Cerebral Palsy (LEC) PDF

‫بسم هللا الرحمن الرحيم‬ Cerebral Palsy By Prof. Dr. Hala I. Kassem  Introduction Cerebral palsy is the commonly used name for a group of conditions characterized by permanent motor dysfunction due to non- progressive brain damage early in lif...

‫بسم هللا الرحمن الرحيم‬ Cerebral Palsy By Prof. Dr. Hala I. Kassem  Introduction Cerebral palsy is the commonly used name for a group of conditions characterized by permanent motor dysfunction due to non- progressive brain damage early in life. There are usually associated disabilities as; emotional, social and family difficulties. The range of severity may be from total dependency and immobility to abilities of talking, independent self-care, walking, running and other skills.  Definition of Cerebral Palsy It is a neuro-developmental impairment caused by a non-progressive lesion in single or multiple locations in the immature brain.  This lesion leads to persistent disorders of movement and posture appearing in infant's life It is not a specific disease but a group of neurological disorders of varied cause.  Cerebral Palsy (CP) CP has been used as an umbrella term for varying disorders. CP is a broad term used to cover many disorders which differ widely in etiology, pathology and associated findings. CP is a nonspecific, descriptive term pertaining to disordered motor function that is evident in early infancy and is characterized by changes in muscle tone, involuntary movements, ataxia, or a combination of these abnormalities. Etiology The series of disorders of the central nervous system known as CP may occur as: *a developmental defect or *as the result of insult or *trauma to the fetal or infant's brain. There are three headings Prenatal (in utero) Perinatal (during birth) Postnatal Prenatal (in utero): May be due to failure in development or mal- development of the brain Due to the mother having viral exposing to infection as rubella radiation drug use Prenatal ……continue Genetic abnormalities leading to malformation of the brain during fetal life. Vascular insufficiency may occur during fetal life.  Perinatal (during birth): Injury during birth may cause damage to the brain particularly when there is a breech or forceps delivery  Perinatal …….continue Injury during birth may cause damage to the brain. Injury may result in asphyxia and consequent brain damage. Peri-natal …….continue: Premature and low birth weight babies are at risk for injury at birth because of immature development of some systems. Postnatal: Post natal factors as accidents and infection of the CNS. Generally the upper age limit for the use of the term CP is approximately 3 years. Postnatal …….continue: The causative factors are *Infections: as meningitis, encephalitis, measles, anoxia and post epilepsy. *Cerebrovascular accidents and mal nutrition. *Jaundice  Possible Causes Problems during Problems during Problems from pregnancy delivery Infancy 60% 30% 10% * Prematurity. * Lack of oxygen due * Fractures. * Mother’s lack of O2. to prolonged labor or * Penetrating wounds. * Direct trauma. Cord around neck. * CNS infections. * R.H. factor – blood * R.H. incompatibilities * Anoxia (lack of O2). incompatibility. not treated. * Rubella (German M.) * Sudden pressure changes. * Toxemia. * Pelvic obstructions. * X-rays exposure. * Metabolic disturbances. * Mother’s age and pelvic infections.  Motor dysfunction The brain damage results in disorganized and delayed development of The neurological mechanisms of postural control or balance and movement.  Motor dysfunction (continue) The muscles activated for these motor aspects are therefore inefficient and in-coordinated  The motor dysfunction (continue) Individual may have hypertonic or hypotonic muscles with weakness Besides neuromuscular components, the motor dysfunction has musculoskeletal components.  Seizures Spasticity Muscle contractions Difficulty sucking Motor-mental or feeding retardation SYMPTOMS Peg teeth Delay development of motor skills Mental Visual or hearing Dysarthria Retardation abnormalities Classification of CP: Based on clinical signs: *Spastic type; hemiparasis, diplegia, quadriparasis ……about 70% *Dyskinetic form; athetosis, dystonia, chorea, ballismus and tremor about 20-25% *Rare types; ataxia, rigidity and atonia *Mixed type Topographical classification Describe what is seen clinically according to the involved body part: ❖Quadriplegia: involvement of four limbs, double hemiplegia is used meaning that the arms are more affected than the legs. ❖Diaplegia: involvement of four limbs, but legs are more affected than the arms. ❖Paraplegia: involvement of both legs…..rare ❖Triplegia: involvement of three limbs ❖Hemiplegia: one side of the body is affected ❖Monoplegia: one limb is affected  Hypertonia Types of muscle tone disturbance Hypotonia Fluctuating  Distribution of muscle tone disturbance Monoplegia Diplegia Hemiplegia Paraplegia Triplegia Quadriplegia Tetraplegia Diaplegia  The type of involvement are; Spasticity, rigidity, athetosis, or hypotonicity. The floppy babies usually become spastic, athetoid or ataxic Spastic CP Spasticity is a disorder of tone characterized by an initial increased resistance to stretch which may be then lessen abruptly (clasp knife phenomena) The degree of spasticity varies with the child’s general condition, emotional state, temperature, health, correct positioning and degree of support of the child.  Resistance to passive movement and abnormal patterns of movement may not be clinically evident in young infant. In some infants, tone tends to increase as the infant develops.  An infant with severe spasticity may have little ability to move in any position. The child is more or less fixed in a few typical patterns due to severe degree of co-contraction of the involved parts, especially around the proximal joints. Some muscles appear weak due to tonic reciprocal inhibition by their spastic antagonists True weakness may develop from long standing disuse  When the child is moved from supine to prone some variation in the degree of tone may be evident due to influence of the tonic reflexes (tonic labyrinthine and tonic neck reflexes). Abnormal patterns of movement have been described in children with spasticity, both at rest and during movement, with a pattern of flexion in the upper limbs and extension in the lower limbs.  The upper limb: - Shoulder girdle; retracted and depressed - Shoulder joint; adducted and internally rotated, elbow flexed, wrist flexed and ulnar deviated, fingers flexed  In the lower limb - Hip is held in adduction and internally rotation, knee extension, ankle planter flexion and foot inversion. Over activity and shortening of latissimus dorsi may be responsible for a side flexion posture of the trunk, with the shoulder pulled down and back and pelvis pulled up and back. Over activity and shortening of the hip adductors will restrict active range of flexion and extension of the hip.  The spastic child may demonstrate an associated movement in response to stimuli as effort, excitement, loss of balance, fear or anxiety. Contractures and skeletal deformities may develop due to an imbalance of muscle activity, lack of active functional movement, prolonged positioning with muscle held at one length and the effect of these on growth.  Physical problems of the child with spasticity 1. Low tone in trunk muscles. 2. Spasticity in extremity. 3. Incomplete righting reflexes, equilibrium reactions and protective responses. 4. Maintains extremities in mid-range. 5. Stereotypical (patterned) movement. 6. Slow movement. 7. Associated reactions. 8. Deformities secondary to muscle and joint tightness. 9. Fearful of movement.  Athetoid CP Athetoid is the most common dyskinetic syndrome of cerebral palsy. It may appear in a pure form or be the major component in a mixture of dyskinetic syndrome as chorea-athetosis or dystonic athetosis. Its occurrence is less frequent than spastic syndrome. About 5% of total CP is pure athetoid and 10% is dystonic.  Children with athetosis demonstrate involuntary movements which can occur both at rest and during volitional movement. Head control is slow to develop, as inability to hold the head steady may affect development of vision and make development of postural adjustment, reaching and manipulation difficult.  Joints are often hyper mobile and joint dislocation may occur in older children. Scoliosis is common when there is muscle imbalance. There is often history of early dysphagia, drooling and difficult breathing.  Physical problems of the child with athetosis 1. Fluctuating level of muscle tone(head, trunk and upper limbs more involved than lower limbs. 2. Muscle spasms. 3. Involuntary movements. 4. Inability to hold segments at various points within the range of motion 5. Lack of co-contraction of the muscles. 6. Lack of muscle grading. 7. Asymmetry in both posture and movement. 8. Lower limbs less involved than head, trunk and upper limbs. 9. Movement of head affects trunk and limbs. 10. Incomplete righting, equilibrium reactions and protective responses. Ataxic CP It is an uncommon type of CP. The disorder in ataxia is; difficulty controlling rate, range, direction and force of movement. In-coordination, difficult balance and lurching staggering gait are the most significant signs of ataxic CP children.  Physical problems of the child with ataxia 1. Usually hypotonic, but some have increased tone. 2. Poor co-contraction and sustained holding of postures. 3. Dysmetria. 4. Present righting reflexes, equilibrium reactions and protective responses but poorly coordinated.  Hypotonic CP Severe hypotonia or flaccidity is present in some CP. It may persist but it is often transient, subsequently being reclassified as spasticity or athetosis. The infant may lie with arms and legs abducted, externally rotated and flexed. The child has loss of head control, protective side turning of the head kicking may be absent. The child may have some respiratory difficulty (shallow respiration). Dysphagia and drooling are common.  Complications Seizures Injuries from mobility Reduced mobility Reduced communication skill (sometimes) Reduced intellect (sometimes) Social stigmatization  Motor disorders in CP Disorders of postural fixation. Failure of suppression of primitive brain stem reflexes. Disorders of tone. Paralysis and disorders of the voluntary movements. Involuntary movements. Failure of development of cortical reactions  Disorder of postural fixation Defective postural fixation, inability to maintain the head or trunk erect, is the most important and obvious defect in all cases of CP except the mildest of hemiplegia. Therefore, it is important to recognize that: In early life the disorder of postural fixation will be most evident because voluntary movement cannot occur on a background of abnormal postural fixation, so it is important to detect these defects in postural adjustment.  Failure of suppression of primitive brain stem reflexes Normally, movements can be regarded as evolving from simple, invariable spinal reflexes to more elaborate patterns governed by higher centers. When the motor system is damaged, complex movements tend to suffer first leaving the cruder or less complex. This process involves a reduction of choice and the severely damaged child may be able to react only by means of certain crude reactions centered in the brain stem  Brain stem reflexes act upon the distribution of postural tone. These reflexes are the tonic labyrinthine reflex,, tonic neck reflexes, and Moro and Startle reactions. These all interact with one another in normal development and they also interact with other complex movement patterns which are not definitely localized within the brain stem.  Tonic labyrinthine reflex affects tone diffusely. The sensor is the otolith organs which provide continuous information about the position of the head in relation to gravity. As a result of this reflex, extensor tone is maximal when the individual is in supine, while the flexor tone is maximal in the prone position.  If this reflex is dis-inhibited, in the supine position, the head will be retracted, shoulders will be retracted, adducted and externally rotated, elbows are flexed hands are fisted. This posture may also be dominant in the erect position. At the same time there is extension and adduction of the lower limbs, which are often crossed. In the prone position there is an increase in flexor tone, specially at the hips and knees and neck which prevents its elevation  Tonic neck reflexes (asymmetrical and symmetrical) are proprioceptive reflexes originating in the muscles and joints of the neck. The reaction of ATNR is normal from 4 to 6 months of infant’s age. In many CP cases rotation of the head is obligatory which prevents the hands being brought together in the midline (dominant ATNR)  The symmetrical tonic neck reflex depends on extension or flexion of the neck. These induced postures are normal part of the motor pattern of the infant beginning to crawl, but they are quickly integrated into other movements. In CP they are not commonly demonstrable as are the ATNR. STNR means that when the child is kneeling with the head raised, extension of the hips is impossible thus he can only crawl by bunny hopping. If he flexes his head, he can not maintain the crawling position because his arms give away.  Moro reflex This important primitive reflex consists of two phases; abduction of the arms with wide spread fingers, abduction of the thighs and slight flexion of the knees, followed by a second phase; adduction of arms or clasping. The abduction phase accompanies the first inspiration at birth. If this response presents beyond 4 months, it is always a sign of abnormality. Over activity of Moro reflex interfere with extension thrust and make sitting impossible. It is impossible to detect the exciting stimulus in athetoid infant. Clinical signs of CP  Feeding difficulties, inability to suck or swallow, lack of interest and very slow feeding. Abnormalities of gaze; failure to fix when feeding and delayed smiling. Abnormalities of tone; reduced or increased. Abnormalities of behavior-irritability, anxiety, lack of interest in sounds or visual cues, and sleep disturbance. Delayed postural development, persistent asymmetry of the head and trunk, no balance reactions Development of asymmetry of movement or tone. Delayed motor development. Management of CP child  Early diagnosis of CP is very important as it allows early treatment and better results. Management comes from different fields; pediatrics, neurology, psychology, social work, physiotherapy, occupational therapy, education, orthopedics, ophthalmology, nurses, etc…. The assessment is carried out to establish developmental and functional levels by drawing a profile of the child’s strength and weakness.  Assessment of CP Medical Physical Neuropsychiatry Speech  Computerized tomography (CT) scanning is a valuable adjunct to neurological evaluation, providing evident of the severity of cerebral injury. Magnetic resonance imaging is capable of showing focal white matter abnormality in the mature brain and can assess the state of myelination in the immature brain  Medical Assessment EEG MRI & CT Hearing screen & Visual testing Blood tests to exclude Physical Therapy metabolic or Evaluation hereditary condition  Physical Assessment History taking Postural tone Reflexes Musculoskeletal Fine motor Gross Oral function Feeding Sensory History taking The physiotherapist must note the following histories and results including: Personal history present history Family history Relevant details of pregnancy-trauma, threatened miscarriage Details of labour Results of scan Relevant details of baby’s history since birth The physiotherapist has two main aims in assessing young CP child To discover gaps in his development To recognize the signs of abnormal postural reflex activity and assess how these interfere with the child’s development. N.B. in order to understand the abnormal movement and motor control that occur in CP children, the therapist must understand the acquisition of motor control, development of righting, equilibrium and protective reactions and musculoskeletal development in normal children.  Associated impairments and disabilities Brain damage in cerebral palsy may also be responsible for special sense defects of vision, hearing, abnormalities of speech and language and aberration of perception. Perceptual defect or agonsia are difficulties in recognizing objects or symbols, even sensation is not impaired. Associated impairments and disabilities (continue) There may also be dyspraxias, some of which are also called visuo- motor defects. This means that the child is unable to perform certain movements even there is no paralysis, because the patterns or engrams have been lost or have not developed.  Associated impairments and disabilities (continue) Dyspraxia can involve movements of the limbs, face, eyes, tongue or be specifically restricted to such acts as writing, drawing, and construction or even dressing. All these defects result in various learning problems and difficulties in communication.  Associated impairments and disabilities (continue) Motor problems create difficulties for a child in social activities and in being able to access educational activities. In order to manage the multiple disabilities and lack of related learning experiences which interfere with a child's development, a physiotherapist or occupational therapist needs to be part of team.  Associated neurological disorders in CP Vision problems: Strabismus is present in 20% to 60% of children with CP. The highest incidence is in the diplegic and quadriplegic children. Esotropia; deviation of eyes toward the midline is more prevalent than extropia. Homonymus hemianopia occurs in 25% of children with hemiplegia. Nystagmus is most common in children with Ataxia. Strabismus (also called crossed eyes, deviation, heterotropia, squint, tropia Exotropia, esotropia and hypertropia are three of the deviations of the eye 👁 from the axis. Nystagmus is an involuntary and repetitive eye moving or tremor consisting in the eye going from side to side (horizontal nystagmus, the most frequent), top-down and bottom-up (vertical nystagmus) or on a rotating basis (rotatory or torsional nystagmus). Usually, both eyes are affected.  Mental retardation About 40 to 60% of CP children have some degree of retardation, with the highest proportion of severe deficits seen in quadriplegic, rigid and atonic children. Communication disorders It may be present in CP children. These disorders may be secondary to poor oral motor control of speech, central language dysfunction, hearing impairment or cognitive deficits.  Dysphagia The dysphagic problems in CP may lead to inadequate fluid and caloric intake, which results in protein-calorie malnutrition and associated problems. The development of eating and drinking behaviors may be impeded by the presence of one or more of the following difficulties in CP children: Poor trunk and head control Poor grasp  Poor co-ordination Persistence of infantile reflexes as extensor thrust and asymmetrical tonic neck reflex Altered reflexes involving oral musculature Hypersensitivity, with lack of awareness of the presence of food in the mouth Drooling Abnormal or limited movements of the tongue, jaw, lips and soft palate Respiration Drooling: It is a problem for a large number of CP children. It interferes with eating, speech, self image and social activities. It may also cause soreness of skin, infections and aspiration A- Assessment of postural tone Postural tone should be assessed at rest and during movement in different positions. It should be assessed through the neck, trunk and extremities. Disorders of tone In the normal state, tone can be diminished (hypotonia) or increased (hypertonia). Under normal condition the tension of the spindle is maintained at approximately constant level so that it can respond immediately to stretch. The normal postural tone is essential for normal movement patterns. All disorders of co-ordination are associated with disorders of tone.  For that the therapist must distinguish between the truly hypotonic muscle (i.e. one in which the stretch reflex is impaired) and the floppiness that results from impairments of postural reflexes. Spasticity is the common type of hypertonus seen in childhood. The increase in tone is usually most evident in those muscles which maintain the body’s posture against gravity.  Paralysis and disorders of the pattern of voluntary movements Weakness is common to all forms of CP, even those characterized by involuntary movements. Weakness of severe CP is generalized, involving the neck, trunk as well as the limbs. Paresis comprises a number of features; slowness of initiation of movement, simultaneous contraction giving a crude ineffective pattern and lack of fraction of movement.  Discrete movement is impossible e.g: ₋ Extension of the wrist is associated with extension of all fingers. ₋ Attempts at flexion result in flexion of all segments of the limb or involved both limbs simultaneously in a crude symmetrical movement; flexion of the hip can only occur together with flexion of the knee. ₋ Even in mild cases “mirror movements” are often seen in the unaffected hand when an effort is made to use the affected one in a case of hemiplegia. Involuntary movements Involuntary movements form the principal features of athetosis with early hypotonia and impairment of postural fixation of the trunk. They are often present in less marked form than other types of cerebral palsy because of the diffuse nature of the lesion. Almost any kind of “unwanted “ movement, from tremor to rapid choreic or slow dystonic movements, can occur in CP, but the violent righting and irregular movements are confined to athetosis.  The irregular arrhythmic movements affect almost all muscles, including respiratory, but are most evident in face, tongue, neck and arms. In infancy they appear first in the toes and fingers. They are absent when attention is deeply held, diminished by fatigue. They are increased by emotion, insecurity, startle or the desire to perform a voluntary act. Frequently cases of athetosis show over-activity of the tonic neck and labyrinthine reflexes. Athetosis is caused by disorders of basal ganglia. The common cause of disorders of basal ganglia is jaundice or anoxia. Because the damage is localized, the intelligence is often preserved.  Failure of development of cortical reactions Many of the phenomena of CP are the result of dis-inhibition of primitive reflexes or of failure of higher centers to gain control of , or assimilate, basic movement patterns. These are termed positive or released phenomena, it includes hypertonic, involuntary movements and over activity of primitive brain stem reflexes. In contrast, in negative phenomena e.g. paresis and inco-ordination, there is absence of function due to disorder of the neural pathway necessary for these functions and failure to develop certain reactions which require cortical functions.  B- Reflex testing Reflexes should be tested in young child according to his chronological and developmental ages. The CP child often displays both retained and abnormal reflex patterns of movement, which are sometimes excessively strong. These persistent abnormal reflexes prevent older child from developing the more mature and controlled patterns of movement. C- Musculoskeletal assessment Persistent shortening of a muscle or muscles group without activation of the antagonists due to spasticity, abnormal reflex activity or static positioning places the child at risk for contractures of soft tissues, the after time bony deformity. The therapist should be alert for the areas at risk for contracture. Assessment includes goniometric measurements, evaluation of the spine, upper and lower extremities and gait. D- Fine motor and adaptive skills It is important to assess hand functions. In hand function the following milestones should be noted; hands to mouth, hands to midline, transfer from hand to hand. It should be noted whether the baby looks at his hands, however persistence of hand regard is usually an indication of mental sub-normality Athetoid movements may be evident as the baby approaches an object with his hand in an in-coordinated pattern (usually normal until 5 months) Spastic baby reach the object with his arm in an abnormal pattern of internal rotation and pronation, wrist ulnar deviated, this should not be confused with normal ulnar deviation in the first few months. Which part the baby grasp by his hand should be noted, whole hand, ulnar, radial side in the pincer grasp of a 12 months old baby  E- Screening tests: Many clinicians use formal screening tests to detect developmental or behavioral problems. The most common test used is Denver developmental screening test (DDST). It is developed by Frankenberg and Dodds (1968). It is widely used to screen for developmental delay. The 105 items in DDST were chosen from pre-existing developmental tests for their ease of administration and interpretation.  The test measures the development in 4 areas 1-Personal-social: the child’s ability to get along with people and take care of him/herself 2-Fine-motor-adaptive: the child’s ability to see and use his or her hands to pick up objects and to draw. 3-Language: the child’s ability to hear, to follow directions and to speak. 4-Gross motor: the child’s ability to sit, walk, and jump. The age range covered 1 to 6 months  F- Assessment of oral function: Oral reflexes (rooting, sucking, bite and gag reflexes) are tested with the baby in supine or in the physiotherapist’s or parent’s lab. The physiotherapist also tests the tongue and watch its movements, as asymmetry and tongue thrusting are frequently found in CP babies. The face should be checked for localized spasm of the muscles around the mouth and nose. Absence of vocalization which normally begins at 7 weeks, may suggest the presence of abnormality A CP may not make sounds or may lack a variety of sounds due to pure coordination of oral function with breathing. G- Feeding The physiotherapist must observe the infant’s drinking, eating and sucking, he must also note the ability of the child to swallow without choking  H- Sensory testing It is performed once the child is old enough to cooperate with simple test procedure. Many of CP children have poor attention to interpret sensory inputs. The aspects of sensation relevant to the disorders of movement in CP children are vision, hearing, touch, pressure and proprioception  Vision is evaluated by the ophthalmologist, hearing by an audiometric laboratory Light touch is assessed by stroking the skin lightly with a piece of cotton, wool, while the child’s eye are closed. Streognosis is tested by placing an easily recognizable object in the child’s hand. The objects chosen will depend on the child’s age. Vision is obstructed during the rest.  Two-point discrimination is assessed by using pair of dividers, the two points which are applied simultaneously to an area , such as the palm of the hand, the child with closed eyes, is asked to say two or one. The points are moved further together until the child feels only one. The normal 5- year old child can discriminate two points until they are 1 cm. apart on the palm of the dominant hand and 2cm. Apart on the non-dominant hand.  Joint position sense indicates awareness of limb in space. It is tested by putting the limb in a position and asking the child to move the other limb to the same position or by asking the child whether the limb is straight or bent. The child’s eyes should be closed during the test.  Tests of perceptual and cognitive functions Some of CP children have perceptual dysfunction as apraxia or visual agonsia or unilateral spatial agonsia. Perception and cognitive function of CP children should be analyzed. Some scales are designed to measure cognitive function and perception for disabled children, e.g. analysis of cognitive structure.  3- Neuropsychiatric assessment Psychologists may use various testing instruments. Among the more commonly used tests of intelligence are: Stanford Bint Intelligence scale, Mc Cathy Scales, Bayley Scales of infant development, Vineland Social Maturity Scale etc…..  4- Speech-language assessment The assessment of child’s communicative ability includes: a-Oral motor abilities, involving voluntary non speech movement, feeding and dysphagia, primitive oral reflexes and oral sensory capacities b-Speech production subsystems including respiratory, laryngeal, velopharyngeal, articulatory functions and speech intelligibility. c-Cognitive-linguistic functions. The structure of each assessment depends on the child’s age  General principles of treatment Team work Early treatment Sensory Motor Repetition of a motor experience activity Parental Individuality participation  Bobath Technique Neurodevelopmental approach Introduced by Berta Bobath Karel Bobath 1940 Aims of Bobath Technique Inhibition Facilitation of the of the Released normal Abnormal movement pattern pattern  Aims of treatment in Bobath technique 1. Inhibit abnormal reflex activity and facilitate normal postural reactions (righting, equilibrium and protective reactions) which are prerequisites for balance and normal movement. 2. Guide the child through the normal sequences of motor development, namely rolling over, sitting, coming up onto hands and knees for crawling, standing and finally walking.  Aims of treatment in Bobath technique (cont.) 3- Normal integration of both sides of the body while associated reactions are avoided. 4- Normal responses once elicited, are always repeated. 5- Voluntary control of normal responses is encouraged. Reflex inhibiting pattern Key points of control Proximal Distal The reflex inhibiting patterns are used to: ◼Inhibit ◼Overcome abnormal reflex abnormal tone activity. that are e.g. released produced by asymmetrical the influence tonic neck reflex of tonic (ATNR). reflexes. E.g. tonic labyrinthine, ATNR. & STNR.  Rood’s Approach By Margaret Rood Activation of Inhibition of Facilitation of muscle action muscle action muscle action Voluntary and involuntary through reflex arc Rood’s Approach Emphasis on Controlled sensory stimulation. The use of autogenetic sequence. Demand a purposeful response through the use of activity. Components of Rood’s theory 1. The normalization of tone through correct sensory input. 2. Sensorimotor control. 3. Movement is purposeful. 4. Repetition is necessary for learning. The main features of Rood’s approach are: 1. Cutaneous stimulation are used to promote reciprocal inhibition between agonist and antagonist. 2. According to the various physiological classification of muscles, the appropriate stimuli for their actions are suggested. 3. Reflexes are used in therapy. 4. Stretch of muscles, tendons and peri-articular structures, manual pressure on bony prominence aroused to activate, facilitate or inhibit motor response through proprioceptive sensation.  The main features of Rood’s approach are: (cont.) 5-Techniques of brushing, icing and pressure are used to stimulate the development of vital function, e.g. respiration, swallowing, sucking….etc. 6-She suggested muscle work in main stages on an autogenetic developmental sequence.  The main features of Rood’s approach are: (cont.) 7-She suggests that there is a reciprocal relaxation of shortened muscles when there is activation of their antagonists. 8-Auto-inhibition by repeated contractions of spastic muscle is suggested; then followed immediately by active contraction of the antagonists. Temple Fay approach (progressive Pattern Movements) Temple Fay (neurosurgeon) Suggests building up motion from reptilian, squirming to amphibian creeping, through mammalian reciprocal motion “on all four” to the primate erect walking.  Stages of Temple Fay 1. Prone lying: head and trunk rotation from side to side. 2. Homolateral stage: prone lying, head turned to side. Arm on the face side is in abduction-external rotation, elbow semi-flexed, hand opens thumb out toward the mouth. Leg on face side is in abduction, knee flexion opposite stomach, foot dorsiflexion. Arm on the occiput side is extended, internally rotated, hand opens at the side of the child or on the lumbar area of his back. Leg on the occiput side is extended. Movement involves head turning from side to side with the face, arm and leg sweeping down to the extended position and the opposite occiput arm and leg flexing up to the position near the face as the head turns round.  Stages of Temple Fay (cont.) 3. Contra-lateral stage: prone lying, head turned to side (as in stage 2). The arm of the face side is flexed and the leg on the face side is extended and the arm of the occiput side is extended and the leg is flexed. As the head turns this contra- lateral pattern changes from side to side. 4. On hands and knees: Reciprocal crawling and on hands and feet stepping in the “bear walk” or “elephant walk”  Stages of Temple Fay (cont.) 4. Walking patterns: This is a sailor’s walk. This technique is first practiced passively for 5 minutes at least five times daily. One person turns the head, another person moves the arms and leg on one side.  Phelps technique Phelps (1952) Orthopedic surgeon Specific diagnostic classification of each child is a base for specific treatment methods  Modalities of Phelps technique 1- Massage for hypotonic but not for spastic and athetosis. 3- Active assisted 2- Passive motion motion 4- Active motion 5- Resisted motion  Modalities of Phelps technique (cont.) 6- Conditioned motion 7- Confused motion 8- Rest periods 9- Combined motion 10- 11- Movement from Relaxation technique relaxation  Modalities of Phelps technique (cont.) 12- Reciprocation in a bicycling pattern. 13- Balance training in sitting and standing. 14- Reach, grasp and release for hand function. 15- Skills of daily living as feeding, dressing, washing and toileting. Modalities of Phelps technique (cont.) Braces & calipers Muscle education  Deaver technique (Muscle education / braces) Extensive use of braces & concentrates on self care or A.D.L. Aims of Deaver technique 1. Maximal use of the hands. 2. Usable speech. 3. Ability to travel. 4. Normal or near – normal appearance.  Phol technique (Muscle education) Based on 3 principles 1- General 2- Muscle consciousness, relaxation function & then isolated co-ordination for training of voluntary relaxation muscle control. 3- The activities observed in the normal sequence of development are the base of the functional phase of his program. Braces are not used, but crutches or cans may be used.  Schwartz technique ◼ He believed that the progression of the emotional and intellectual level is followed by progression in the physical motor level. ◼ This technique is based on simplifying the external environment and providing motivation.  Schwartz technique ◼ A device called the Hartwell carrier is designed for this purpose. ◼ The motivation is provided by successful performance of play activities. ◼ No braces, but crutches and canes were used for independent locomotion.  Gillette technique Based on How to gain good alignment ? By Stretching: performed daily to correct or to prevent contractures in spastic muscles. A specific exercise program: designed to provide optimal range, tone, strength and functional activities. Braces and splints may be recommended.  Eirene Collis She stressed on Neuro-motor development 1. The mental capacity of the child would determine the results. 2. Early treatment was advocated. 3. Management through the day. 4. Strict developmental sequence.