Spastic cerebral palsy

Definition of Cerebral palsy (CP):

• Cerebral palsy is a chronic disability of central nervous system origin characterized by abnormal control of the movement of posture, appearing early in life and not the result of progressive neurological disease.

• TOPOGRAPHIC CLASSIFICATION OF CEREBRAL PALSY:
• MONOPLEGIA: Paralysis of 1 limb involvement.
• HEMIPLEGIA: Upper Motor Neuron Lesion (UMNL) of one side of body involvement.
• DIPLEGIA: Upper Motor Neuron Lesion (UMNL) of all four limbs involvement but legs more involved than arms. Maybe symmetric or asymmetric.
• QUADRIPLEGIA(TETRAPLEGIA): Total loss of all 4 limbs and torso.
• DOUBLE HEMIPLEGIA: Bilateral Upper Motor Neuron Lesion (UMNL). Arms & legs are involved. Pseudobulbar palsy also.
• TRIPLEGIA: Paralysis of 3 limbs, both extremities on one side and one on the other. Paralysis of an upper & a lower extremity & of the toes.

PHYSIOLOGICAL CLASSIFICATION OF CEREBRAL PALSY:

• Many motor function names describe Cerebral Palsy’s effect on muscle tone and how muscles work together.
• When muscle tone is damaged, muscles do not work together and can even work in opposition to one another.
• Two names used to describe muscle tone are:

1. Hypertonia/Hypertonic: Increased muscle tone, frequently resulting in very stiff limbs. Hypertonia is related to spastic Cerebral Palsy.
2. Hypotonia/Hypotonic: Decreased muscle tone, frequently resulting in loose, floppy limbs. Hypotonia is related to non-spastic Cerebral Palsy.

Two classifications by motor function:

• pyramidal (spastic) and extrapyramidal (non-spastic)

What is pyramidal or spastic cerebral palsy?

• Spastic cerebral palsy is the appearing frequently type of cerebral palsy.
• The muscles of people with spastic cerebral palsy feel stiff and their movements may look stiff and jerky.
• Spasticity is a structure of hypertonia or increased muscle tone.
• This results in stiff muscles which can create movement difficult or even impossible.
• Muscles are seen stiffly because the messages to the muscles are sent incorrectly through the injured part of the brain.
• When a muscle is affected by spasticity, the faster the limb is moved, the stiffer it looks.
• Spasticity appears as a result of injury to bundles of neurons in the brain and spinal cord called the corticospinal tracts and corticobulbar tracts.
• Spasticity is looked at in a number of different conditions including cerebral palsy, traumatic brain injury, spinal cord injury, stroke, and multiple sclerosis.
• People may have difficulty moving from one position to another and controlling individual muscles or muscle groups needed for performing certain tasks admire as handling objects or speaking.

What are the types of spastic Cerebral palsy?

• There are 4 main types of cerebral palsy, and each Cerebral palsy diagnosis can be further broken down to more accurately describe one’s brain damage and related symptoms.
• The different types of spastic cerebral palsy are classified based on the location of movement issues.
• For example, children with spastic Cerebral palsy may have muscle stiffness in one arm, both legs, or one full side of their body.

Spastic Diplegia

• Spastic diplegia impacts two limbs, which most commonly are the legs.
• Children with diplegia may have little movement issues in the upper body as well.
• Diplegia is commonly an outcome of premature birth that results in cerebral palsy.

Spastic Hemiplegia

• Spastic Hemiplegia affects 1 whole side of the body.
• The arm is commonly more affected than the leg and is distinguished by a rigidly flexed wrist or elbow.
• Prenatal brain bleeding can lead to hemiplegia.

Spastic Quadriplegia

• Spastic Quadriplegia happens when all four limbs are affected.
• The legs are commonly impacted more than the arms.
• Quadriplegia may cause limited jurisdiction over facial muscles.

EXTRAPYRAMIDAL OR NON-SPASTIC CEREBRAL PALSY:

• Non-spastic Cerebral Palsy is divided into 2 groups, ataxic & dyskinetic.
• Together they build up 20% of Cerebral Palsy cases. Broken down, dyskinetic build up 15% of all Cerebral Palsy cases, and ataxic comprises 5%.

Ataxic/ataxia:

• Ataxic Cerebral Palsy affects coordinated movements. Balance and posture are involved. A walking gait is frequently very wide and sometimes irregular.
• Control of eye movements and depth of perception can be impaired. Sometimes, fine motor skills requiring coordination of the eyes and hands, like writing, are difficult.
• Does not create involuntary movements, yet instead indicates impaired balance and coordination.

Dyskinetic:

• Dyskinetic Cerebral Palsy is subdivided further into two different groups; athetoid and dystonic.

Athetoid:

• Athetoid Cerebral Palsy includes cases with an involuntary movement, especially in the arms, legs, and hands.

Dystonia/Dystonic:

• Dystonic/Dystonia Cerebral Palsy encompasses cases that affect the trunk muscles more than the limbs and result in fixed, twisted posture.
• Because non-spastic Cerebral Palsy is predominantly associated with involuntary movements, some may classify Cerebral Palsy by the specific movement dysfunction, like as:

Athetosis:

• Slow, writhing movements that are sometimes repetitive, sinuous, and rhythmic

Chorea:

• Irregular movements that are not repetitive/rhythmic, & tend to be more jerky and shaky.

Choreoathetoid:

• A combination of chorea & athetosis; movements are irregular yet twisting and curving.

Dystonia:

• Involuntary movements are accompanied by an abnormal, sustained posture.

Mixed:

• A child’s impairments can fall into both categories, spastic & non-spastic, referred to as mixed Cerebral Palsy.
• The most common form of mixed Cerebral Palsy involves some limbs affected by spasticity & others by athetosis.

Gross motor function classification scale(GMFCS):

• The Gross motor function classification scale is a universal classification system applicable to all forms of Cerebral Palsy.
• Using the Gross motor function classification scale assists to determine the surgeries, treatments, therapies, and assistive technology likely to result in the best outcome for a child.
• Additionally, the Gross motor function classification scale is a powerful system for researchers; it improves data collection and analysis and consequently results in better understanding and treatment of Cerebral palsy.

Gross motor function classification scale (GMFCS) classification levels:

• GMFCS Level I – walks without limitations.
• GMFCS Level II – walks with limitations.
• Limitations include walking long distances and balancing, yet not as able as Level I to run or jump; may require the use of mobile devices when first learning to walk, usually prior to age four; and may rely on wheeled mobility equipment when outside of the home for traveling long distances.
• GMFCS Level III – walks with adaptive equipment assistance.
• Requires hand-held mobility assistance to walk indoors, while utilizing wheeled mobility outdoors, in the community, and at school; can sit on own or with limited external support, and has certain independence in standing transfers.
• GMFCS Level IV – self-mobility with use of powered mobility assistance.
• Generally supported when sitting; self-mobility is limited and likely to be transported in a manual wheelchair or powered mobility.
• GMFCS Level V – severe head and trunk control limitations.
• Need extensive use of assisted technology and physical assistance; and transported in a manual wheelchair, unless self-mobility can be achieved by learning to operate a powered wheelchair.

What are the signs and symptoms?

• The signs and symptoms of spastic cerebral palsy are different for individual children.
• Differences in symptoms depend on the exactingness of the child’s brain injury and any co-occurring disorders that may be present.
• In widespread, the most common symptoms of spastic Cerebral palsy are:

1. Rigid, tight muscles on one or both sides of the body
2. Exaggerated movements
3. Limited mobility
4. Abnormal gait
5. Crossed knees
6. Joints do not full extend
7. Walking on tiptoes
8. Contractures
9. Abnormal reflexes

• Co-occurring issues may also present themselves, seem as hearing and vision impairment, yet these are not directly related to cerebral palsy, they are caused by the initial birth injury.
• In the first years of a child’s life, it can be very hard to acknowledge the signs of cerebral palsy.
• This is because symptoms typically do not present themselves to a child who begins missing developmental milestones.
• During toddlerhood, many children tend to exhibit some of the equal jerky reflexes associated with spastic Cerebral palsy.
• It can take up to 5 years of age before a whole cerebral palsy diagnosis is reached.

What are the causes of Cerebral palsy?

• Cerebral palsy is the idea to be caused by a brain injury or problem.
• In spastic (SPASS-tik) Cerebral palsy, the injury or problem is in an area of the brain called the motor cortex.
• The motor cortex plans & controls movement.
• A child might be born with Cerebral palsy or develop it later.
• The brain injury or problem does not get worse, but someone with Cerebral palsy may have different needs over time.

• Cerebral palsy can be caused by:

• infections or other medical problems during the woman’s pregnancy
• having a stroke while in the uterus or after birth
• untreated jaundice (like yellowing of the skin and whites of eyes)
• genetic disorder
• a problem during birth
• being shaken as a baby
• injury in early childhood (like from a car accident)
• Premature babies (babies born early) are at higher risk for Cerebral palsy than babies born full-term.
• So are low-birth-weight babies (even if carried to term) and multiple births, like twins and triplets.

Damage to the motor cortex

• The motor cortex is situated in the cerebral cortex, which is the largest part of the brain.
• The motor cortex is collected of several parts that are responsible for relaying signals to other parts of the brain to control movement.
• A predominant aspect of the motor cortex in relation to cerebral palsy is its regulation of voluntary movement.
• Damage to this region of the brain makes voluntary movement harder to control and low fluid, or “spastic”.

Damage to the pyramidal tracts

• The pyramidal tracts in the brain are the roads of communication between the cerebral cortex & the nerves in the spinal cord.
• If pyramidal tracts are damaged, the motor cortex can not send proper signals to the spinal cord.
• The spinal cord is one half of the central nervous system, with the other half being the brain & brain stem.
• These parts of the brain are essential for sensory functions like sight, touch, and movement.

The motor cortex & pyramidal tracts may be damaged by:

• Prenatal brain hemorrhage or infection,
• Lack of oxygen to the brain during birth,
• Brain trauma or infection after birth.

• Several risk factors may increase the probability of a developmental brain injury occurring.
• Poor maternal health and less birth weight are just some of the risk factors for any type of cerebral palsy.

Is my child at risk for Spastic cerebral palsy?

While it is not possible to predict if a child will develop cerebral palsy, some factors increase the risk:

1. Low birth weight,
2. Pre-term birth,
3. Complications during labor and delivery,
4. Infertility treatment,
5. Maternal infections,
6. Chemical exposure,
7. Mismatched Rh blood factor between baby and mother,
8. Jaundice in the baby,
9. Multiple gestations (twins or triplets).

• Mothers cannot manage all the risk factors.
• You can decrease the risk your child will develop spastic cerebral palsy by staying healthy during pregnancy and keeping up with doctor’s appointments.

DIAGNOSTIC STUDY:

• Physical Assessment.
• Observe LBW, preterm, and those with low Apgar scores at five minutes.
• Observe babies who have seizures, intracranial hemorrhage, and metabolic disturbances.
• Later control of movement does not occur until late infancy, diagnosis may not be confirmed until after six months of age.

Warning signs:

• Physical Signs:
• poor head control after three months,
• stiff or rigid arms or legs, arching back, floppy or limp posture,
• Can’t sit up without support for eight months,
• Uses only one side of the body/only the arms to crawl.

• Behavioral Signs:
• Utmost irritability or crying,
• Failure to smile by three months,
• Feeding difficulties,
• Persistent gagging/choking when fed,
• After six months of age, the tongue pushes soft food outside the mouth.

How is spastic Cerebral palsy diagnosed?

• Most children with spastic cerebral palsy are diagnosed in the first two years of life.
• Health care providers look for signs of Cerebral palsy if a baby is born early or has another health problem that is associated with Cerebral palsy.
• No single test can diagnose spastic Cerebral palsy.
• So health care professionals see at many things, including a child’s:

1. development,
2. growth,
3. reflexes,
4. movement.

Testing may include:

1. brain MRI, CT scan, or ultrasound,
2. blood and urine tests to check for other medical conditions, including genetic conditions,
3. electroencephalography (EEG) too seems at electrical activity in the brain,
4. electromyography (EMG) to check for muscle weakness,
5. evaluation of how a child walks & moves,
6. speech, hearing, and vision testing.

• Our age-specific overviews can give you a sense of how your child might develop from birth to age five.

Development

Your Child’s Development: Newborn

• From the moment babies are born, they respond to the world around them.
• Their reactions — being calmed by a parent’s hug or startled by a loud sound — are examples of normal infant development.
• Doctors use milestones to talk if a baby is developing as expected.
• There is a broad range of what is considered normal, so some babies may gain skills earlier or later than others.
• Babies who were born prematurely may extend milestones later.
• Always talk with your doctor about your baby’s progress.

Here is what your newborn might do:

1. Communication and Language Skills

• turns his or her head side of the parent’s voice or other sounds
• cries to communicate a need (to be held/fed, to have a diaper changed, or need to sleep)
• stops crying when a need is met (when picked up, fed, changed, and put down for a nap)

2. Movement and Physical Development

• moves in response to sights & sounds
• rooting reflex: turns the side of the breast or bottle and sucks when a nipple is placed in the mouth
• Moro reflex (startle response): when startled, stretches arms & legs out, then curls them back in
• fencer’s pose (tonic neck reflex): when the head is turned to one side, straightening the arm on that side while bending the opposite arm
• grasp reflex: holds a finger placed in the palm and toes curl when touched on the sole of the foot

3. Social and Emotional Development

• soothed by a parent’s voice & touch
• has periods of the alertness

4. Cognitive Skills (Thinking & Learning)

• looks at faces when quiet & alert
• follows the faces

When Should I Call the Doctor?

• Every child develops at their admit pace.
• But if something concerns you, tell your doctor.

Additionally, tell the doctor if your baby:

• does not suck well at the breast or on a bottle nipple
• has an arm or leg that looks weaker than the other
• is very fussy/hard to soothe.

Your Child’s Development: 3-5 Days

• Though only a few days old, your baby already is able to interact in certain ways.
• When alert, your baby will probably focus on your face.
• Babies are especially drawn to the higher-pitched voices, so give in to that urge to use “baby talk.”
• You are introducing your baby to language & your baby will enjoy it.
• Doctors use milestones to talk if a baby is developing as expected.
• There is a broad range of what is considered normal, so some babies may gain skills earlier or later than others.
• Babies who were born prematurely may extend milestones later.
• Always talk with your doctor about your baby’s progress.

Here is what your newborn might do:

1. Communication and Language Skills

• turns his or her head side of the parent’s voice or other sounds
• cries to communicate a need (to be held/fed, to have a diaper changed, or need to sleep)
• stops crying when a need is met (when picked up, fed, changed, and put down for a nap)

2. Movement and Physical Development

• moves in response to sights & sounds
• rooting reflex: turns the side of the breast or bottle and sucks when a nipple is placed in the mouth
• Moro reflex (startle response): when startled, stretches arms & legs out, then curls them back in
• fencer’s pose (tonic neck reflex): when the head is turned to one side, straightening the arm on that side while bending the opposite arm
• grasp reflex: holds a finger placed in the palm and toes curl when touched on the sole of the foot

3. Social and Emotional Development

• soothed by a parent’s voice & touch
• has periods of the alertness

4. Cognitive Skills (Thinking & Learning)

• looks at faces when quiet & alert
• follows the faces

When Should I Call the Doctor?

• Every child develops at their admit pace.
• But if something concerns you, tell your doctor.

Additionally, tell the doctor if your baby:

• does not suck well at the breast or on a bottle nipple
• has an arm or leg that looks weaker than the other
• is very fussy/hard to soothe.

Your Child’s Development: 1 Month

• Have you noticed how your baby’s tiny fingers curl around yours/close into fists?
• how does your small one startle at a loud noise?
• Your baby was born with these and other reflexes, which will get less noticeable as your baby grows.
• Doctors use milestones to talk if a baby is developing as expected.
• There is a broad range of what is considered normal so some babies may gain skills earlier or later than others.
• Babies who were born prematurely may extend milestones later.
• Always talk with your doctor about your baby’s progress.

Here are certain new skills your baby may have:

1. Communication and Language Skills

• startles at loud noises,
• makes sounds other than crying.

2. Movement and Physical Development

• keeps hands in tight fists,
• arms and legs move similarly on both sides,
• when lying on the tummy, holds head up shortly.

3. Social and Emotional Development

• recognizes parent’s voice,
• when upset, responds to a parent’s cuddles, voice & affections,
• becomes alert when hearing an affable sound, like music.

4. Cognitive Skills (Thinking and Learning)

• will stare at an object placed in front of the face, specifically something brightly colored,
• follows faces.

When should I call the doctor?

• As your baby becomes more alert, they will watch you constantly.
• And you will be watching your little one closely too.
• So this is an excellent time to watch for any subtle signs that could point to a problem.

Tell the doctor if your baby:

• has one eye that is crossed or eyes that do not line up in the same direction,
• does not respond to pleasing sounds, like as a soft voice or gentle music,
• has legs/hands that do not move in unison: for example, only one leg kicks or just one arm shakes.

Your child’s development: 2 months

• Doctors use milestones to talk if a baby is developing as expected.
• There is a broad range of what is considered normal, so some babies may gain skills earlier or later than others.
• Babies who were born prematurely may extend milestones later.
• Always talk with your doctor about your baby’s progress.

Here are things babies commonly do by this age:

1. Communication and Language Skills

• produce sounds other than the crying,
• react to the noisy noises.

2. Movement and Physical Development

• when on their belly, clasp up their head,
• move both arms & both legs,
• open their hands shortly.

3. Social and Emotional Development

• calm down when spoken to and picked up,
• look like your face,
• look happy to see you,
• smile when you talk or smile.

4. Cognitive Skills (Thinking and Learning)

• watch you as you move,
• seems at a toy for several seconds.

When should I call the doctor?

• You know your baby best.
• Share your cares — even little ones — with your baby’s doctor.
• If your baby is not meeting one or more milestones or you notice that your baby has skills yet has lost them, tell the doctor.

Your child’s development: 4 months

• Doctors use milestones to talk if a baby is developing as expected.
• There is a broad range of what is considered normal, so some babies may gain skills earlier or later than others.
• Babies who were born prematurely may extend milestones later.
• Always talk with your doctor about your baby’s progress.

Here are things babies commonly do by this age:

1. Communication and Language Skills

• create sounds like ooh and aah (cooing),
• turn their head toward your voice,
• create sounds in response to being spoken to.

2. Movement and Physical Development

• use their arms to swing at the toys,
• bring their hands to the mouth,
• grasp a toy when you put it in their hand,
• grasp their head steady without support when being held,
• push up on elbows or forearms when on their stomach.

3. Social and Emotional Development

• smile to get your attention,
• chuckle (not a full laugh) when you attempt to make them laugh,
• look at you, move or make the sounds to get or keep your attention.

4. Cognitive Skills (Thinking and Learning)

• look at their hands with interest,
• when hungry, open their mouth if a breast or bottle approaches.

When should I call the doctor?

• You know your baby best.
• Share your cares — even little ones — with your baby’s doctor.
• If your baby is not meeting one or more milestones or you notice that your baby has skills yet has lost them, tell the doctor.

Your child’s development: 6 months

• Doctors use milestones to talk if a baby is developing as expected.
• There is a broad range of what is considered normal, so some babies may gain skills earlier or later than others.
• Babies who were born prematurely may extend milestones later.
• Always talk with your doctor about your baby’s progress.

Here are things babies commonly do by this age:

1. Communication and Language Skills

• acquire turns making sounds with you,
• blow the raspberries,
• create squealing noises.

2. Movement and Physical Development

• roll from stomach to back,
• push up with straight arms when on their stomach,
• lean on their hand to sit with the support.

3. Social and Emotional Development

• know familiar people,
• enjoy watching in a mirror,
• chuckle.

4. Cognitive Skills (Thinking and Learning)

• put things in their mouth to explore,
• reach to the grab a toy,
• close their lips to show they do not want more food.

When should I call the doctor?

• You know your baby best.
• Share your cares — even little ones — with your baby’s doctor.
• If your baby is not meeting one or more milestones or you notice that your baby has skills yet has lost them, tell the doctor.

Your child’s development: 9 months

• Doctors use milestones to talk if a baby is developing as expected.
• There is a broad range of what is considered normal, so some babies may gain skills earlier or later than others.
• Babies who were born prematurely may extend milestones later.
• Always talk with your doctor about your baby’s progress.

Here are things babies commonly do by this age:

1. Communication and Language Skills

• create different sounds like “ba-ba-ba” or “ma-ma-ma”,
• raise their arms to be picked up,
• Movement & Physical Development,
• acquire into a sitting position without any help,
• sit without any support,
• use their fingers to “rake” food toward them,
• pass things from one hand to the others.

2. Social and Emotional Development

• are shy, clingy, or fearful of strangers,
• see, reach for or cry when caregivers leave,
• see when you call their name,
• show several facial expressions, like as happy, sad, angry, and surprised,
• smile/laugh when you play peek-a-boo.

3. Cognitive Skills (Thinking and Learning)

• look for objects when dropped out of sight,
• bang two things together, like blocks.

When should I call the doctor?

• You know your baby best.
• Share your cares — even little ones — with your baby’s doctor.
• If your baby is not meeting one or more milestones or you notice that your baby has skills yet has lost them, tell the doctor.

Your Child’s Development: 1 Year (12 Months)

• Doctors use certain milestones to describe if a toddler is developing as expected.
• There is a wide range of what is considered normal, so some children may gain skills earlier or later than others.
• Toddlers who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things toddlers commonly do by this age:

1. Communication and Language Skills

• call caregiver “mama” or “dada” or another special name,
• waving goodbye,
• understand “no” (pause/stop when you say it).

2. Movement and Physical Development

• pull up to the stand,
• walk holding onto the furniture (cruising),
• with assistance, drink from a cup without a cover,
• pick up things like small pieces of food with their thumb and forefinger.

3. Social and Emotional Development

• play pat-a-cake & other games.

4. Cognitive Skills (Thinking and Learning)

• put something into a container, like a block in a cup,
• look for things that they see someone hide, like a toy under a blanket.

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your toddler is not meeting one or more milestones or you notice that your child has skills yet has lost them, tell your doctor.

Your Child’s Development: 15 Months

• Doctors use certain milestones to describe if a toddler is developing as expected.
• There is a wide range of what is considered normal, so some children may gain skills earlier or later than others.
• Toddlers who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things toddlers commonly do by this age:

1. Communication and Language Skills

• point to inquire about something or to get help,
• try to say one or two words (besides “mama” and “dada”), like a “ba” for the ball,
• look at the familiar object when you name it,
• follow directions when given with both a gesture & words.

2. Movement and Physical Development

• take some steps on their own,
• use their fingers to feed themselves.

3. Social and Emotional Development

• show affection to the caregivers with hugs and kisses,
• show caregivers object that they like,
• hug stuffed dolls or teddy bears or other toys,
• similar things doing other children while playing,
• applaud when excited.

4. Cognitive Skills (Thinking and Learning)

• stack at least two small things, like blocks,
• try to use things the right way, like a phone or book.

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your toddler is not meeting one or more milestones or you notice that your child has skills yet has lost them, tell your doctor.

Your Child’s Development: 1.5 Years (18 Months)

• Doctors use certain milestones to describe if a toddler is developing as expected.
• There is a wide range of what is considered normal, so some children may gain skills earlier or later than others.
• Toddlers who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things toddlers commonly do by this age:

1. Communication and Language Skills

• try to say three or more words (besides “mama” and “dada”),
• follow one step to the directions said with words & not gestures (“Pick up the toy.”).

2. Movement and Physical Development

• walk without holding on to anyone or anything,
• climb on & off a chair or couch without help,
• drink from a cup without a cover and may spill sometimes,
• use their fingers and maybe a spoon for the eat,
• scribble.

3. Social and Emotional Development

• point to show you something interesting,
• move away from you, yet look to make sure you are close by,
• puts hands out to get them washed,
• help with getting dressed by pushing their arm through a sleeve or lifting up to a foot,
• look at some pages in a book with caregivers.

4. Cognitive Skills (Thinking and Learning)

• copy you doing chores, like as sweeping,
• play with toys in a simple way, like pushing a toy car,

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your toddler is not meeting one or more milestones or you notice that your child has skills yet has lost them, tell your doctor.

Your Child’s Development: 2 Years (24 Months)

• Doctors use certain milestones to describe if a toddler is developing as expected.
• There is a wide range of what is considered normal, so some children may gain skills earlier or later than others.
• Toddlers who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things toddlers commonly do by this age:

1. Communication and Language Skills

• say at least 2 words together, like “more milk”,
• point to the things in a picture book when asked (“Where is the dog?”),
• point to a minimum of two body parts when asked (“Where is your nose?”),
• use more gestures, like blowing a kiss or nodding yes.

2. Movement and Physical Development

• run,
• kicking the ball,
• walk (not climb) up some stairs with or without help,
• eat with the spoon.

3. Social and Emotional Development

• notice when others are hurt or upset, like as pausing or looking sad,
• see at your face to see how to react to a new situation.

4. Cognitive Skills (Thinking and Learning)

• grasp something in one hand while using the other, like as holding a container and taking the lid off,
• try to use switches, knobs, or buttons on the toy,
• play with more than one toy at a time, like putting toy food on a toy plate.

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your toddler is not meeting one or more milestones or you notice that your child has skills yet has lost them, tell your doctor.

Your Child’s Development: 2.5 Years (30 Months)

• Doctors use certain milestones to describe if a toddler is developing as expected.
• There is a wide range of what is considered normal, so some children may gain skills earlier or later than others.
• Toddlers who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things toddlers commonly do by this age:

1. Communication and Language Skills

• say around fifty words,
• say two or more words together, with one action word, like “doggie run”,
• say words like an “I,” “me,” or “we”,
• address things in a book when you point & ask “What is this?”

2. Movement and Physical Development

• take certain clothes off by themselves,
• jump with both feet,
• use hands to twist things, like turning a doorknob or unscrewing a lid,
• turns pages in a book one at a time.

3. Social and Emotional Development

• play next to other children & sometimes play with them,
• expose you what they can do by saying “Look at me!”,
• follow simple routines when told, like picking up toys when you say “It’s clean-up time.”

4. Cognitive Skills (Thinking and Learning)

• use things to pretend, like feeding a block to a doll as if it were food,
• show simple problem-solving, like using a stool to reach something,
• follow 2-step instructions (“Pick up the toy and put it on the shelf.”),
• know at least one color, like pointing to a red crayon when asked “Which one is red?”

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your toddler is not meeting one or more milestones or you notice that your child has skills yet has lost them, tell your doctor.

Your Child’s Development: 3 Years (36 Months)

• Doctors use certain milestones to describe if a preschooler is developing as expected.
• There is a wide range of what is considered normal, so some children may gain skills earlier or later than others.
• Kids who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things preschoolers commonly do by this age:

1. Communication and Language Skills

• say the first name when asked,
• talk with you in conversation with at least two back-and-forth exchanges,
• inquire who, where, or why questions,
• say what action is happening in the picture when asked, like as running, eating, or playing,
• talk well sufficient for others to understand most of the time.

2. Movement and Physical Development

• string items together, like as large beads or macaroni,
• put on certain clothes by themselves,
• use the fork.

3. Social and Emotional Development

• calm down within ten minutes after you leave,
• see other children and join them to play.

4. Cognitive Skills (Thinking and Learning)

• make a circle when you show them how
• avoid touching hot objects, like a stove, when you warn them.

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your preschooler is not meeting one or more milestones or you notice that your child has skills yet has lost them, tell your doctor.

Your Child’s Development: 4 Years

• Doctors use certain milestones to describe if a preschooler is developing as expected.
• There is a wide range of what is considered normal so some children may gain skills earlier or later than others.
• Kids who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things preschoolers commonly do by this age:

1. Communication and Language Skills

• say sentences with four or more words,
• say certain words from a song, story, or nursery rhyme,
• speak about at least one thing that happened during the day,
• answer the simple questions, like “What is a crayon for?”

2. Movement and Physical Development

• grab a large ball most of the time,
• assist the serving food; pour drinks with help,
• unbutton certain buttons,
• hold pencil or crayon amid fingers & thumb (not in a fist).

3. Social and Emotional Development

• pretend to be something else during play, such as a teacher, superhero, or animal,
• permission to go play with other children if none are around,
• comfort others who are hurt or sad, like hugging a friend who is crying,
• avoid danger, like jumping from a high playground set,
• likes to be a “helper”,
• changes behavior based on environments, like at a library or playground.

4. Cognitive Skills (Thinking and Learning)

• name some colors,
• talk about what comes next in a well-known story,
• sketch a person with three or more body parts.

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your preschooler is not meeting one or more milestones or you notice that your child had skills yet has lost them, tell your doctor.

Your Child’s Development: 5 Years

• Doctors use certain milestones to describe if a preschooler is developing as expected.
• There is a wide range of what is considered normal, so some children may gain skills earlier or later than others.
• Kids who were born prematurely may achieve milestones later.
• Always speak with your doctor about your child’s progress.

Here are things preschoolers commonly do by this age:

1. Communication and Language Skills

• describe the story they heard or made up with at least two events,
• answers the easy questions about a story after hearing it,
• keep a conversation going with more than three back-and-forth exchanges,
• use or recognize simple rhymes, like as a bat-cat.

2. Movement and Physical Development

• button certain buttons,
• hop on 1 foot.

3. Social and Emotional Development

• obey rules or take turns when playing games,
• sing, dance, or act for you,
• do simple chores, like clearing the table after eating.

4. Cognitive Skills (Thinking and Learning)

• count to ten,
• name certain letters; name numbers between one and five when you point to them,
• use words about time, like yesterday or tomorrow, morning or night,
• pay attention for 5–10 minutes during activities, like arts and crafts (screen time does not count),
• write certain letters in their name.

When should I call the doctor?

• You see your child best.
• Participate in your concerns — even little ones — with your child’s doctor.
• If your preschooler is not meeting one or more milestones or you notice that your child had skills yet has lost them, tell your doctor.

What does spasticity look like?

• Spasticity may affect any muscle group in the body however there are certain common patterns that are seen in cerebral palsy.

Effect on the upper limbs

• If spasticity affects 1 or both of the arms it can lead to:

1. Flexion at the elbow
2. Flexion at the wrist
3. Flexion at the fingers

• Spasticity in these areas can lead to difficulties with tasks involving the hands & the arms:

1. getting dressed,
2. washing and toileting oneself,
3. eating or drinking,
4. writing,
5. manipulating objects.

• It may also affect a person’s ability to use their arms for balance which can lead to difficulty standing & walking.

Effect on the lower limbs

• If spasticity affects 1 or both of the legs it can lead to:

1. Flexion at the hip (which causes the leg to lift upwards when lying/the body to lean flexion in standing)
2. Adduction or ‘scissoring’ of the thighs (which results from the legs pulling together)
3. Flexion at the knees (resulting in changes in a person’s standing posture)
4. Equinovarus foot posture (where the toes point downwards & inwards with the heel off the ground – this causes tightness in the calf muscles)
5. Hyperextension of the big toe (where the toe is pulled upwards & backward towards the shin)

• Spasticity in the muscles of 1 or both legs may affect a person’s ability to

1. Stand upright,
2. Sit upright,
3. Transfer from one position to another,
4. Move and reposition in bed,
5. Walk and run,
6. Effect on speech,
7. Spasticity can also be present in smaller muscles or muscle groups like the tongue, facial muscles, or vocal folds.

• Spasticity in these areas can result in:

1. Study oral movements that are imprecise and require a lot of effort (eating and drinking may also be affected),
2. Speech sounds that are slurred,
3. A voice that might sound hoarse/tight,
4. This can impact a person’s ability to communicate using speech and may mean that alternative methods of communication (like pictures, symbols, or voice-generating devices) are used.

What can change over time?

• While the damage to the brain that causes spasticity does not change over time, the effects of spasticity on the body can result in changes.

Effects of spasticity over time:

• Changes in the soft tissues (muscles, tendons, and ligaments) lead to muscle stiffness, atrophy (deterioration or wasting of the muscle) & fibrosis (changes in the properties of the muscle fibers).
• Muscles that are affected by spasticity have trouble stretching out to keep up with bone growth – resulting in muscles that are shorter than they should be.
• This prevents a joint from achieving its normal full range of movement and is called a contracture.
• Shortened, contracted muscles can pull on the bony structures of the body leading to bone deformities like scoliosis of the spine & hip dislocation.
• Pain – continuing overactivity in spastic muscles can cause pain in the muscle.
• Pain can also happen as a result of the changes in the joint position and deformities due to the abnormal pull of the spastic muscle.

How is spasticity assessed?

• An accurate and comprehensive assessment is most important in determining the presence, severity, and effect of spasticity.
• It is also emphasized in evaluating an individual’s response to spasticity management intervention.
• When assessing spasticity, the clinician will assess.
• Which muscles are affected by spasticity?
• Security of the spasticity in each of the affected muscles.
• How a person is able to control their muscles (can they activate separate muscles, can they voluntarily control their muscles to perform functional tasks).
• Any secondary effects of spasticity (like contracture) which are affecting the person’s ability to perform functional tasks.
• A clinician will also complete.
• A clinical examination involves a ‘hands-on’ feel for stiffness when moving a limb, measurement of range of movement of the joints, also strength.
• A functional assessment will incorporate observation of the person performing daily activities in a natural environment with or without the utilization of equipment or other aids (eg. bathing, dressing, sitting, walking, climbing stairs).

How is spastic cerebral palsy treated?

• There is no cure for cerebral palsy.
• Yet resources and therapies can help kids grow and develop to their greatest potential.
• The treatment plan may include:

1. physical therapy, occupational therapy, speech therapy,
2. leg braces, a walker, and/or a wheelchair,
3. medicine for muscle pain or stiffness,
4. special nutrition to help the child grow,
5. surgery to improve movement in the legs, ankles, feet, hips, wrists, and arms.

Physiotherapy treatment of Spastic cerebral palsy

Treatment Approaches

• An extensive range of therapeutic interventions has been used in treating and managing children with cerebral palsy.
• They appear that there is evidence to support the use and effectiveness of neuromuscular electrical stimulation, while conformation in support of the effectiveness of the neurodevelopmental treatment is equivocal at best.
• The effectiveness of the many other intercessions, including include: sensory integration, body-weight support treadmill training, conductive education, constraint-induced movement therapy, and hyperbaric oxygen therapy used in the treatment of cerebral palsy have not been clearly accepted based on well-controlled trials.
• We provide an outline of salient aspects of popular approaches and interventions used in the management of children with Cerebral Palsy.
• Identifies an extensive range of choices and availability of various techniques which may vary both between therapists and from country to country.
• The table below lists many of the most common physiotherapy and physiotherapy-related approaches utilized in the management of Cerebral Palsy during the past few decades.

Neurodevelopmental Treatment (NDT)

• One of the more popular approaches utilized in the management of cerebral palsy, the Neurodevelopmental Treatment Approach also known as the Bobath Approach, was developed in the 1940s by Berta and Karl Bobath, based on their particular observations working with children with cerebral palsy.
• The basis of this approach is that motor abnormalities seen in children with Cerebral Palsy are due to uncommon development in relation to postural control and reflexes reason for the primary dysfunction of the central nervous system.
• This approach aims to facilitate typical motor development and function and to fend off the development of secondary impairments due to muscle contractures, and joint and limb deformities.
• Although the effectiveness of Neurodevelopmental Treatment in Cerebral Palsy has been questioned by specific published reports, there are certain studies suggesting its efficacy.

Constraint-Induced Movement Therapy (CIMT)

• Constraint-induced Movement therapy is used predominantly in the individual with Hemiplegic Cerebral Palsy to better the use of the affected upper limb.
• The stronger or non-impaired upper limb is immobilized for a variable duration in order to Force the Use of the damaged upper limb over time.
• Antilla et al (2008) identified one high and one lower-quality trial which measured both body functions and structures, and activity and participation outcomes through the use of Constraint-induced Movement therapy.
• Use of a cast with Constraint-induced Movement therapy showed positive effects in the amount and quality of functional hand use in the impaired limb and new emerging behavior as compared to the no-therapy group, yet no effects were found on QUEST.
• The use of a sling during Constraint-induced Movement therapy also had positive effects on functional hand use on the impaired upper limb, time to complete tasks, and speed and dexterity, yet no effects on sensibility, handgrip force, or spasticity.
• Thus Antilla et al (2005) found there is moderate evidence for the effectiveness of Constraint-induced Movement therapy on functional hand use in the impaired upper limb.
• According to Patel (2005), the success of this approach has not been established, in particular in relation to the adverse effects of lengthened immobilization of the normally developing upper limb.

Patterning

• The concept of patterning is established on theories developed during the 1950s and 1960s by Fay, Delacato, and Doman.
• Patterning is established on the principle that typical development of the infant and child progresses through a well-established, pre-determined sequence; with failure to typically complete one stage of development causing impediment or impairment in the development of subsequent stages.
• Established on this principle they suggested that in children with Cerebral Palsy typical motor development can be facilitated by passively repeating and putting the child through the sequential steps of typical development, a process called patterning.
• Parents and other caregivers are taught to carry out this patterning process at home yet the approach is hugely labor-intensive and time-consuming as it requires multiple sessions every day.
• Although Patterning has been utilized for many years of its use is now surely controversial and its effectiveness has not been established.
• It is a very passive therapy, with a small opportunity to encourage the child in their active involvement and its use in children with Cerebral Palsy is not recommended.

Therapeutic Interventions

Passive Stretching for Spasticity

• It is a manual application for spastic muscles to relieve sloppy tissue tightness.
• Manual stretching may increase the range of movements, decrease spasticity, or improve walking efficiency in children with spasticity.
• Stretch may be applied in a number of ways during neurological rehabilitation to attain different effects.

The types of stretching used include:

1. Fast or Quick
2. Prolonged
3. Maintained

• When we look at the use of a stretch for facilitation, we employ a fast or quick stretch.
• The fast or quick stretch produces a relatively short-lived contraction of the agonist’s muscle and short-lived inhibition of the antagonist muscle which facilitates a muscle.
• It achieves its effect along stimulation of the muscle spindle primary endings which result in reflex facilitation of the muscle along the monosynaptic reflex arc.
• The presence of increased tone can ultimately first to joint contracture and changes in muscle length.
• When we look at the use of stretch to normalize tone and maintain soft tissue length we employ a steady, prolonged stretch to maintain or stop the loss of range of motion.
• While the effects are not wholly clear the prolonged stretch produces inhibition of muscle responses which may help in reducing hypertonus, for example, Bobath’s neuro-developmental technique, inhibitory splinting, and casting technique.
• It appears to have an influence on both the neural components of muscle, along the Golgi Tendon Organs and Muscle Spindles, and the structural components in the long term, along with the number and length of sarcomeres.

1. Muscle Immobilised Shortened Position = Loss of Sarcomeres and Increased Stiffness related to enlargement in connective tissue.
2. Muscle Immobilised Lengthened Position = Increase Sarcomeres.

Manual Stretching

• Prolonged physical stretch may be applied manually, using the effect of body weight and gravity, or mechanically, using machines or splints.
• Stretch should provide enough force to overcome hypertonicity and passively lengthen the muscle.
• Unlikely to provide enough stretch to cause a change in a joint that already has contracture.

Weight Bearing

• Weight-bearing has been reported to reduce contracture in the lower limb through the use of Tilt-tables, and standing frames via a prolonged stretch.
• Angles are key to making sure the knees remain extended during the prolonged stretch as the force exerted on the knee can be quite high.
• Certain research also challenges the assumption of the benefits of prolonged standing.

Splinting for Spastic cerebral palsy

• Splints and casts are exterior devices “Splints and casts are external devices designed to apply, distribute or remove forces to or from the body in a controlled manner to perform one or both basic functions of control of body motion and modification or prevention in the shape of body tissue.”
• Splinting can be used to produce low-force, long-duration stretching although there is a deficiency of evidence to support this.
• A wide range of splints has been used to influence swelling, resting posture, spasticity, and active and passive Range Of Motion (ROM).
• A systematic review suggested that Lower Limb Serial Casting increased ankle dorsiflexion passive range of motion, reduced hypertonicity, and improved gait in children with Cerebral Palsy.

Serial Casting

• Serial casting is a usual technique that is used and is most effective in managing spasticity-related contracture.
• Serial casting is a specialized technique to give an increased range of joint motion.
• The process requires a joint or joints that are tight, which are immobilized with a semi-rigid, well-padded cast.
• Serial casting requires the repeated applications of casts, typically every one to two weeks as the range of motion is restored.
• The duration of the stretch to reduce both spasticities and prevent contracture is not clear from the research and requires further research to determine the most appropriate technique and duration to produce the required effect.

Static Weight-bearing Exercises

• Stimulation of antigravity muscle strength, the precaution of hip dislocation, reduction in spasticity, and improvements in bone mineral density, self-confidence, and motor function have all been achieved through the use of Static Weight-Bearing exercises like as Tilt-Table and Standing Frame.

Muscle Strengthening Exercises

• It aims to increase the power of fragile antagonist muscles and of the corresponding spastic agonists and to provide the functional benefits of strengthening in children with Cerebral palsy.
• It increases to power of weak muscles and provides strengthens muscles in cerebral palsy children.

Functional Exercises

• Training related to specific functional activities combining aerobic and anaerobic capacity and strength training in ambulatory children has been shown to significantly increase overall physical fitness, the intensity of activities, and quality of life.
• Training programs on static bicycles or treadmills have been shown to be beneficial for gait and gross motor development yet have not shown to have any impact on spasticity or abnormal movement patterns.
• A study suggests the application of plyometric exercises to the physical rehabilitation programs of children with unilateral Cerebral palsy could achieve more significant improvement in muscle strength and walking performance.

Body Weight Supported Treadmill Training

• Stepping movements from Reflex Stepping Reactions are normally present in newborns and infants, in front of the infant starts to bear weight, stand and walk.
• Body Weight Supported Treadmill Training, is achieved through supporting the child in a harness on the treadmill in an upright posture limiting overall weight-bearing, on a steady moving treadmill, and eliciting the stepping movements.
• Treadmill training consequently allows the development of stepping movements needed for ambulation.
• Studies using 3-4 sessions per week lasting for 3-4 months have shown an increase in the lower extremity movements and gait patterns in children with cerebral palsy.

Electrical Stimulation

• The goal of electrical stimulation is to improve muscle strength and motor function. Electrical stimulation is given by Transcutaneous Electrical Nerve Stimulation (TENS) Unit which is portable, non-invasive, and can be used in the home setting by parents or the patient.
• Neuromuscular Electrical Stimulation (NMES) requires the application of transcutaneous electrical current that results in muscle contraction.
• Neuromuscular Electrical Stimulation has been postulated to increase muscle strength by increasing the cross-sectional area of the muscle and by increasing the recruitment of type two muscle fibers.
• Functional Electrical Stimulation (FES) mention to the application of electrical stimulation during a given task or activity when a specific muscle is expected to be contracting.
• Patel (2005) has shown there is certain evidence to support the use and effectiveness of Neuromuscular Electrical Stimulation in children with Cerebral Palsy yet found that many of the studies are limited by confounding variables including concomitant use of other therapies, broad variation in methods of application, heterogeneity of subjects, difficulty in measuring functional outcomes and less of control subjects.
• Mintaze (2009) proposes that neuromuscular and threshold electrical stimulation as a modality in Cerebral Palsy is used for strengthening the quadriceps muscles in ambulant diplegic children with Cerebral Palsy, who have difficulty with specific resistive strength training.

Gait Training

• kids with cerebral palsy at physical therapy to increase walking.
• Gait training is a type of physical therapy that focuses specifically on increasing walking functions.
• Many individuals with cerebral palsy may walk with an abnormal gait due to spasticity in the legs. During gait training, a physical therapist may focus on improving walking speed or correcting walking form.
• Correcting abnormal gait patterns is required because the poor form can ultimately compromise function and potentially lead to the development of chronic pain.
• Gait training may involve the use of equipment like walkers, bodyweight supporting treadmills, and parallel bars to help individuals practice walking without losing stability.
• Additionally, a PT may recommend wearing orthotics like a leg brace to support correct musculoskeletal alignment and gently stretch spastic muscles.
• Gait training focuses on increasing the functions like:

1. walking speed
2. walking endurance
3. gross motor function
4. step length

Aquatic Therapy for Spastic cerebral palsy

• Aquatic therapy is a form of physical therapy that takes place in a pool.
• Being immersed in water allows individuals to feel weightless, which enables them to focus on developing their form without straining the joints.
• Additionally, moving against the resistance of water assists mildly in strengthening the muscles.

Aquatic therapy for cerebral palsy can involve different water-based exercises, including:

• Walking (or skipping, galloping, or running) in shallow or deep water
• Aquatic yoga
• Swimming
• Floating
• Motion exercises
• Resistance exercises
• Balance exercises
• Games
• Deep breathing exercises
• Stretching

Benefits of aquatic therapy for cerebral palsy involve improved:

• Gait
• Gross motor function
• Joint range of motion
• Cardiovascular endurance
• Posture
• Balance
• Spasticity reduction
• Circulation

Hippotherapy

• Gross Motor Function including Muscle tone, Range of Movement, Balance, Coordination, and Postural Control in Children with Cerebral palsy has been shown to improve with Hippotherapy – Therapeutic horseback riding which may decrease the degree of motor disability.
• Many none physical benefits may also be developed via enjoyment and providing a setting for increased social interaction, and cognitive and psychosocial development.
• Sharan et al (2005) have noted satisfactory results with Hippotherapy in Bangalore, especially the post-surgical rehabilitation.
• There is limited evidence available with two lower-quality trials on saddle riding on a horse that found no connecting-group differences in muscle symmetry or in any of the seven different outcome measures, excluding the sub-item of grasping.

Sensory Integration Training

• Sensory integration therapy is based on the idea that certain kids experience “sensory overload” and are oversensitive to certain types of stimulation.
• When children have sensory overload, their brains have trouble processing or filtering lots of sensations at once.
• Meanwhile, other children are under-sensitive to certain kinds of stimulation.
• Children who are under-sensitive don’t process sensory messages quickly or efficiently.
• These children may notice disconnected from their environment.
• In either case, children with sensory integration issues scuffle to organize, understand, and respond to the information they take in from their surroundings.
• Sensory integration therapy reveals children to sensory stimulation in a structured, repetitive manner.
• The theory behind this treatment approach is that, over time, the brain will adapt and permit them to process and react to sensations more efficiently.
• In this concept, struggling in planning and organizing behavior are attributed to problems in processing sensory inputs within the Central nervous system, including vestibular, proprioceptive, tactile, visual, and auditory.
• Children with sensory integration dysfunction regularly use different sensory combination strategies.
• Treatment centers on the integration of neurological processing by facilitating the individual to process the type, quality, and intensity of sensation.

Games and Activities

• When working with children, physical therapists may employ fun games and activities in addition to exercises to inspire the carryover of skills learned in therapy to a child’s daily life.
• This may include using obstacle courses, balance games, or even employing technology like Wii Fit.
• Ultimately, the key to increasing motor functions is to keep moving.
• Teaching children fun, engaging activities that they can play at home can be an effective way to promote movement outside of physical therapy sessions and improve the carryover of skills and improvements.

1. Arts and Crafts
2. Adaptive Sports
3. Board Games
4. Karaoke(singing)
5. Music Glove
6. Photography
7. Horseback Riding

Horseback riding is one of the best activities for kids with cerebral palsy because it encourages:

• Balance,
• Strength,
• Posture,
• Coordination,
• Range of motion.

8. Swimming
9. Swinging
10. Hula Hooping
11. Dance Party

Certain examples of songs with hand motions or dance moves include:

• Hokey Pokey,
• Head, Shoulders, Knees, and Toes,
• Hand Jive,
• Cha Cha Slide,
• Cupid Shuffle,
• Macarena.

12. Hand-Clapping Games
    

The corresponding hand motions usually involve repetitive:

• Bending and straightening of the elbows,
• Accuracy to clap your partner’s hands,
• Wrist range of motion,
• Opening and closing of the hands.

Examples of hand-clapping games involve:

• Miss Mary Mack,
• Down by the Banks of the Hanky Panky,
• Slide,
• Lemonade,
• I Went to a Chinese Restaurant.

13. Hot Lava

• This game will help your child control where they place their steps and encourage balance.

14. Darts

Playing with darts is a fun, challenging activity that can assist kids with cerebral palsy practice:

• Gripping smaller objects,
• Timing when to let go,
• Aiming,
• Bending and straightening their elbow,
• Wrist movements.

15. Create a Secret Handshake

Task-oriented approach

• This treatment is established on the requirements of the child.
• Today the child is given the possibility to be further an active problem solver (instead of, as previously, a passive recipient of treatment) in the context of the day-to-day environment.
• The aim of this therapy for children with Cerebral palsy, as for most children with developmental disabilities, is to facilitate the child’s participation in everyday life situations, for example, to communicate with parents, siblings, and peers; to proceed from one place to another; to dress and undress; to eat, and to play.
• The choice of goals for therapy is supported by many factors: the child’s liking and the family’s preferences, the society and environment in which the family lives, and the child’s degree of disability.
• Consequently, it is important to integrate principles of motor learning into the treatment concept and adapt the principles to the prerequisites of each specific child.
• The regulated goals should be specific, measurable, attainable, relevant, and timed (SMART).

Conductive Exercise

• Conductive education (CE) is a combined educational and task-oriented approach for children with Cerebral palsy.
• Specially instructed ‘conductors’ give education to homogeneous groups of children with motor disorders.
• These proceeds have their origins in learning theory.
• The conductor who is trained in all aspects of motor and cognitive development structures the activities, especially the self-care activities.
• The emphasis of interference is on independence in attaining goals rather than on the quality of movement.

Bimanual Training

• Bimanual Training (BIT) provides bimanual training activities, which focus on increasing the coordination of both arms using structured tasks in bimanual play and functional activities with intensive practice.
• Recently has an exhaustive bimanual training program, the hand-arm bimanual exhaustive training (HABIT) been published to substantiate its effectiveness.
• This approach is founded on motor learning theory (practice specificity, types of practice, and feedback), neuroplasticity (i.e., the potential of the brain to change by repetition, increasing movement complexity, motivation, and reward), and focuses on the same use of both arms in bimanual tasks.
• Intensive Bimanual training (e.g., HABIT), was developed with the recognition that increased functional independence in the child’s environment needs the combined use of both hands.
• It as well as focuses on improving coordination of the two hands using structured task practice embedded in bimanual play and functional activities.
• Hand-arm bimanual intensive therapy including lower extremities (HABIT-ILE) integrates upper and lower bilateral extremity training.
• Usually used bilateral lower extremity tasks are ball sitting, standing, balance board standing, virtual reality (Wii-fit, Kinect), walking/running, jumping, cycling, and making scooters.
• Bimanual activities that require trunk and lower extremities postural adaptations are performed at a table of appropriate height (50% of the time) on unstable supports: sitting on fitness balls or standing on balance boards.
• Moreover, 30% of the time is devoted to activities of daily living were standing and/or walking is required (dressing, brushing teeth, doing one’s hair, transporting objects such as a tray, and household chores like as sweeping and washing dishes).
• Finally, the remaining time (20%) is spent in gross motor physical activities/play, like as bowling, ball playing, jumping rope, street hockey, use of Wii-fit, balance bike (without pedals), scooter use, and wall climbing.
• These are performed in standing, walking, and running (or jumping) with the lower extremities and simultaneously involve bimanual coordination.
• These activities are graded toward more demanding tasks for the lower extremities.

Robot-assistive therapy

• Robot-assisted therapy (RAT) is conducted using robotic devices that allow the patients to perform specific limb movements.
• The foremost interest in using robots is to allow the patients to achieve a large amount of movement in a limited time.
• Additionally, the attractive human-machine interface has the capacity to motivate the child to perform his or her therapy via playful games, like car races, or to perform exercises that mimic activities of daily living.
• Moreover, robotic devices permit the patient to receive visual, auditory, or sensory feedback.
• A device specifically developed for locomotion training is the Lokomat (Hocoma, CH), made of 2 active orthoses, a weight-bearing system, and a treadmill.
• This robotic rehabilitation has been proposed to increase walking and physical fitness.

Virtual reality

• Virtual reality has been defined as the use of interactive simulations created with computers to perform users in virtual environments that appear, sound, and feel the same as real-world objects and events.
• Virtual reality can improve the patient’s motivation and achievement in activities of daily living.
• Preliminary data suggest that this type of therapy also improves motor function in the upper and lower extremities that are caused by Cerebral palsy.

State of the Evidence

• Novak et al. (2013) have developed a chart founded on their Systematic Review, which looked at the State of the Evidence in relation to Interventions for the management of children with Cerebral Palsy, to help with comparative clinical decision-making amongst intervention options for the same desired outcome.
• They charted the interventions using bubble charts, with the size of the circle correlated to the volume of published evidence.
• The circle size was calculated using;

The number of published papers on the topic:

• Entire score for the level of evidence (calculated by reverse coding of the Oxford Levels of Evidence, for example, expert opinion=1, randomized controlled trial [RCT]=5).
• The location of the circle on the Y-Axis of the graph correlates to the GRADE System Rating.
• The Colour of the circle corresponds to the Evidence Alert System.

Speech and Language Therapy for Cerebral Palsy:

• Individuals with Cerebral Palsy frequently have difficulties with their speech and swallowing. Difficulties in written and non-verbal communication can too be experienced.

Our specialist speech and language therapists can help with:

• Training for family and carers on how to communicate with the person with dysphasia.
• Advice and management with different communication aids.
• Treatment in the middle or in your own home.
• Assistance with a written communication as well as adaptive equipment.

Neuropsychology for Cerebral Palsy:

• Cerebral Palsy is a long-lasting condition and affects people of all ages.
• Coming to terms with the symptoms and mislaying of independence at any age is a challenge.

Our clinical neuropsychologists can help to provide:

• Detailed assessment of a client’s functioning in specific to their cognition, behavior, and emotional state.
• Providing advice, consultation, teaching, and supervision to other professionals also family and carers.
• Management and guidance for anxiety and changes in mood.

Orthotics for Cerebral Palsy

• Orthotics may be an everyday requirement that often needs re-adjusting as the person grows.
• Our specialist orthodontist can help by designing, fitting, and altering orthoses to satisfactory complement your treatment and rehabilitation.

These include:

• Orthotics to fend off foot drops and aid walking,
• Night and day resting splints to prevent alignment and prevent contractures,
• Insoles to make better alignment, proprioception, and gait,
• Variation to shoes to assist with leg length discrepancies, alignment, and improved mobility.