

Vojta method of therapy

Vojta established 18 points in the body for stimulation and used the
positions of reflex crawling and reflex rolling. He proposed that placing the
child in these positions and stimulation of the key points in the body would
enhance CNS development. In this way the child is presumed to learn
normal movement patterns in place of abnormal motion. Positioning and
stimulation techniques are different from NDT. Vojta states that therapy
should be applied by the primary caregiver at home at least 4-5 times
daily and stopped after a year if there is no improvement

Conductive Education: Peto Technique

The treatment was based on educational principles in which motor
skills that children could just barely perform were identified, then they
were assisted over and over again until the skill was learned. This
approach is the same as is typically used to teach the multiplication
tables. Conductive education also includes a great emphasis on instilling a
sense of self-worth and a sense of accomplishment in the children. The
motor skills were performed with a series of simple ladder-type devices
that can be used to assist standing, stepping, walking, and even sitting
activities. This approach is only applicable to individuals with some useful
motor function, but not such a high level of function that they are
essentially independent ambulators.