LORMACOLLEGES

Col
legesofPhysi
calTher
apyandRespi
rat
oryTher
apy
Car
lat
an,SanFer
nandoCi
tyLaUnion

CP
(
Cer
ebr
alPal
sy)

Submit
tedby:
JoeMarkR.Lanuza
BSPTIV

Submittedt
o:
Mr
s.Di
anneHy aci
nthR.Beni
to,
PTRP
 PART1
MEDI
CALBACKGROUND
INTRODUCTI ON
Cer
ebralpalsy( CP)i soneoft hemostcr ippli
ngandhandi cappi
ngcondi t
ionsi n
childhoodt odaybecauseoft hecompl exityofbr aininvolv
ementandt heassoci at ed
handi capsthatmaybepr esentwi thit
.
I
twasf i
rstdescr i
bedbyWi l
li
am JohnLi t
tl
e,anor t
hopedicsurgeonfrom Engl and
i
n1862.Si ncet hen,theconceptofCPhasdev el
opedandi twasSi rWil
li
am Osl erwho
fi
rstused t he t er
m “ cerebralpal sy” derived from t he German t erm “ cerebrale
kinder l
ahung”meani ngcer ebralchildparalysis.
I
nthePhi li
ppines,t hefir
stcer ebralpalsyclinicwasest abl
ishedattheNat ional
Or t
hopedi cHospitaldur i
ngt hel ate1950’ s.Twodecadesl ater
,theElk’
sCer ebralPal sy
Rehabi li
tat
ionCent erwasbui lt
,whi chi npr esentisoneoft hebiggestcent erst hat
prov i
deacompr ehensiver ehabil
itati
onpr ogram forCPchi l
drenandadultsinthecount ry
.

 Ref
erence:(
delMundo,Fe,Est r
ada,Fel
ixA.,Ocampo,PerlaD.andNav ar
ro,
xesR.Text
Xer bookofPedi
atr
icsandChil
dHealt
h,4thEdi
ti
on,
pp1093-
1100)

I
. DEFI
NITI
ON
Ot
herRel
atedTerms:
1.Encephalopathi
es
 aregenerali
zeddisorderofcerebr
alfuncti
onthatmaybeacut eorchronic,
progressi
veorstatic
 theetiol
ogyofencephal opati
esinchil
drenincl
udesinfect
ious,
toxi
c(e.g.,
carbonmonoxi de,drugs,
lead)
,metaboli
c,andischemiccauses

 Reference:(
Behr
man, Ri
chardE.,Kl
i
egman,Rober HalB.Nel
tM.andJenson, son
TextbookofPedi
atr
ics,17thEdi
ti
on,
pp2023-
2025)

Cer
ebr
al Palsy( CP)
 isadi sorderofmov ementandpost urecausedbyst ati
cdef ectorl esionoft he
i
mmat urebrai
n
 I mpl i
cationsoft heabov edef i
niti
onar easf oll
ows:
1.Ther eisanabnor malityofmot orf uncti
on( str
ength,tone, posture,
andcoor dinati
on) .
2.The under l
ying br ain pat hology i s st ati
c; howev er, wi th
dev el
opmentandmat urati
on,therewi llbealterati
oninmot orand
non- motormani festations.
3.Thei nsulttot hebr ainoccur sdur i
ngt he“ earlyyear sofbr ain
dev el
opment ”(gener ally
,under3y earsofages) .
 r ather t han a speci f
ic di sease, i t also encompasses a spect rum of
neur odev el
opment al sy ndromes char acteri
zed by per sistent mot or del ay,
abnor malneur omot orexami nat i
on,andof tenanext ensiverangeofnon- mot or
associ ateddeficit
sincogni t
ive,neur obehav i
oral,
or t
hopedic,andot herar eas
 Ref erence:(delMundo,Fe,Est rada,FelixA. ,Ocampo,Per laD.andNav arro,
Xer xesR.Text bookofPedi atricsandChi l
dHeal th,4thEdit
ion,pp1093- 1100)
 i
s a cl inicalent it
y char act eri
zed by a t hree-partdef i
nition:a di sorderof
mov ementand post ure( 1)caused by a non- progressiv ei njury( 2)t ot he
i
mmat urebr ain( 3)
 Ref erence: (Braddom)
 i
s def ined as a mot ordi sorderaccr uing because ofa l esion t hati s non
progr essi v eandoccur si nthedev elopingbr ain
 I snotaspeci ficdiseasebutr atheracol lect
ionofdi sorderwi thsome
common f eatures and i st he mostcommon phy sicaldi sabili
ty of
childhoodseeni npract icebyr ehabi litati
onpr ofessional s.
 Ref erence: (DeLisa)
 i
sacommonandof t
enext remel ydisabl ingaf f
ectionseeni nmostf r
equent lyin
i
nf ant sand chi ldren and char act erized cl inicall
ybydi sturbanceofv ol
untary
mot orf unctiont hatincludesav ari
et yofnonpr ogressiveneur ologicent it
ies
char act er i
zedbyabnor mal cont rol ofmov ementorpost ure
 Ref erence: (Brashear )
 i
s a col lecti
on ofsy ndromes ofdi verse et iology,pat hology ,and cl ini
cal
mani fest ati
onscausedbynon- progressi v elesionsofani mmat ur ebr ainwhi ch
l
eadst oneur omuscul arandot hersy mpt omsofcer ebraldysf unction
 Ref erence: (Santos)
 i
sadi agnost i
cter m usedt odescr ibeagr oupofmot orsy ndr omesr esul t
ingf r
om
disor der sofear lybr aindev elopment
 Ref erence: (Berhman, Kliegman, Jenson)
 TheNat ionalInst it
utesofHeal thpaneldef i
nedCPasanonpr ogr essi vemot or
disor derofear lyi nfantonset ,i nvolv i
ng one ormor el i
mbs,wi t
hr esult
ing
muscul arspast icityorpar alysis.
 Ref erence: (Cunni ngham, MacDonal d, Gant ,Lev enoandGi l
strap)

CLASSI FI
CATIONOFCEREBRALPALSY
CPhasbeencl assif
iedi nanumberofway s.Thecl
assi
fi
cati
oncurrentl
yinusei s
modifiedfrom asy st
em desi gnedbyt heAmeri
canAcademyofCer ebralPalsy.I
tis
composed ofsev er
alf act
ors:physiol
ogi
cal(motor)
,topographi
cal,etiologi
cal
,
supplement al(associ
at ed defici
ts)
,neuroanatomi
cal
,functi
onalcapaci ty,and
ther
apeutic.

A.PHYSI
OLOGI
CALCLASSI
FICATI
ONOFCP
Tabl
e28.
2Phy
siol
ogi
cal
Classi
fi
cat
ion

 Spast
ic  Tr
emor

 Ext
rapy
rami
dal  At
oni
c

 Ri
gid  Mi
xed

 At
axi
a  Uncl
assi
fi
ed

1.Spast
ic
 muscl
es ar
e hy
per
act
ive or t
he
 tensionisi
ncreasedbyanexagger at
edmusclestr
etchref
lex
 pathologyi
n:cerebrum andthedescendi
ngpathwaysofpy r
ami
dal
tract
 mostcommont ypeamongchi l
drenwit
hCP( 65%)
o (50to60%)i nsomeaut hors
o (75%)accor di
ngto(Braddom)
 l
ikenedt oacl
aspkni fewherei
ntheresi
stancewaxesandwanes

Ty
pesofSpast
icCP

a.Spast
icmonopl egia
o onel imb,eit
heranar m orleg
o isolatedupperorl owerextremityinvol
vement
o r ar
elyseen
o usual l
ymi l
dclini
calpresentati
on
o of t
ent hepresentati
onofami sdiagnosed
hemiplegi
a

b.Spast
icdi
plegia
o mostcommonpr esent
ati
onofCP2°t
opr
emat
uri
ty
o (+)scissori
nggai
t
o (+)strabismus
o Bunnyhoppi ng
o Combat /
Commandocrawl
o ambul ati
onusual
l
ypresentat3t
o4y/
o
o (N)intell
i
gence

c. Spast
ictr
ipl
egia
o threeextremiti
esi nv
olved,cl
assicall
ybil
ater
al
l
owerextremi t
iesandoneupperext r
emity
o spastici
tyininvolvedli
mb
o uppermot orneuronsignsininvolvedli
mbs
o scissori
ngandt oewalking

d.Spast
icquadr
ipl
egia
o mostsev er
et ypeofCP
o ambulati
onusual l
ypresentat7y
/o
o (+)sei
zuredisor der
o (+)mentalretardation
o (+)str
abi
smus
o (+)str
aphangersi gn

e. Spast
ichemipl
egia
o (+)Dovidoff
-DykeMassonSy ndrome
o (+)homony moushemi anopsia
o (+)negl
ectont heaff
ectedside
o (+)cort
icalthumb
o (+)hemiplegicgai
t

2.Ext
rapy
rami
dal
/Dy
ski
net
ic/At
het
hoi
d
  mostcommon pr esentat
ion in CP 2°t
o Rh i
ncompat
ibi
l
ityof
ker
nict
erussincebi l
ir
ubintendstodeposi
tint
hebasal
gangl
ia
o intel
li
gentandhappy
o (+)tonguet hrust
ing
o (+)“fl
oppybabysy ndrome”
o poorf uncti
onal i
nstabi
li
ty
o poorv isualtr
acking
o abnormal i
nfanti
lerefl
exes

 commonsubt ypeischor eoathet osis

 mov ement di sorder char acter ized by i nv
olunt
ary wri
thi
ng
mov ement,continuous,coarse, andr hyt
hmic
 “snake-l
ike”mov ement
 exagger at
ed byv olunt
ar ymov ementort ensi
on;absentduri
ng
sleep
 distalport
ionsoft hebodyi smor einvol
ved
 pathologyin:basal ganglia
 l
esscommont ypethanspast icCP ( 19%)
o ( 25to30%)i nsomeaut hor s

3.Ri
gid
 resi
stanceisconstantandt
hespeedofmov ementdoesnotal
ter
theresponse
 resi
stancetomov ementisi
nall
dir
ecti
ons
 pathologynot
ed:diff
usedamagetothebr
ain

4.At
axi
a/Ataxi
c
 lossofkinestheticsense;
lossofcont
rol
andcoor
dinat
ion
 lossofpost ureandbalance
 pathologyin:cerebell
um
o (+)reboundphenomenon
o (+)ny stagmus
o (+)intentiontr
emor
  ptmov eslikesomebodywhoi si
nt oxi
catedwit
hawi debasedgai
t
andswagger s
 Dysdiadochokinesi
a(inabil
it
ytoper form al
ter
nat
ingmov ement
s)
i
spr esent
 hypotonici
tyofmuscles; hy
poref
lexive
 occursinptwithCP( 10%)
o ( 5%)insomeaut hors

5.Tr
emor
 i
nvoluntar
y,r
hythmic,andosci
ll
ati
ng,toandfromovement
 cl
assifi
edbyr ate,amplit
ude,andt herelati
onshi
pwit
hr estor
movement( i
ntenti
onalornoni
ntent
ional
)
 pat
hologyin:basalgangl
iaandextr
apyramidaltr
act

6.Fl
acci
d/Hy pot
oni
c
 presenceofdeeptendonr
efl
exes
 positi
vepl
antarr
esponse

7.At
oni
c
 lack oft one and fai
lure ofmuscl
es t
orespond t
ovol
i
tional
st
imulati
on
 weakst retchr
eflexes
 increaseddeeptendonr ef
lexes
 ofraretype

8.Mi
xed
 morethanonet
ypeofmovementdi
sorder
 mostcommon:Spast
icwi
that
hethoi
d

 Tablan,i
nastudyof1,
950Fili
pinochi
ldr
enwithCP,not
edthat51.
5%wer e
spasti
c,23.
5%wer eat
hethoid,6.2%weref
lacci
d,5.1%weremixed,4.
1%
wererigi
dand3.2%wereataxic.

B.TOPOGRAPHI
CALCLASSI
FICATI
ONOFCP
 i
sbasedont
henat
ureofl
i
mbi
nvol
vement
Tabl
e28.
3Topogr
aphi
cal
Classi
fi
cat
ion

Condi
ti
on Char
act
eri
sti
cs

Monopl
egi
a I
nvol
vesonel
i
mb

Hemi
plegi
a Lat
erali
zed one-
halfoft
he bodyaf
fect
ed;ar
m usual
l
ymor
e
aff
ectedthantheleg

I
sol
ated® hemi
plegi
aist
wiceascommonas(
L)hemi
plegi
a
(
Braddom)

Di
plegi
a Bot
hlegsaf
fect
ed;
sli
ghtupperext
remi
tyi
nvol
vementnot
ed

Tr
ipl
egi
a I
nvolvesthr
eeext
remit
ies,maypresentei
therahemi
plegi
apl
us
di
plegiaori
ncompl
etequadri
plegi
a

Quadr
ipl
egi
a Al
ll
imbsaf
fect
ed

Doubl
ehemi
plegi
a Evidenceofmor
espast
ici
nvol
vementoft
hear
mst
hanoft
he
legs(rar
e)

Par
apl
egi
a I
nvol
vest
hel
egsonl
y,wi
thnor
malupperext
remi
tyf
unct
ionof
CP
 C.EXTENDEDCLASSI
FICATI
ONOFCP
 based on t
he degr
ee ofmotordelay,the neur
omot
orsi
gns,t
he
associ
ateddysf
unct
ions,
andt
hefuncti
onalabi
li
ty

Tabl
e28.
4ExpandedCl
assi
fi
cat
ion

Cl
assi
fi
cat
ion Rat
eOfMot
orDev
elopment

Mi
nimal Nor
mal
;Mot
orquot
ient(
MQ75-
100)

Qual
i
tat
iveabnor
mal
i
tiesonl
y

Mi
l
d 2/
3nor
mal
;(MQ50-
70)

Wal
ksbyage24mont
hs

Moder
ate ½nor
mal
;(MQ40-
50)

Wal
ksbyage3;
mayneedbr
aci
ng

Usual
l
ydoesnotr
equi
reassi
sti
vedev
icesorsur
ger
y

Sev
ere/
Prof
ound Lesst
han½nor
mal
;(MQ<40)

Maynotwal
kfr
eel
yint
hecommuni
ty

May need br
aci
ng,assi
sti
ve dev
ices,and or
thopedi
c
sur
ger
y
  Ref
erence:
(del
Mundo,
Est
rada,
OcampoandNav
arr
o)

D.GROSSMOTORFUNCTI
ONALCLASSI
FICATI
ONOFCP
 Gross Mot orFuncti
onalClassifi
cati
on System (GMFCS)st r
ati
fi
es
chil
dren based on gr
oss mot ormobi li
tyand is used ty
pical
lyin
addit
iontodescri
bingthet
onedi sorderandthel
imbdi st
ri
buti
on.

Box54-
3Gr
ossMot
orFunct
ional
Classi
fi
cat
ion

Lev
el1:
wal
kswi
thoutr
est
ri
cti
on,
li
mit
ati
onsi
nhi
gh-
lev
elski
l
ls

 Wal
ksi
ndependent
lybyage2y
ear
swi
thoutdev
ices

 Wal
ksaspr
efer
redmobi
l
itybyage4

 Di
ff
icul
tywi
thspeed,
coor
dinat
ion,
andbal
ancef
orhi
gh-
lev
elt
asks

Lev
el2:
wal
kswi
thoutdev
ices,
li
mit
ati
onswal
ki
ngout
door
s

 Si
tswi
thhandsuppor
tbyage2

 Cr
awl
sreci
procal
l
yorwal
kswi
thdev
iceaspr
efer
redmobi
l
itybyage4

 Useshandst
ogetupf
rom t
hef
loororachai
rbyage6

 Wal
kswi
thoutdev
icesi
ndoor
sbyage6

Lev
el3:
wal
kswi
thdev
ices,
li
mit
ati
onswal
ki
ngout
door
s

 Si
tswi
thsuppor
tbyage2

 Cr
uisesbyage4,
wal
kswi
thdev
iceshor
tdi
stances

 Doesst
air
swi
thhel
pbyage6

 Wal
ksi
ndoor
swi
thadev
icebyage12

Lev
el4:
li
mit
edmobi
l
ity
,powermobi
l
ityout
door
s

 Rol
l
sbyage2y
ear
s

 Si
tswi
thhandsuppor
tbyage4

 Maywal
kshor
tdi
stancesi
ndoor
swi
thdev
ice,
poorbal
ance
  Pr
efer
redi
ndependentmobi
l
ityi
sawheel
chai
rbyage12

Lev
el5:
ver
yli
mit
edsel
f-
mobi
l
ity
,ev
enwi
thassi
sti
vet
echnol
ogy

 Needshel
ptor
oll
byage2

 Doesnotat
tai
nindependentmobi
l
itybyage12

 Wi
thhi
gh-
lev
elassi
sti
vet
echnol
ogy
,mayl
ear
ntousepowermobi
l
ity

 Ref
erence:
(Br
addom)

Tabl
e37-
6CLASSI
FICATI
ONANDPATTERNSOFCEREBRALPALSY
NEUROLOGI
C EXTENT SEVERI
TY OTHERS

Hemi
plegi
a Mi
l
d Congeni
tal
/acqui
red

Fl
acci
d Ri
ght Moder
atel
ysev
ere Unknownet
iol
ogy

Spast
ic Lef
t Sev
ere Epi
l
epsy
/noepi
l
epsy

Bi
lat
eral -
-- Mi
l
d Congeni
tal
/acqui
red
Hemiplegi
a
Moder
atel
ysev
ere Epi
l
epsy
/noepi
l
epsy

Sev
ere

Di
plegi
a
Congeni
tal
:
Hy
pot
oni
c
Par
apl
egi
c Mi
l
d Associ
atedċl
ow
Dy
stoni
c bi
rt
hwt .
Tr
ipl
egi
c Moder
atel
ysev
ere
Ri
gid/
spast
ic Notl
owbi
rt
hwt
.
Par
apl
egi
c Sev
ere
Acqui
red:
(rar
e)

Epi
l
epsy
/noepi
l
epsy

At
axi
cdi
plegi
a Congeni
tal
/acqui
red
Par
apl
egi
c Mi
l
d
Wit
hhy
drocephal
us
Tr
ipl
egi
c Moder
atel
ysev
ere &/
orspi
nabifi
da

Tet
rapl
egi
c Sev
ere No
 hy
drocephal
us/
spi
na
bi
fi
da

Epi
l
epsy
/noepi
l
epsy

Congeni
tal
/acqui
red

Wit
hhy
drocephal
us
At
axi
a Pr
edomi
nant
ly Mi
l
d &/
orspi
nabifi
da

Uni
l
ater
al(
rar
e) Moder
atel
ysev
ere No
hy
drocephal
us/
spi
na
Bil
ater
al Sev
ere
bi
fi
da
sy
mmet ri
cal
Hear
ingl
oss/no
hear
ingl
oss

Epi
l
epsy
/noepi
l
epsy

Di
sequi
li
bri
um
sy
ndrome/no
di
sequi
li
bri
um
sy
ndrome

Congeni
tal
:

Kerni
kter
us/
no
ker
nikt
erus

Acqui
red(
rar
e)

Monopl
egi
c(r
are)
Dy
ski
nesi
a Mi
l
d

Hemi
plegi
c(r
are)
Moder
atel
ysev
ere
Tr
ipl
egi
c
Sev
ere
Tet
rapl
egi
c

 Ref
erence:
(DeLi
sa)
I
I. EPI
DEMI
OLOGY
 Age
o isoneofthemostcommondi sabl
ingcondit
ionsaffect
ingchi
ldr
en
o nospecifi
cager eported
o age<5y earsold
o common: 1to7y /o
o Gestat
ionalage<32weeks
o bet ween32and42weeksgest ati
onwi thbir
thwei ow10th
ghtbel
percenti
le:4to6t i
meshigherr
iskforCPt hanbetween25th&75th
percenti
leforbir
thwei
ght
o lowbir
thwei ght(<2500sto<1000g)

 Sex
o sli
ghtpr
edomi
nancei
nmal
es(
60%)ov
erf
emal
es(
40%)

 I
nci
dence
o Approxi
mat
ely1t
o2.
3per1000l
i
vebi
rt
hs

 Pr
ev al
ence
o Rat eof5.2per1000l
ivebi
rt
hsat1yearofagebutr
epor
tedr
esol
uti
oni
n
uptohalfoft
hesechi
l
drenby7year
sofage

 Mor
tal
it
y&Sur vi
val
o Associatedwithseverit
yandheal t
hburden
o I
njur
ies,abuseandnegl ectarealsopotent
ialcausesformorbidit
yand
mortal
ityinchil
drenwi t
hCP.
o Lack of i ndependent mobi l
i
ty such as r ol
l
ing,t
he use of
tracheost
omy ,andl ackofanyhandf uncti
onareassociatedwi
th
highermor t
ali
ty.
o ageofsur viv
al: 40yearsormore
o SEVENFACTORSi npredi
cti
ngsurvi
val
1.cogni t
ivelevel
 2.abil
i
tyt ospeak
3.abil
i
tyt orecogni
zevoices
4.abil
i
tyt oint
eractwi
thpeers
5.physicalabil
it
yandmobi l
i
ty
6.tubefeeding
7.i
ncont i
nenceandseizure

 Ref
erences:
(Br
addom)
,(del
Mundo,
Est
rada,
OcampoandNav
arr
o)

I
II
. ANATOMYANDPHYSI
OLOGY
THEBRAIN
 isthelar
gestandmostcomplexport
ionoft
hener
voussyst
em
 itoccupi
esthecrani
alcav
ityandiscomposedofonehundredbi
l
li
onmul
ti
pol
ar
neur
ons

A.Funct
ionsoftheBr
ain
 inter
pret
ssensat
ions
  determi nesperception
 storesmemor y
 reasoning
 makesdeci si
ons
 coordinatesmuscul armov ement
s
 regulatesvisceralacti
vit
ies
 determi nespersonalit
y
 etc

B.Maj
orPar
ts
 Cerebrum
 Diencephal
on
 Brainst
em
 Cerebell
um

1.CEREBRUM
 t helar
gest,mostconspi cuousport
ionofthebrain
 has2hemi spheresconnect edbycorpuscall
osum
 composedofani nnerpor t
ion(bul
kofcerebrum)thati
scomposedof
white matt
erand an out erpor t
ion,the cer
ebralcort
ex whi
ch is
composedofgr aymat ter
 t hesurfaceismar kedbyr i
dgescalled gyr
iseparat
edbygr oov
es
caledsul
l ci

a.Cer
ebr
al Cort
ex
 r esponsiblef orallconsci ous behav i
orbycont aini
ng 3
kindsoff unct i
onalareas,whi chi ncludesmot or
,sensor y,
andassoci at
ionar eas:
i
. Mot orar easarelocatedi nthef rontal cort
ex
ii
. Sensor y ar eas are concer ned wi t
h consci ous
awarenessofsensat ionsandar el oacatedi nt he
pari
etal,occipi
tal
,andt empor al cortex
i
ii
. Associ ationareasincludear east hatar einv olv
edi n
many t rait
sl ike analyzing,i nterpreting sensor y
experi
ences, memor y , r easoning, v erbalizing,
j
udgementandemot i
ons
 b.Hemi
sphereDominance(BrainLateral
i
zati
on)
 Mostbasi cf uncti
ons ( sensory & motor) ar
e equal
l
y
cont
rol
ledbybothleft&righthemispher
e
 communi cati
ngexitsthr
oughcor puscal
losum

Lef
tHemi
spher
e Ri
ghtHemi
spher
e

Sequent
ial
anal
ysi
s: Hol
i
sti
cfunct
ioni
ng:

 Syst
emat
ic,
logi
cal
int
erpr
etat
ionof  Pr
ocessingmulti
-sensoryi
nput
i
nfor
mati
on si
multaneousl
ytoprovide“hol
i
sti
c”
pi
ctur
eofone’senv i
ronment

I
nter
pret
ationandpr
oduct
ionofsy
mbol
i
c Hol
i
sti
cfunct
ionssuchas:
i
nfor
mation:
 danci
ng
 l
anguage
 gy
mnast
ics
 mat
hemat
ics
 si
ngi
ng
 abst
ract
ion
 ar
ts
 r
easoni
ng
Vi
sual
spat
ial
ski
l
ls

Memor
yst
oredi
nlanguagef
ormat Memoryisst
oredi
naudi
tor
y,v
isual
and
spat
ial
modali
ti
es

THEMOTORCORTEX
THEKORBI
NIANBRODMANN
 Thecerebralcor
texhasbeendiv
idedbyKORBI
NIANBRODMANNi
nto47di
sti
nct
r
egi
ons,eachhavingaBrodmann’snumber

Funct
ional
Areas:
 TheBr odmann’
sar
eas
 divi
dedint
o47cyt
oar
chi
tect
ural
areas

BRODMAN’
S NAME FUNCTI
ON AFFECTATI
ON
AREA

FRONTALLOBE(
mot
orf
unct
ion)

Ar
ea4 Pr
imar
ymot
orar
ea Vol
unt
arymov
ementofskel
etal I
mmedi at
epar
esi
sif
muscl
es damaged

Ar
ea6 Pr
emot orcor
tex/ Appr
opr
iat
eresponseof Complexdefect
sof
Motorassoci
ati
on movement movementsintheabsence
ar
ea ofweakness

Ar
ea8 Fr
ontal
eyefi
eld Mov
ementoft
heey
ebal
l Defect
ivescanni
ngof
movementar
ea opposi
teside,noconj
ugat
e
eyemov ement

Ar
ea9,
10,
11,
12 Pref
rontal I
nsi
ght
,emot
ion Dist
urbancei
nbehavior,
cort
ex/area poorjudgment
,noinsight

Ar
ea44 Br
oca’
sar
ea Speechpr
oduct
ion Broca’s/
nonfl
uent
/non-
expressi
ve,ant
eri
oraphasi
a

PARI
ETALLOBE(
somat
osensor
yfunct
ion)
Ar
ea3,
1,2 Pr
imarysensor
y Recei
vest
act
il
est
imul
us Impaired2point-
ar
ea/Somatosensor
y discri
minati
on,t
ouch,
ar
ea positi
onsense,and
stereognosi
s

Ar
ea5,
7 Sensor
yassoci
ati
on I
nter
pret
stact
il
esensat
ions -
-
area

Ar
ea43 Pr
imar
ygust
ator
y Tast
esensat
ion Lossoft
ast
e
ar
ea

Ar
ea39,
40 Gnost
ic/
Common Memor
y,behav
ior
,sexual
desi
res Area39: Angulargyrus
i
ntegr
ati
onar
eas syndrome( akaGer stmann’s
syndrome) ;combined
acalcul
ia,agraphi
a, f
inger
Ar
ea39:
Angul
ar agnosisR- Ldisor
ientati
on
gy
rus
Ar
ea40:
Ideomot
orapr
axi
a

Area40:
Temporalgy
rus

TEMPORALLOBE(
hear
ing)

Ar
ea41,
42 Pri
maryaudi
tor
y Hear
ing Compl
etecor
ti
cal
deaf
ness
cor
tex
Heschl
’
sgy
rus

Ar
ea21,
22 Wer
nicke’
sar
ea Speechint
egrat
ion/l
anguage Werni
cke’
s/fl
uent/
expr
essi
v
i
nterpr
etat
ion e/
poster
ioraphasi
a

OCCI
PITALLOBE(
sight
)

Ar
ea17 Pri
maryvi
sual Si
ght Compl
etesi
ghtbl
i
ndness
cor
tex/
Cal
cari
near
ea

Ar
ea18,
19 Vi
sualassoci
ati
on I
nter
pret
ati
onofv
isual
sti
mul
us -
-
ar
eas

2.DI
ENCEPHALON
 formsthecent
ralcoreofthef
orebrai
n
 incl
udestwoimportantar
easofgraymat
ter
:

a.Thalamus
 cent ralrel
aystati
onf orincomingsensor
yi mpul
ses(except
smell)thatdir
ectsthei mpulsetot
heappr opr
iat
eareoft he
cerebralcor
texfori
nterpr
etati
on

b.Hy
pothal
amus
 main vi
sceral cont
rol center the body (
i.
e. r
egul
ates
homeost
asis)
i. heartrat
e&bloodpressure
i
i. bodytemperat
ure
 i
ii
. water&electr
oly
tebalance
i
v. contr
olofhunger&bodywei ght
v. contr
olofdigest
ivemov ement s&secret
ions
vi
. regul
ati
onofsleep-wakecy cl
es
v
ii
. contr
olofendocri
nesy stem funct
ioni
ng

 i
nvol
vedinemotionalr
esponse: Li
mbicSystem
 control
semot i
onalexperi
enceandexpr essi
on
 canmodi f
ythewayaper sonacts
 producesafeeli
ngoff ear,
anger,
pleasure,andsor
row,
etc.

3.BRAI
NSTEM

 l
ocat edbetweenthecerebrum andthespinalcordwhichpr
ovi
des
pathway fort r
actsrunning between higherand lowerneural
centers
 consistsofthemidbr
ain,pons,andmedullaoblongat
a
 produceautomat i
cbehavior
snecessaryforsurvi
val

3Maj
orPar
ts:

a.Mi
dbrain
 locat
edbet weendiencephal
onandpons
 2bulgingcerebr
alpedunclesontheventr
al si
de
 actsinrefl
exacti
ons( vi
sualandaudi
tor
y)
 alsocontai
nsareasassociatedwithr
eti
cularfor
mat
ion

b.Pons
 li
teral
lymeans“bri
dge”orpat
hwayofconducti
ontracts
 locati
onofpneumot axi
carea(r
egulat
ionofbreat
hingrate)of
r
espirat
orycent
er
 relaysnervei
mpulsestoandfr
om themedull
aandcer ebel
lum

c. Medul
l
aobl ongata
 enl
argedcont inuati
onoft hespinalcord
 contai
nsanaut onomicr ef
lexcent erinvolvedi
nmai nt
aini
ng
homeost asi
sofi mpor t
antvisceral
or gans,andcont
ains:
o car diaccent er
o v asomot orcenter
o r espi
r atorycent
er
o r eti
cularf or
mation

4.CEREBELLUM
 lar
ge,caul
i
flower
-l
ikest
ruct
urel
ocat
eddor
sal
l
ytot
heponsand
 medul l
a and inf
eri
orl
yt ot he occi
pit
allobe oft he cer
ebrum
(separatedbytr
ansver
sefissure)
 patter
nofwhi t
emat t
er(withi
ngraymatter
)-“arborvi
tae”
 coordinatesal
lv ol
untar
ymuscl emov ement s(subconsci
ously
);
skil
ledmov ements,
posture,bal
anceandequil
ibri
um

THEBASALGANGLI
A
 aregroupofi nterconnectedsubcort
icalnucleit
hatr
epr
esentoneoft
he
brai
n’
sf undament alprocessi
ngunit
s
 theyaresituatedatt hebaseofthef orebrai
nandstr
ongl
yconnect
edw/
thecerebralcort
ex ,
thalamusandotherar eas

Funct
ions
 cont r
olsv oluntarymovements
 establishingpost ur
e
 percept i
on
 learni
ng( r
einforcementl
earni
ng)
 memor y
 attention
 mot ivati
on
 eyemov ement s
 compar ati
veanat omyandnami ng
 manyaspect sofmot orf
uncti
on(compl
ex)

Cont
ent
s

1.St
ri
atum
 lar
gestcomponentofBasal
gangli
a
 recei
vesdi
recti
nputfr
om mostregionsoft
hecer
ebr
alcor
texand
 l
imbstr
uctur
esincl
udingamygdal
a&hi
ppocampus
 compri
sedof:(
Corpusstr
iat
um)
a.Caudatenucl
eus
b.Putamen

2.Pal
l
idum
 contai
nslar
gestructur
e(gl
obuspall
i
dus)and(vent
ral
pal
l
idum)
 appearsassingl
eneuralmass
 neuronsoperat
eusingadisi
nhi
bit
ionpr
inci
ple

3.Subst
anci ani
gra
 r ecei
vi
ng aff
erent f
rom ot
her BG nucl
eipr
ovi
ding ef
fer
ent
connecti
onst
othethal
amusandbrai
nst
em

4.Subt
hal
amicnucl
eus
 an i
mportantrel
ayint he ”
indi
rectoutputpat
hway
”fr
om t
he
st
ri
atum v
iatheext
ernal
globuspall
idus

BASALGANGLI
AMOTORCI
RCUI
T

 Themotorcircui
toftheBGpr ovi
desasubcor ti
calf
eedbackloopf
rom t
hemot or
andsomatosensoryareasofthecort
ex,thoughporti
onsoftheBGandthalamus,
andbacktothecorti
calmotorareas(pr
emot orcort
ex,suppl
ement
arymotorar
ea,
andmotorcortex)
.
 BASALGANGLI
APATHOLOGY

Aki
nesi
a I
nabi
l
ityt
oini
ti
atemov
ement
;associ
atedwi
thf
ixedpost
ures

At
het
osi
s Sl
ow,i nv
oluntary
,wr it
hing,t
wisti
ng,“wor
mli
ke”mov
ement
s;
fr
equentl
ygreaterinv
olvementindi
stal
UEs

Decr
easedampl
i
tudeandv
eloci
tyofv
olunt
arymov
ement
Br
ady
kinesi
a

I
nvolunt
ary
,rapi
d,ir
regul
ar,j
erkymov
ement
sinv
olv
ingmul
ti
ple
Chor
ea j
oint
s;mostapparentinUEs

Mov
ementdi
sor
derwi
thf
eat
uresofbot
hchor
eaandat
het
osi
s
Choeoat
het
osi
s

Sust
ainedi
nvol
unt
arycont
ract
ionsofagoni
standant
agoni
st
Dy
stoni
a(dystoni
c muscles
movements)

Lar
ge-ampli
tudesudden,v
iol
ent
,fl
ail
i
ngmot
ionsoft
hear
m
Hemi
bal
l
ismus andlegofonesideoft
hebody

Abnor
mal
l
yincr
easedmuscl
eact
ivi
tyormov
ement

Hy
per
kinesi
s
Decr
easedmot
orr
esponseespeci
all
ytoaspeci
fi
cst
imul
us

Hy
poki
nesi
s
I
ncr
easeinmuscletonecausi
nggr eat
err
esi
stancet
opassi
ve
movement
;gr
eateri
nflexormuscl
es
Ri
gidi
ty
Uni
for
m,const
antr
esi
stanceasl
i
mbi
smov
ed

Ser
iesofbr
iefr
elaxat
ionsor“
cat
ches”asl
i
mbi
spassi
vel
y
 Leadpi
pe moved
  Cogwheel

I
nvol
unt
ary
,rhy
thmi
c,osci
l
lat
orymov
ementobser
vedatr
est

Tr
emor

 Ref
erence:
(Sul
l
ivan)
,(Snel
l
)

I
V. ETI
OLOGY
 specif
ic et i
ologicfactorsresponsibl
ef ormot orimpairmentremain
unknownespeci al
lyamongthosebor natt er
m
 prenataldefectsorinsult
sar
et hemostcommonet i
ologi
es
 bir
thinjuri
esaccount sfor8t
o12%ofcases
 postnatalinj
uriesaccountsf
or10%ofcases
 i
nsulttot heCNSmayoccurpr enatal
ly,peri
natal
l
y,duri
nglaborordur
ing
theneonat alperi
od,andpostnatal
lyinearlyl
ife

ACHI
LDCOULDHAVECPDUETO:
A.Lackofoxy
geni
nthebr
ain

B.Ot
hercauses
1.Beforebir
th
o congeni tal
:abnormalsi
zeofthebrain(
enlar
gedorreduced)
o t he mot herhad an inf
ect
ion duri
ng the fi
rsttr
imesterof
pregnancy(TORCHS)
o bl oodincompatibi
li
tyoft
hemot herandchil
d(Rhfact
or)

2.Dur
ingbir
th
o l ackofoxygeninthebrainduetoprol
ongedlabor(
anoxi
a)
o hemor rhageinthebr ai
nofthechi
ld(bl
eedi
ng)
o umbi li
calcordisaroundtheneckofthechi
ld
o headi njur
ycausedbyf orceps
o pr ematurebir
th
 3.Af
terbi
rt
h
o sicknesssuchasmeasl es,diarr
hea,convulsi
ons,dehy
drat
ion,
amongot hers
o braininf
ecti
onssuchasmeni ngi
ti
s,encephali
ti
s
o braininj
ury2°t
oaccidents(fall
)

 I
nthePhi
l
ippines( studybyTablanetal
)
o prenat alcauseswer ethemostcommonet
iol
ogi
cfact
ors(
44.
2%)
o post natal(27.7%)ofcases
o perinatalfactors(17.
2%)ofcases
o unknown( 11.4%)ofcases

Tabl
e28.
1HI
GHRI
SKFACTORS

Pr
enat
alf
act
ors

 Hy
per
emesi
sgr
avi
dar
um

 Toxemi
a

 Ter
atogeni
cdr
ugs

 Pl
acent
aabr
upt
ion

 I
ntr
aut
eri
nev
iral
orbact
eri
ali
nfect
ion

(STORCH:syphi
li
s,toxopl
asmosis,r
ubel
l
a,
cytomegal
ovi
rus,andherpeszoster
)

 Chr
omosomal
abnor
mal
i
ty

 Genet
icmal
for
mat
ions

 Mat
ernal
mal
nut
ri
ti
on

 Posi
ti
vef
ami
l
yhi
stor
y

Per
inat
alf
act
ors

 Pr
emat
uri
ty

 Br
eechorf
acedel
i
ver
y

 I
ntr
aut
eri
neasphy
xia
  Asphy
xianeonat
orum

 LowApgarscor
e

 Sei
zur
es

 Respi
rat
orydi
str
esssy
ndr
ome

 Hy
ali
nemembr
anedi
sease

 Hy
per
bil
i
rubi
nemi
a

Post
nat
al

 Headt
rauma

 I
ntr
acrani
al i
nfect
ion (
encephal
i
tis,
meningi
ti
s)

 Toxi
cencephal
opat
hies

 Cer
ebr
ovascul
aracci
dent

 Ref
erence:
(del
Mundo,
Est
rada,
OcampoandNav
arr
o)

RI
SKFACTORSASSOCI
ATEDWI
THCEREBRALPALSY

A.Gener
al
o Gestat
ionalage<32weeks
o Bi
rthweight<2500g

B.Mat
ernal
History
o Ment alretar
dati
on
o Seizuredisorder
o Hy pert
hy r
oidi
sm
o Twoormor epri
orfet
aldeaths
o Sibli
ngwi thmotordefi
cit
s
o Mul t
iplebirt
hpregnanci
es(secondt
win)

C.Dur
ingGestation
o Twi ngest at
ion
o Fet algr owthr et
ardati
on
o Thi rd-t
rimest erbl
eeding
o I ncreasedur ineprotei
nexcr
eti
on
o Chor i
oni t
is
 o Prematur
eplacentasepar
ati
on
o Lowplacent
awei ght

D.Fet
alFact
ors
o Abnormal f
etalpresent
ati
on
o Fetal
malformat i
ons
o Fetal
bradycardia
o Neonatalsei
zures

 Ref
erence:
(Br
addom)

POSSI
BLECAUSESOFCPBYTYPEI
NCLUDETHEFOLLOWI
NG:

1.Spast
ichemi plegic
 Ofal lcases,70- 90%ar econgenitaland10- 30%ar eacquired(eg,vascular
,
i
nflammat ory,traumat ic)
.
 I nuni l
aterall esionsoft hebr ai
n,thev ascul arterr
it
orymostcommonl y
aff
ectedi st hemi ddlecerebralartery
;thel eftsideisinvolvedtwiceas
commonl yast her i
ght.
 Ot her st ructuralbr ai
n abnor malit
ies include hemi br
ain at r
ophy and
posthemor r
hagi cpor encephaly
.
 I n premat urei nfants,this may resultf r
om asy mmetric peri
vent
ricul
ar
l
eukomal acia.

2.Spast
icdiplegi
c
 I n prematurei nf
ant
s,spastic di
plegi
a may r esul
tf r
om parenchymal
-
i
ntraventri
cul
arhemorrhageorperi
ventr
icul
arleukomal
acia.
 I ntermi nf
ants,nori
skfactor
smaybei dent
if
iableort
heetiol
ogymightbe
multif
actori
al.

3.Spast
icquadr iplegi c
 Appr oximat ely50% ofcasesar epr enatal,30% areper inat
al,and20% are
post natal i
nor igin.
 Thi st y
pei sassoci atedwithcav i
tiest hatcommuni catewiththelateral
ventricl
es,mul tiple cyst
iclesions i nt he whi t
e mat t
er,diff
use cort
ical
atrophy ,andhy dr ocephal
us.
 Thepat ientof tenhasahi storyofadi ff
icul
tdel i
verywi thevi
denceof
perinatal asphy xia.
 Pr etermi nf antsmayhav eperi
vent r
icularleukomal aci
a.
 Ful l-
term i nf ants may hav e struct ur
albr ai
n abnor malit
ies orcerebral
hypoper fusi on i n a wat ershed ( i
e,maj or cerebralar t
ery end zone)
distri
but i
on.

4.Dy
ski
netic(extr
apy r
amidal)
 Thisty pemaybeassoci at
edwi t
hhy per
bilir
ubinemi
aint
erminf
ant
sorwit
h
premat uri
tywithoutpromi
nenthyper
bili
rubinemia.
 Hy poxiaaffecti
ngthebasalgangli
aandt halamusmayaff
ectt
erminf
ant
s
 mor
ethanpr
eter
minf
ant
s.

 Ref
erence:
(Behr
man,
Kli
egman,
Jenson)

V. PATHOPHYSI
OLOGY
 
 
Themostcommoncur rent l
yunder stoodcausesar er elatedt obrai
ni nj
ur y
occurringi nchi l
drenbor npremat ur el
y.Thecombi nationofi mmat uri
ty,fragil
e
brainv ascul at
ure,andt hephy sicalstressesofpr emat ur
itypr edisposest hese
childr
ent ocompr omi sedcerebr albloodf low.Thebl oodv essel sar epart
icularly
vulnerablei nthewat ershedzonenextt othelateralventri
clesi nt hecapill
ariesof
theger minalmat ri
x.Bl eedi
ngi nt hisar eaisar t
erialinor i
gi nandcanoccuri n
dif
fering degr ees:cer ebralintrav entr
icularhemor r
hage i solat ed to germi nal
mat ri
x( gr
ade1) ,i
ntraventri
cularhemor rhagewi t
hnor malv entricul
arsize( grade
2),i nt r
av entri
cul
ar hemor rhage wi th v entri
cular di latation ( grade 3) ,
i
ntravent r
icularhemor rhagewi thpar enchymal hemor rhage( grade4) .

Pr
emat
uri
ty
(
<32wksofgest
ati
on.
)
↓
I
mmat
uri
tyoft
hebr
ain,
fragi
l
ebr
ainv
ascul
atur
e,phy
sical
str
esses
↓
Compr
omi
secer
ebr
albl
oodf
low
↓
I
ntr
avent
ri
cul
arhemor
rhage
(
Ger
minal
mat
ri
x)
↓
Necr
osi
sofbr
aint
issue
↓
Cer
ebr
alPal
sy

 Ref
erence:
(Br
addom)
VI
. CLI
NICALMANI
FESTATI
ON
FI
VEMAJORFI NDINGSI NCP
1.Del
ayedmot ordevel
opment
2.Abnor
mal tone
3.Abnor
mal posture
4.Abnor
mal refl
exes
5.Abnor
mal mot orper
for
mance

CLI
NICALEFFECTS

Ear
lymanifestat i
ons
 Hy potoni aandmot ordelay
 UMNi njur y
o ↑t oneandr efl
exes
o ( +)Babikski’
sr efl
ex
o negat ivef i
ndingsofr educedst r
ength,sel
ect
ivemot orcontr
ol,
balanceandcoor dinat
ion
 spast i
city(three-quart
er sofchil
drenwithCP
 retenti
onofpr imiti
ver efl
exes(ATNR, STNR,andtoni
clabyr
int
hineref
lex
 i
rritabi
lity,l
ethargy
 weaksuckwi tht onguet hr
ust
 poorheadcont rol
 high-pitchedcr y
 oral hypersensitivi
ty
 tonicbi te
 asy mmet ri
cmov ement s/unusualpostur
ing

Lat
ermanifestat i
ons
 roll
ingf ormobi li
ty
 combatcr awling
 “W sitti
ng”
 bunnyhoppi ng
 trunkorcent ral hypotoni a
 abnor mal postur i
ng“ scissor i
ng”
o Sci ssor i
ngi st hesi multaneousadduction,kneehy per
extension,
andpl ant ar
flexionoft heLE’ s.
o Fl exorsy nergypat ter
nofUEl i
keflexi
onoff inger
s,wrists,and
elbows, wi t
hshoul derabduct i
on
 ↓abi l
itytodi stinguisht wo- pointdiscr
imi
nation(UE)
 ↓st ereognosi sandpr opri
ocept ion(hemipl
egicCP)
 balancedi ff
iculties
 cont r
act ures
  bonedef ormi t
y
o coxav al
gus
o ky phosis
o scol i
osis
o r otati
onal defor
mit
ies
 atl
antoaxialinstabili
ty(
spast
icCP)
 rockerbottom ty peoffoot

Tabl
e8.
2Modi
fi
edAshwor
thScal
eforGr
adi
ngSpast
ici
ty
Gr
ade Descr
ipt
ion

0 No↑i
nmuscl
etone

1 Sli
ght↑i nmuscletone,
manifest
ed
byacat ch&releaseorbymi n
resi
stanceattheendoft heROM
whent heaff
ectedpart(
s)ismovein
fl
exionorextension

1+ Sli
ght↑i nmuscletone,
manifest
ed
byacat chfol
lowedbymi n
resi
stancethr
oughoutthe
remainder(l
essthanhalfoft
he
ROM)

2 Moremar ked↑i
nmuscletonet
hru
mostoft heROM,butaf
fect
ed
par
t(s)easil
ymoved

3 Consi
der
abl
e↑inmuscletone,
passi
vemovementdi
ff
icul
t

4 Aff
ectedpar
t(s)r
igi
dinf
lexi
onor
ext
ension

ASSOCI
ATEDMEDI
CALANDFUNCTI
ONALPROBLEMS

A.Vi
sual
sequel
ae
 40%ofpremat
urechi
l
dren

1.Str
abismus&Exot r
opia
o commoni nchil
drenwithdiplegi
a
2.Hemianopsi
a
o seeninchildr
enwi thhemiplegia
3.Reti
nopat
hy
o associat
edwi t
hpr ematur
ity

B.Hear
ingi
mpai
rment
s
  rel
atedtoototoxicdr
ugexposur
e,hy
per
bil
i
rubi
nemi
a,orTORCH
i
nfecti
oninutero
 10%ofchildr
enwi t
hCP

C.Or
almot
ordy
sfunct
ion

 due to weakness and incoordi

nati
on of l i
ps,tongue,and
masti
cator
yandf aci
almuscles
 ai
rwaypatencycanbeobstructedi
nsomechi ldr
enduetospast
ic,
fl
oppy
,orstenosedti
ssuesintheupperair
way
 i
nseverecases,aspi
rat
ionmaycausehy poxemia

1.Dr
ool
i
ng
o ref
lectpoorswall
owi
ngabil
it
y
o couldcauserashordent
alpr
obl
ems

2.Dy
sphagi
a
o duetopr
obl
em i
nor
alphaseorl
ary
ngeal
phase

3.Dy
sar
thr
ia

D.Feedi
ngdi
ff
icult
ies
 cont
ribut
etosubst antial
undernutri
ti
onormal nutri
ti
on
 1/ 3ofchi
ldr enwithhemiplegia&di pl
egia
 mor ethan2/ 3withquadri
plegia
 27%ofchi ldr enwithCPwer emal nouri
shed

E.Gast
roi
ntesti
nalsympt oms
1.Gastroint
est
inalreflux
o duet oweaknessoft heloweresophageal
sphi
nct
er
o causi ngepisodicemesis
2.Chronicconsti
pation
3.Fecalincont
inenceordefecati
on

F.Ur
inar
ysy mptoms
1.Diff
icul
tyurinati
ng
2.Detrusorinstabi
lit
y
3.Vesicoureti
cr ef
lux
4.Detrusor-
sphinctersy
ssy
ner
gia

G.Cogni
ti
veimpai r
ment s
1.Ment alretardat i
on( 30%)ofcases
2.Specifi
cl earningdi sabil
it
ies(20-30%)ofcases
3.Cogni t
iveabnor maliti
es(40-50%)ofnor mal bir
thwei
ghtCPpt
4.Seizuredi sorders(1/ 3)ofchil
drenwi t
hCP
o mostf requentin: Spasti
cquadr i
plegia(92%)
o Spast ichemi plegi
a( 55to72%)
o leastcommont o:Choreoathet
osisandAt axi
cfor
ms(23%)
 H.Ost
eopor
osi
s
 Calci
um andVit
aminDcanbedefi
cient
 ↓weightbear
ingandmuscl
est
resses

 Ref
erence:
(Br
addom)
,(del
Mundo,
Est
rada,
OcampoandNav
arr
o)

PROBLEMSOFACPCHI
LD

A.Pr obl
em wit
hmov ement
Thebraincontr
olsal lourmov ements.Ift
hebr ai
nisaff
ect
ed,problems
wit
hmov ementsdev elop.Thismayr esulti
nflacci
dit
yand/
orspast
ici
ty.The
pr
ocessoft hedevelopmentofmov ementi sslowamongCPchi l
dren(such
asheadraisi
ng,cr
awl i
ng,sit
ti
ng,andwal ki
ng).

B.Pr obl
em i
nbalancingheadandt r
unk
Achildwit
hCPhasdi ff
icul
tybal
anci
nghisorherheadandt r
unk.Iti
s
dif
fi
cultfort
hechi l
dt oremainseatedbecausetheheaddr opsforwar
d
causi
ngthechil
dtof allf
orward.Wit
hearl
y,r
egul
ari
nter
vent
ion,
thechil
dcan
event
uall
yhaveheadandt r
unkcontr
ol.

C.Pr oblem i
nfeeding
Mov ementsassoci at
edwithfeedi
ngsuchassucking,bi
ti
ng,chewi
ng,
swall
owi ngandev ent heactofputti
ngfoodint
oachi l
d’smouthcanbe
di
ff
icultbecauseofflacci
dit
yorl
ackofmuscul
arcont
rol
.

D.Ot
herproblemsduetoCP
1.Ment alpr
oblem
Of t
enti
mes,mentalretar
dati
on isfound among CP chi
l
dren
dependingonthear
easofthebrai
nthatar
eaff
ected.

2.Behavioralpr
obl
em
Pr
oblems associ
ated wi
th behav
ior l
i
ke i
rr
it
abili
ty or bei
ng
withdrawnar eoft
ent
imesobser
v edamongCP chil
dren.Somear e
hyperacti
ve.

3.Communi cati
onpr oblem
Thisproblem existswhenaCPchi l
disnotabl
etocommunicat
e
orhasdi ff
icult
yunder standi
ng,ar
ti
cul
ati
nghisorherthought
sor
respondi
ngt oquestions.

4.Epil
epti
cfi
ts
5.Visual
oraudit
orypr
obl
ems

COMPLI
CATI
ONSASSOCI
ATEDWI
THCP

1.Cont
ract
ures
 thi
scondi
ti
onoccur
swhent
hemuscl
espul
lsot
ight
lyont
hebonest
hat
 theaff
ectedli
mbcur l
sin
 Sev er
econt r
acturescanr esulti
njoi
ntdefor
miti
esordisl
ocati
on.
2.Mal
nut
riti
on
 swal l
owingorf eedingpr oblemscanmakei tdif
fi
cul
tforsomeonewho
hascerebral
palsy,parti
cularl
yaninfant
,togetenoughnutr
it
ion

3.Scol
iosi
s
 later
alcur
vat
ureoft
hev
ert
ebr
a

4.Ment
alretardat
ion 
 50% ofi nci
dence;mostcommoni nri
gid,atoni
candsever
elyspasti
c
quadr i
plegia
 sev eret
opr ofoundment
alret
ardat
ioncomprisesabout½oft
heret
arded
group

VI
I. DI
FFERENTI
ALDI
AGNOSI
S
1.Str
oke
 isanon- tr
aumat i
cbr aininjur y
, causedbyoccl usi
onorr uptureofcer ebr
al
bloodv essel
s,t hatr esultsi nsuddenneur ologi
cdef i
citcharacterizedby
l
oss of mot or cont rol, altered sensat i
on, cogniti
v e or l anguage
i
mpai rment,disequi li
brium, orcoma
2.TBI
 I sani nsulttot hebr ainthati scapabl eofproducingphy si
cal,i
ntellectual,
emot i
onal,social,andv ocational changes
3.Neuromuscul ardisorder s
 char acteri
zedbyweaknessanddecr easedDTR
4.Neurodegener ativ
edisor der s
 likeSphi ngoli
pi dosis,Kr abbedi sease,NeuronalCeroidLi pof
usci noses,
Adr enoleukody strophy ,andSi alidosis
 char acteri
zed by l oss of cogni t
ive skil
ls together wi t
h mot or
abnor mal i
ti
es
5.I
nborner r
or sinmet abol i
sm
 char acteri
zedbyi ntermi t
tentv omi ti
ngandlethargy
6.Mentalretardation
 associ atedwi thmot ordef ici
tsbutnomor esev er
et hant hecogni ti
ve
deficits

7.Ot
herEncephal
opat
hies

a.Mit
ochondri
alEncephal omy opathy,Encephalomyopathy,Lacti
cAcidosi s,
andStr
okeli
keEpisodes( MELAS)
 maybenor malf orthefir
stseveralyearsbuttheygraduall
ydisplay
delayedmot orandcogni tiv
edev el
opmentandshor tst
ature
 onsetwas bef ore age 15 y /o and hemi anopsia orcor t
ical
bli
ndnesswast hemostcommonmani f
est
ati
on

b.My
ocl
onusEpil
epsyandRagged-RedFiber
s(MERRF)
 charact
eri
zed byprogressi
ve myocl
i
nic epi
lepsy
,mitochondr
ial
my opat
hy,andcer
ebel
larataxi
awit
hdysarthr
iaandny
stagmus
 c. Bur
nEncephalopathy
 dev el
opsi nappr oxi
matel
y5% ofchil
drenwi t
hsi
gnif
icantburns
dur
ingthef i
rstsever
alweeksofhospi
tal
i
zation
 seizures ar et he most common cl i
nicalmani
festat
ion but
hal
luci
nationsandcomamayal sooccur

 Ref
erence:
(Ber
hman,
Kli
egman,
Jenson)

VI
II
. MANAGEMENT

A.PHARMACOLOGI
CALMANAGEMENT

1.Baclof
en
 helpsdecr easer eleaseofexcit
atoryneur otr
ansmitterfrom
aff
erenttermi nal
s
 dosage: 2.5-%. 0mgBI D
 isusedf ort het r
eatmentofmuscl espast
icityassoci
at edwith
neuromuscul ardi seases such as muli
tiple scler
osi s and
musclerigi
dity

2.Dantrol
ene
 hel ps decrease r el
ease of calcium from sar coplasmic
reti
culum
 dosage: 0.
5mgBI D
 isuset ocontrolspasti
cit
yresul
ti
ngf r
om uppermot orneuron
disorders,i
ncluding spi
nalcordi njur
y,my ast
henia gravis,
muscul ardyst
rophy

3.Benzodiazepenes
 itincreasesGABAbi
nding,
potenti
ati
ngpr
esy
napti
cinhi
bit
ion
 dosage: 1to2mgBIDthenincr
easeto20mgQID

4.Cl
onidi
ne
 inhi
bit
sshor
tlat
encyofmot
orneur
on

5.Ti
zanidine
 pr eventreleaseofexci t
atoryami noaci dsfr
om presynapt
ic
terminal
ofspi nali
nter
neurons
 mayf aci
li
tateglycer
icandani nhibi
tor
yt r
ansmit
ter
 dosage:2. 4mgatbedt imet henincreaseto2mg( maxof
36mg)

6.Phenol
 denatur
esprot
einanddi
sruptsmy
oneur
alj
unct
ions
 dosage:4-
6%aqueoussolut
ionmaxi
mum 20ml

7.Bot
uli
num Toxi
nTypeA
 prevent
srel
easetoxi
nofacet
ylchol
i
ne
  eff
ecti
vei ni mprov
ing ROM and reduci
ng tone and al
so
potent
ial
lyeff
ecti
veini
mprovi
ngmotorcontrol
 dosage:1-2unit
sperkgdependi
ngonsizeofmuscle

I
NDI
CATIONSFORTHEUSEOFBOTULI NUM TOXI NINCP
o calfinj
ecti
onf ordy nami cequi
nesper sistentt
hroughoutthegait
cycle
o hamst ri
nginj
ect ionf ordynamickneef l
exion
o hipadductorinject i
onf orsci
ssoring
o diagnosti
cmeasur esbeforesurgery
o managementoff ocal li
mbdy st
oni a
o analgesiaf
orpai nandspasm i ntheperioperati
veperi
od
o upperl i
mb:per sistentthumbi npal m,wr i
stpostur
epr event
ing
effecti
vehanduse, andelbowflexion

B.SURGI
CALMANAGEMENT

CommonOr
thopedi
cSur
ger
yinCP

Surgi
cal Pur
pose Posi
ti
oni
ngConsi
der
ati
on Tr
eat
ment
Procedur
e

Hi
pfl
exor o ↑ext
ensi
onROM o Avoidpr
olonged o Maintai
nlengt
hof
l
engt
heni
ng si
tti
ng hi
pf l
exormuscles
o ↓muscle
*
Usuall
y i
mbalance-r
iskof o Pr
onewedge o Strengt
henhip
i
l
iopsoas hi
psublaxati
on pr
efer
red fl
exors(needfor
stair
s,gait
)
*Someti
mes o Improveal
i
gnment o Standi
ngframewith
proxi
malrect
us stance,
gai
t footcont
rol(
cast
sor o Str
engt
henhi
p
femori
s AFO’s) ext
ensor
s

*
Rar
elysar
tor
ius o Pr
oneatnight(wi
thor
w/obodyspli
nt)

Hi
padduct
or o ↑hi
pabduct
ion o Abducti
onatnight
, o Maintai
nhip
l
engt
heni
ng usual
lyprone adductorl
engt
h
o ↑baseofsuppor
t
*Usual
ly o Wit
h/wi
thoutni
ght o Str
engt
henhip
proxi
mal--
-or
i n o I
gi mprovehygi
ene, spl
i
nt adduct
orsand
adductorl
ongus, posi
ti
oni
ng abduct
ors
graci
li
s o Abduct
ionwedgeon
o ↓sci
ssor
inggai
t pr
one
*Someti
mes wedge/wheel
chai
r
adduct
orbr
evs o ↓abnor
i malmuscl
e
i
mbalance
Hamstr
ing o ↑kneeext
ensi
on o Avoidpr
olonged o Maint
ainlengt
hof
l
engt
hening si
tti
ng hamstri
ngs(avoi
d
o ↑stancephase knee
*Medialorlat
eral stabili
tyingait
, o Pronewedge hyper
extensi
on)
hamstri
ngs i
mpr oved prefer
red( consi
der
al
ignment softkneespl i
nts) o Str
engt
hen
*Almostalways Hamstri
ng&Quads
dist
al o ↑stepl ength→ o Standingframewi th (pr
oxi
mal &di
stal
)
i
ncreasedt er
minal footcontrol
swingphaseand o Monit
orfor
heel str
ikeabil
it
y o Proneatni ghtwit
h ov
eracti
vequads
softkneespl i
ntsor
o ↑posi ti
oning nightspli
nts (
↑ext
ensort
one)
options

o ↓cr
ouchpost
ure

o Improv
estandi
ng
ali
gnment

Achi
l
lest
endon o ↑DFROM o I
niti
all
yNODFbey
ond o Maint
ainl
engt
hof
l
engt
heni
ng neutr
al PF
o ↑fullfootcont
act
*Fivediff
erent forstanding&gait o Standi
ngwit
hneutr
al o St
rengt
henPF&DF
types:Baker, DFonly
percutaneous, o ↑abili
tyforheel o Avoi
d
sli
ding,fr
actional str
ikedur i
nggait o Temporar
yspli
nt ov
erstr
etchi
ng
l
engt heni
ng,
o Al
l
owf
orbr
aci
ng o CasttomaintainROM (Speci
alat
tent
ion
vulpl
us
--
begi
near l
y whenconsider
ing
o I
mpr
ovegai
t support
iveweight hingedAFO)
beari
ng

o AFO≈6mos

o AFO,
cast
,spl
i
ntat
ni
ght

Ot
herNeur
osur
gical
int
erv
ent
ions

1.Sel
ect
iveDorsalRhi
zotomy(SDR)
 toreducespasti
cit
ybyint
err
upt
ingt
hesensor
yinputi
nto
thedorsalhor
ns

2.I
ntr
athecalbacl
ofen(I
TB)
 anot herneurosur
gicalopti
onforhypert
oni
a
 i nadditi
ontospastici
tyreduct
ion,
ithasanimpacton
dyst
onia

 Ref
erence:
(Br
addom)
C.PTMANAGEMENT

1.PoolTherapy
 Suppor tless weightf orthe chil
di nt eachi
ng patt
erns of
mot i
onwor ki
nsidethepool i
nform ofplay.
 Wat erhel
pscerebralpalsychi
ldt
omov einway stheymaynot
abletodoonlandRel iv
ebodywei ght  
  
  
  
  
  
  
  
  
  
  
 

2.El
ectr
ical
Sti
mulat
ion(ES)
 Usetoimprovedmuscl
est
rengt
h

3.FES 
 Havebeenr
ecommendedt
otr
aincont
rolofspeci
fi
cmuscl
e
gr
oups

4.Br
aces
 IthelpstheCPpat i
enti
nthecont
rolofl
i
mbdef ormi
ti
essuch
asequi nusorflexi
ondefor
mit
iesofthewr i
standhand.To
correctdefor
mity.Toobtai
nupri
ghtposit
ionandtocontrol
athetosi
stype.

5.Pl
aytherapy
 Toy sandotherobjectsar
eselectedwi t
hvar
iet
yofshapes,
textur
es,
consist
ency,andf
unct
ionaluse. 

6.St
ret
chi
ngExerci
ses
 t
ostr
etchthemuscl
esbei
ngspast
ic

7.Manual
therapy
 Uset or el
axt
hemusclesontheext
remi
ti
es;f
orwar
m up
beforeandaf
tert
reat
ingonsomemodali
ti
es

8.Ther
apeut
icbal
ls
 Usetofaci
li
tat
eandi
mpr
ovebodybal
ance,
post
ureand
equil
i
bri
um

9.Ther
apeut
icbands
 Tofaci
li
tat
est
ret
chi
ngofti
ghtmusclesandt
oimpr
ove
fl
exi
bil
it
yandt
oneofdi
ff
erentaf
fect
edmuscles

10.Wheel
chai
r
 Useforambul
ati
onandl
ocomot
ion
 Ty
pesofBr
aces:

1.Longl
egbraces
 thechi
ldr
enar
etaughtt
ost
andandst
ep

2.Ful
l
-lengthbr
ace
 haslocki
ngj
oint
sathi pandkneesot hatt
hecont
rol
canbe
t
aughtwi
tht
hem lockedorunlocked

3.Spi
nal
brace 

Or
thosi
s

1.Mol dedpol ypropylenehingedanklef

ootor t
hosis
2.Knee- ankle-footorthosis(KAFO)
3.Hip-knee-ankle-footorthosis
4.Balancef orearm or t
hosis
5.Anklef ootor t
hosis( AFO)
 mostf r
equent l
yprescri
bed  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
​ 
  
  
 usedt ocont rolspasti
cequinus,pr omot ealignmentofthe
hindfootandcont rolmidf
ootandexcessi vekneeadhesionin
stance

NEUROMOTORTHERAPYAPPROACHES
A.Ayres
 sensor yi nt egratedusedt oenhancedev elopmentofpr eschool
-school
agechi l
dr enwi thlearningdi sabili
ti
es( sensoryintegrationapproach)
 v est i
bularexer cises
B.Bobath
 dev elopedappr oachcal l
edneur odev elopmentaltreatment
 adv i
sedf orCPatear lystage
 mai n goal :nor mali
ze t one,i nhibitabnor malpr i
mi ti
ver efl
ex pattern,
facili
tateaut omat icreactionsandki nestheti
cnormal feedback
C.Crother
s
 i nvolvedpat ientinameani ngfulprogr am
 needact iv emov ementandst imul ati
onact i
vit
iest opr eventcontr
actures
andencour agepar ti
cipati
onsev erelyinvolv
edchildren
 ov er protect i
onf rom par entsisdi scour aged

D.Denver
 emphasi
zedfunct
ionalabi
l
ityr
athert
hanpat
ter
nsofmov
ement
 ext
ensi
vel
yusedbracing

E.Doman
  i
ntegr
atedt
heconceptsintoather
apycal
l
ed“
pat
ter
ning”;nol
onger
r
ecommended(
Patter
ningther
apy
)

F.Fay
 post
ulat
ed thatmot ordev
elopmentl
evel
s ofbr
ain compar
abl
eto
evol
uti
onar
yprocess

G.Rood
 devel
opedthesensor
imotorapproach
 usedspeci
fi
csensoryst
imulati
ontoeli
citmov
ement

H.Phel
ps
 used or
thopedic approach wi
th conv
ent
ionalt
echni
ques f
rom pol
i
o
tr
eat
mentr egimens
 emphasi
zedi nhi
bit
ingabnormal
mov ement

Tabl
e54-
3Si
mil
ari
ti
esandDi
ff
erencesbet
weenNeur
omot
orTher
apyAppr
oachest
oCP
Neur
odev
elopmental Sensori
motor Sensory Voj
taappr
oach Patterni
ng
t
reat
ment(Bobat
hs) appr oacht
o i
ntegrati
on therapy(Doman-
tr
eatment(Rood) approach Delacato)
(Ayr
es)

CNSmodel Hi
erar
chi
c Hi
erar
chi
c Hi
erar
chi
c Hi
erar
chi
c Hi
erar
chi
c

Goal
sof
t
reat
ment
Tonor
mal
i
zet
one  Toact i
vate  Toimpr ove  TopreventCP  Toachi
eve
postural effi
ciencyof i
ninfantsat i
ndep.mobi
li
ty
Toinhi
bit responses neural ri
sk
pr
imiti
veref
lexes (stabi
l
ity) processing  Toimprove
 Toimprov
e motor
Tof acil
i
tate  Toacti
vate  Tobet ter motori
c coor
dinat
ion
automat i
c movement organize behav
iori
n
reacti
onsand (mobi
li
ty) adapti
v e i
nfant
swith  Topr eventor
normal mov ement oncestabi
l
ity responses fi
xedCP i
mpr ove
patterns i
sachieved communi cati
o
ndisorder s

 Toenhance
i
ntel
l
igence

Pri
marysensory  Kinesthet
ic  Tact
il
e  Vest
ibul
ar  Pr
opr
iocept
ive Al
lsensor
y
syst
emsut i
li
zed sy
stemsare
toeff
ecta  Propri
ocepti
ve  Pr
opr
iocept
ive  Tact
il
e  Ki
nest
het
ic ut
il
ized
motorresponse
 Tactil
e  Ki
nest
het
ic  Ki
nest
het
ic  Tact
il
e
Emphasisof  Posit
ioni
ng& Sensor y Therapistgui
des Tri
ggerrefl
ex Sensory&r efl
ex
tr
eatment handli
ngto stimulati
onto butchild l
ocomot iv
e sti
mulation,
acti
vi
ti
es normali
ze activatemotor control
ssensory zonesto passive
sensoryi
nput response i
nputt oget encourage mov ement
(tapping, adaptive mov ement patter
ns,
 Faci
li
tat
ionof brushing,i
cing) purposeful patter
ns(e.g. encouragement
acti
vemov ement response ref
lexcrawl) ofindependent
mov ement s

I
ntendedcl
i
nical Chi
ldrenwi
thCP Chil
drenwith Chi
ldr
enwit
h Younginf
ant
sat Chil
drenwit
h
popul
ati
on neuromotor l
earni
ng ri
skforCP neonatal
or
Adult
spostCVA di
sorderssuch di
sabi
li
ti
es acqui
redbrai
n
asCP Younginfant
s damage
Chi
ldr
enwi
th wit
hfixedCP
Adul
tspostCVA aut
ism

Emphasi
son Yes No No Yes No
tr
eat
ingi
nfant
s

Emphasi son Yes No No Yes Yes

fami l
y
i
nv olvement Handl
ing& Suppor
tiv
erol
e Fami
ly Family&fri
ends
during posi
ti
oningf
orADL encour
aged admi
nist
ers administ
er
treatment tr
eat
mentat tr
eatment
homedail
y severalt
imes
dail
y

Empi
ri
csuppor
t Fewst
udi
es Ver
yfewst
udi
es Manyst
udi
es Fewst
udi
es Fewst
udi
es

Conf
li
cti
ngr
esul
ts Confl
ict
ing Confl
ict
ing Confl
ict
ing Confl
ict
ing
resul
ts resul
ts resul
ts resul
ts

Wit
hschool
age
chi
l
dren

Positi
veresul
ts
fortact
il
eand
vesti
bulari
nput
withinf
ants

 Ref
erence:
(Br
addom)

THERAPYFORCHI
LDRENWI
THCP

A.Consi
derthechi
ld’slevelofdev
elopment
1.Whi l
ethechi
ldi sly
ingonhis/herback
a.Keept hehandandt runkstr
aight.
 Useapi llowundertheheadt o
controlthehead’
sside-t
o-side
mov ement
 b.Doexerci
sestomovet
hej
oint
soft
heext
remi
ti
es.Thenr
oll
thechi
l
d
ov
erfrom si
detosi
de.

c. Whent
ur ningtotheleft
i. r aisethelefthandtowardthehead
i
i. bendt herightknee
i
i
i. r ollthechil
d’str
unkslowlyunt
ilt
hechi
l
dli
esonhi
s/her
stomach

2.Whi
l
echi
l
disl
yi
ngonhi
s/herst
omach

a.Whenlyi
ngonthestomach,
usetheel
bowsassupportt
o
gi
veweightt
otheelbow
j
oint
sandshoulder
s.

b.Shif
tthewei ghtbet weent
he
ri
ghtandl ef
tar msby
encouragingthechi ld
toreachoutf or
somet hi
ngofi nterest,
l
ikeaf avori
tetoy .

Remember :
foraandb, t
he
tr
unkcanbesupportedby
putt
ingapil
lowunderthe
chi
ld’sst
omach.
 c. Supportt
hechildfr
om theelbowtokeepi
tst
rai
ght
.Indoi
ngt
his,
the
weighti
sshift
edfrom t
heelbow
tothehands.Holdontothe
elbowstokeepthearm str
aight
.

d.From thi
sposit
ion,
pull
thechild
tosi
tti
ngpositi
onandsupport
him/herfr
om theback.
 Pusht hechildf
rom ri
ght,
left
,
fr
ont,andbacktodevelop
goodsitt
ingbal
ance.

3.Whi
l
ethechi
l
disi
nasi
tt
ingposi
ti
on

a.Placethechil
dony ourlap.
Raiseyourkneesal ternat
ely
todevelopbalance.Suppor t
thechil
donhi s/herupper
trunkt
opr ev
enthi m/ her
from f
all
ing.

b.Whilet
hechi
ldi
sseated,
encour
agehi
m/hertoreachfor
somethi
ngfr
om hi
s/herside.
4.Whi
let
hechi l
disonallf
ours
a.From asi t
ti
ngpositi
on,posi
tionthechi l
donhis/herstomachandlet
hi
m/ hersuppor
thimself/
herselfwit
ht hehandsandknees.Suppor t
hi
s/herstomachwithpill
owst opreventthefacefrom hit
ti
ngthe
gr
ound.Supportbotharmst okeept heelbowsstraight.
b.Hav ethechildt
ransferanobjectfr
om onehandt oanothertoshi
ft
wei
ghtonbot hhands.

5.Whent
eachi ngt hechi ldhowt ocrawl,dot hefol
l
owi ng:
a.Posi tiont hechi l
donhi s/
herst omach.
b.Bendt heleftelbowandsl ightl
ybendt herightknee.
c. Touchhi sbut tocksorelseticklethesoleoft herightf
oot
.Assoonas
thechi l
dst retcheshi s/
herl eg.Hol dittoal l
ow thechil
dt opush
himsel f/
hersel fforward.Repeatt hesamepr ocedurewi
tht heot
her
sideoft hebody .
d.Pl aceabot tleofmi l
korany thingthatwil
lat tr
actthechi
ldsohe/she
willbeencour agedt omov etowar dit
.

6.From posi
tion#4,thechi
l
dcanbepull
eduptokneel
i
ngposit
ion.Suppor
tthe
chil
dfrom behind.
a.Uset oy
st okeept
hechi
l
dinthekneel
i
ngposit
ion.
 b.Useot
herf
ormsofsuppor
t.

7.Whenst andi
ng
Beforeall
owingthechil
dtost and,make
surethathe/shehasdev el
opedgoodhead
andtrunkcontrol.Thisi
sv er
yimpor t
antto
keep his/her balance in standing and
walki
ng.

8.Pr
epar
ati
onf
orwal
ki
ng

a.Thetwol egsoft hechil

dmustnotbe
too close.In keeping t
hestandi
ng
posit
ion t he whole body mustbe
keptstraight
.

b.I
n assumi ng t
he standi
ng posi
ti
on
forthefir
stt
ime,supportt
hechil
dat
thewai stand shoul
dersforbetter
balance.
 c. Placethechil
dinbetweentwochai
rsforsuppor
t.Lethi
m/herst
and
andteachhim/herhowtobal
ancei
npreparat
ionf
orwalki
ng.

d.Letthechil
dstandbyhimsel
f/
hersel
f.Fi
rst
,holdhim/heronbot
h
hands,
thenononehandonl
yandfi
nall
ywit
houtanysupport
.

9.Wal
ki
ng
a.Letthechil
dwalkwi thsupportonhi
s/herarm orhand.
b.Letthechil
dwal ksidewayswithdi
ff
erentfor
msofsupportli
kechai
rs,
abedortabl
e.
c. Lett
hechil
dwalkwhi lehol
dingontoar ol
l
ingball
,adrum,
aroll
i
ngtoy,
orachai
rthathe/shecanpush.

(
a.) (
b.) (
c.)

10.Ty
pical
standi
ngposi
ti
onofaCPspast
icchi
l
d
 Thelowerextr
emi t
iesareheldv er
ycl osebecauseofspasti
cit
y.This
makesitdi
ffi
cul
tforthechildt
oshiftweight.Theupperext
remi
ti
esarehel
d
cl
osetothebodywithinter
nalr
otat
ionofbot harms,
andthehandsar
et i
ght
ly
cl
osed

Tohelpthechi
l
dwalk:
Putt
hechil
dinastandi
ngposi
ti
on.Str
etchbot
harmsupwar
d;r
otat
ethe
ar
m outwardwhil
epushi
ngtheshoul
dersfor
wardandupwar
d.

B.Exer
cisesf
orJoi
ntMobi
l
ity

I
tisi
mport
anttomaint
aint
heful
lROM ofthej
oint
s,whi
chf
ort
hechi
l
d
wi
thCPareoft
ent
imesei
thert
ooti
ghtortool
oose.

Thef
oll
owi
ngshoul
dber
emember
edwhengi
vi
ngexer
cisesf
orj
ointmobi
l
ity
:

1.Placethechi l
dinapositi
onaccor di
ngtohis/
herlev
elofdevel
opment.
2.All
owt hechildt
ol i
eonhi s/herbackandholdtheotherjoi
ntswhi
chthe
chil
di snotabl et omov epr operl
y.Feelwhichmusclesarespast
icor
thoset hatli
mitj
ointmovement s.
3.Ifthemov ementcausespai n,do
notf or
cet omov ethejoint.Take
noteupt owhatpoi ntthechi l
d
canmov ethejoi
nt.
4.Aj ointcanbemov edinv ari
ous
way s:

a.For joi
ntsthat can be
mov ed activ
ely, move
them dur
ingacti
vi
ti
est
hat
 t
hechi
l
dcandobyhi
msel
f/her
sel
f.

b.Forjointsthatar e
l
imited but can
be mov ed
acti
v el
y, t here
shoul d be some
assistance f rom
the poi ntwher e
thechi ld canno
l
ongermov et he
j
ointact i
vely up
totheendoft he
range of
mov ementoft hepar
ti
cul
arj
oint
.

c. Evenifthechi
ldisnotabletomov eajoi
nt,i
tcanst
il
lbeusedf
or
anactiv
ity.Whenmov ingthejoi
ntpassi
vely
,doitwithi
napai
n-
fr
eerange.Verbali
nstr
ucti
onisimpor
tantsothechi
l
dknowswhat
i
sbeingdonet ohi
m/ her.

d.Theexer
cisesorgamesshoul
dnott
ir
ethechi
l
d.Mov
ingachj
oint
5to10ti
meseachdayisenough.

C.Muscl
eSt
ret
chi
ng

Iti
simpor tanttohelpaCPchildmov ehis/herbodybecausethemuscles
aretightorspast i
c.Butcar eshoul
dbet akeninhel pingthechi
l
dst ret
cht
he
muscl es,asov erstret
chi
ngcancausef ractur
es.St r
etchi
ngshoul
dl ast5to7
seconds.Followingar estepsinst
ret
chingthehipjoint:

1.Letthechil
dli
eonhis/herbackwi thbentknees.
2.Slowly st
ret
ch both hips by separati
ng the knees accor
ding tothe
toler
anceoftheCPchild.Countfrom 5t o7beforethel
egsareallowedto
rel
ax.
3.Placeanythi
ngthatwil
lhelpsepar at
et hetwolegssuchasapi l
l
ow.This
canalsobedonewhent hechi
ldissitti
ng.
D.Exer
cisesf
orCoor
dinat
ionofBot
hUpperExt
remi
ti
es

The exer
cises f
orcoor
dinati
on of
bot
hUEcanbedonewhi l
et hechi
ld
i
splayi
ngandbeingt
rai
nedtosit.

Forexampl e,tr
ansferr
ingaballf
rom
onehandt oanot herortr
ansfer
ring
aballf
r om therightsi
deofthebody
totheleftsideusingbothhands.

Anotherexampl
eislett
ingt
hechi
l
d
hol
d a bag wi th sand t
o have
di
recti
onandcontr
ol.

E.Sensor
yInt
egr
ati
on

1.Audit
ory
a.Whilecar
ingf
ort
hechi
l
d,t
alktot
hechi
l
dandment
ionhi
s/hername.
b.Singorpl
aymusi
ctohi
m/her.

2.Vi
sual
andaudi t
ory
a.Poi ntandnamet hi
ngsforthechil
dwhil
eusi
ngthem,f
orexampl
e,
toy
s, comb,water
,sl
ipper
s.
b.Poi nttothedi
ff
erentpart
softhebodywhi
l
enamingt
hem.

3.Tacti
l
e
a.Lett hechi l
dtouchcer
tai
nobject
sofdiff
erentsi
zes(
bigandsmal
l),
di
fferenttext
ures(
fi
neandrough),anddi
ff
erentt
emperat
ures(
war
m
andcol d)
.

4.Tacti
l
eandpropri
ocept
ive
a.Whil
et hechi
ldi
satpl
ay,hel
phi
m/herusehi
s/herhandsandhi
s/her
 whol
ebody
.

5.Vesti
bular
a.Swi ngingthechil
dwhenput ti
nghim/hert
osleepwillgi
vehi m/her
vesti
bular st
imulat
ion. Opport
uni
ti
es to bal
ance himsel
f/her
self
shouldbeencouraged.

6.Vi
sual
,audit
or y
,tacti
l
e,propei
ocepti
veandv est
ibul
ar
a.Taket hechi l
df orawal k.Whateveropportuni
ti
est onamet hings,
touch,f eel
,mov e around,and play mustbe encour aged.Give
suffi
cienttimefort hechil
dtounder st
andandr ecogni
zet hethi
ngs
aroundhi m/her.

FEEDI
NGACHI
LDWI
THCP

Nor
mal
l
y,aCPchildhasproblemsi nfeedi
ngbecauseof
1.l
ackofheadandt r
unkcont rol
2.l
ackofbalanceinsit
ti
ng
3.l
ackoftonguecontrol
;whichresult
sindi
ffi
cul
tyi
nswal
l
owi
nganddr
ool
i
ng
4.i
neff
ect
ivewayoff eeding
5.l
ackofeye-handcoordinat
ion

TheCor
rectPosi
ti
oni
nFeedi
ngaCPChi
l
d

A.Bot
tl
eFeedi ng
 Pl acet hewedgeagai nstt het able,t hen
yourhandsont hechestoft hechi l
dgent ly
pressi ng t he chest .Feed t he chi l
d as
he/shef acesy ou.From y ourposi t
ion,y ou
cancont roltheheadmov ement sandhel p
thechi l
dswal l
owbet ter.
 Whenf eeding,al wayspl acet hechi ldinan
almost seat ed posi ti
on f or bet ter
swal lowi ngandt oav oidov erext ensionof
thet runk.
 Makesur ethechi ldisseat edony ourlap.
Keept hehi psandkneesbentwhenseat ed.
Remembert of eedt hechi ldwhenhe/ she
i
sf aci ngy ou.
 Foranol derchild,puthi m/ heri nanal most
seated posi tion so he/ she can dev elop
sit
tingbal ance.Tokeept heheadst rai
ght ,
feedt hechi l
dwhi l
ehe/ shef acesy ou.Useani nf
antseattoprov
ide
sufficientsuppor t.
 I fyounot i
ceani mprov ementi nt hechi ld’ssi
tt
ingbal
ance,makehi
m/her
sitst raight,wi t
hst raightenedl egsandf l
exedhip.Makesurethechil
d
 doesnotgooutofbal
ance.
 Seetoi tthatt
hechil
di shol
dingthebott
le,whichshoul
dhel
pkeep
hi
s/herheadatt
hecenterandl
earnmidl
i
neori
entat
ions.

B.Teachi
ngaChil
dwit
hCPHowtoChewProper
ly
 Techni
quest
odev
elopj
awcont
rol

1.I
fthechi l
disony ourri
ghtside
o Pl acethet humbatthejoint
oft hejaw,theindexfi
nger
betweent hechinandlower
l
ip,and t he middlefi
nger
below t he chi n. Appl y
pressure on these areas
wher e t he finger
s ar e
placed to encourage t he
chil
dt ochew.

2.I
fthechi
ldisfacingy ou
o Place t he t humb
between t he chin
and the l owerl i
p.
Place t he i ndex
fi
ngeron t he j
aw.
Then pl ace t he
middlefingerbelow
thechin.

C.Spoont ouse
Theuseofspooni nf eedingisimportantfor
the chil
dt ol earn how t o eatsoli
df oods.
Remembert oappl ypr essurealwaysont he
tongue whi lef eeding t he chil
d.Thi s wil
l
preventthechi ldfrom pushi ngthefoodoutof
his/
hermout h.
o Wr ong:Thespooni stoodeepandt oo
point ed.
o Cor rect:Thespooni sneit
hertoodeep
nort oo shal low.The spoon can be
bentaccor ding tot he needsoft he
child.

Thi
ngstoRemember :
1.I nfeedi
ngthechi
l
d,makesur
ethespoondoesnottouchtheli
ps
andtheteet
h.
2.Keept hemouthcl
osedt
ochewthefoodaf
teri
thasbeentakeni
n.
TheCor
rectWayt
oTeachaChi
l
dwi
thCPHowt
oDr
ink

Wr
ong:
o The gl
ass i
s hi
gherlev
elthan t
he
chi
ld.This makes t
he chi
ldlean
backwar
d.

Cor
rect
:
o The chi l
di s seat ed;the head and
trunk ar e st r
aight. The glass is
offeredt othechi ldfr
om thef r
ontat
his/herl ev
el.Ift hechildcannotsit
wi t
hout suppor t, some dev i
ces
(straps)willbeneededt oensurethat
t
hechi ldwillnotfallf
rom t
hechair.

ToCont
rol
Drool
i
ng

a.Wi thy ourindexandmi ddlef ingers,massage

thet hroatdownwar dsev eralt imessot hat
thechi ldwi l
lswal lowt heaccumul atedsal iva
i
nt hemout h.
b.Whi l
edoi ng t hi
s,askt hechi ldt o swal l
ow
his/ hersaliva.Thi sway ,y ouar emaki ngi t
cleart othechi ldhowy ouwanthi m/ hertoeat .
Lat eron,he/ sheshoul dbeabl et oswal l
ow
without y ou massagi ng hi s/her t hr oat
any mor e.
c. Ifthechi l
ddr ools,wi pehi s/hermout h.Then
l
at er,t each hi m/ herhow t o wi pe his/ her
mout hev eryt imehe/ shedr oolsbygui ding
his/ herhand.Dot hisuntilthechi ldlearnst o
doi tbyhi msel f/herself
.I twi l
lbebet teri fahandker
chi
eforahandt
oweli
s
pinnedont hechest .

GeneralInformationonFeedi ng
a.Sweetf oodscausesal i
vation.
b.Iti sdiff
iculttochewmeat .Iti
seasi ertochewsoftfoodsl
ikesquashorpotat
o.
c. I
ti seasiertoeatst ickyfoods.
d.Iti seasiertoswal lowmi lkandf r
uitjui
cesthanwater.
e. Alway scheckt heposi t
ionoft hechi l
d.Makesuret hatt
heheadi sneit
herbent
forwardnorbackwar d.
f. Usey ourt hreefingers.
g.Useasmal landnot -
too-deepspoon.Pl acethespooninfrontandatthemiddle
oft hetongue.
h.Pl aceasmal l
amountoff oodont hespoon.
i
. Useagl assinsteadofabot tl
efordr i
nking.
Bat
hingaChil
dwi thCP
 AstheCPchi ldgrowsol der,
itbecomesmor edif
fi
cultt
ot akecareofhi
m/ her
.
 Iti
sal oteasierifanotherchil
djoinshim/herinthebathtub.
 Thechi l
dmustbeseat edinthetubwithbothkneesst r
aight.
 Thehei ghtoft hebasi nmustbeatt helevelthatissuitedtoboththechild
andthecar egiver,
sot hatthelat
tercanavoidhav i
ngbackpai ns.
 Ift
hecar egivergivesabat hwhi l
estandi
ng,t hebasinmustbeatt helevelof
thecaregiver
’swai st
.
 Thefloormustnotbesl i
ppery.I
tisagoodi deatouseabat hmat .

A.Somewaysofcar
ryi
ngachi
l
dwi
thCPt
othebat
hroom
1.Spast
ic

Wr
ong:
o Itiswrong to car
rya spastic
chi
ld wi
th both arms str
aight
and both legs strai
ght and
ti
ghtl
ycl
osetooneanot her
.

Cor
rect
:
o Pl ace the arms of t he chil
d
aroundy ourshoul
ders.Separat
e
the hi ps by hol ding t hem
outward and away f rom each
other.

2.Fl
oppy

Wr
ong:
o The posi t
ion shown i n t he
il
lustrati
on on t he ri
ght (not
included)isnotgoodforafloppy
child because he has no head
and t r
unk contr
ol.He i s not
encour agedtomov eandsupport
himsel f.

Cor
rect
:
o Thisi
sthecor
rectwayt
ocar
rya
 f
loppychi
ld(
onr i
ght)
.Hislegsarebentwhi
l
eyourar
m suppor
ts
t
hehipstost
rai
ghtenhisheadandback.

3.At
het
oid

Cor
rect
:
o I l
lust
rat
ionont heri
ghtshowshow t o
properl
ycarr
ytheat het
oidchi
ld.Pl
ace
yourarmsunderhisar mpi
t.Pressy
our
armsgentlyasy oupushhisarmswi t
h
yourar ms f
orward.Then place y
our
handsunderhisthi
ghssoy oucancarr
y
thechil
d.

o Il
l
ustr
ati
onont herightshowsabet t
er
waytocarryanat hetoidchil
d.Lethim
bendhisneckal i
tt
lewhileyouholdhim
onhischest.Inthi
sposi t
ion,hishands
arefr
eet o mov e.Thechi ld wil
lalso
l
earntocontrolhi
sneckandt r
unk.

Remember :
Placethechildinthebatht
ubwhi l
eiti
s
sti
llempty .All
ow thechildtoplayf orsome
ti
meandwai tunti
lhei salr
eadycomf ort
abl
y
seated.Then,fi
llupthetubwit
hwat er.Thiswil
lkeepthechi
ldf
rom bei
ng
afrai
doft hewat er
.Makesur ethatthet ubisnotsli
ppery
.Theuseofa
rubbermatwi l
lbehelpful
.

Way
sofDressi
ngupaChi l
dwi t
hCP
 Inchangingthechil
d’sclot
hes,makesur ethateveryt
hingyouneediswithi
nyour
reach.
 Aspasticchild6to8mont hsoldwil
lattimesresistbodymov ementsandmake
thi
sactiv
itymor edi
ffi
cult
.
 Itwil
lbeal oteasi
erwithanathetoi
dchil
dbecauset hereisl
essresi
stance.
 Thediaperscanbechangedi nar ecl
ini
ngpositi
on.

A.Way
sofdr
essi
ngupay
oungCPchi
l
d

1.Spastic
o Hol dthechi l
d’selbowandupperf orearm.
o Rai sebot hhandst ogetherwhi l
er otati
ngthem externall
yandpulli
ng
them towardy ou.Indoi ngthis,youhel pthechil
dr aisehis/
herhead
andst r
aightenhis/herbackt omakedr essi
ngeasi
er.
Correct:
 Hol dthejointitself
,thenturni ti
nwardandout ward
 o Itwil
lnotbedifficultt
obendhi slegifyoubendt hehipsf ir
stbefor
e
separat
ingthelegs.
Correct
:
 Hol dbot hkneesandsepar atethel egswhi l
et urni
ngt hem
outsi
de.Thiscanbedonewhenput ti
ngonhispant s.
 Makesur et hatthelegisnoti
nternall
yrot
ated,andt henbend
thelegbef orestrai
ghteni
ngthet oes.Aft
erhav i
ngdonet hi
s,
youcanputont hesocksandshoes

2.At
hetoi
d
o Turnt hearmsinternal
lyandslight
lydownwar dwhilepull
ingthem
towar dyou.Thenslowlyrai
sethearmsupwar d.I
ndoingthis,youare
helping the chi
l
dt o bend hi
s/herneck forward and check the
hyper ext
ensi
onoft heback.Itshouldnow beal oteasi
ert oputon
his/herclot
hes.
DEVELOPMENTALMI
LESTONES
Age Gr
ossMot
or Fi
neMot
or Per
sonal
/Soci
al Speech Cogni
ti
ve Emot
ional

Newbor
n  Fl
exort
one  Handf
ist
ed  Habit
uat
ionand  cry  Sensor
i-motor  Basi
cTrust&
pr
edominat
es somecontrol
of peri
od:0-24mos. Mist
rust
 Gr
aspr
efl
ex stat
e  stat
eofbeing
I
npronet
urns dependent  Ref
lexst
age  Normal
headt
osi
de symbiot
ic
 quiet
ingand phase
 Automati
c headt ur
ning
ref
lexwal
king torat
tleor
voi
ce

4mos. Rol
lfr
om pr
onet
o  Handsmost
ly Recogni
zes  cues& Tur
nst
ov oiceand  Lapbaby
si
de open bott
le chuckl
es bel
l
sconsistent
ly
 devel
opi
nga
 Midl
i
neHand l
augh senseofbasi
c
pl
ay tr
ust

 Pal
margr
asp

5mos. Roll
pronet
o
supi
ne

6mos. Rol
lsupi
net
o
pr
one

7mos.  Maint
ains  Transf
ercube  Dif
ferent
iat
e Usesasingle Canret
ri
evean Hasasenseof
si
tt
ing fr
om handto b/nfamil
iar anddouble obj
ecthi
ddeni
nhi
s belongi
ngtoa
hand person& consonant- vi
ew central
per
son
 Mayl
eanon str
anger vowel
ar
ms  Bangsobj
ect combinati
on
 Tal
kstohi
s
 Hol
dsbot
tl
e mir
rori
mage E.
g.Ma,
Pa
10mos.  Creepsonal
l  Pi
ncergr
asp  Play
speek-
a-  Shoutfor  Dif
ferenti
ate “
Lov
eaffai
rwi
th
fours boo att
enti
on avai
lable t
hewor
ld”
 Matur
ethumbt
o behavior
 Pi
votsi
tt
ing i
ndexgrasp  Fingerf
eeds; I mit
ates patt
ernsf ornew
Chewwi th speechsound ends;E.g.pull
s
 St
and rotat
or rugonw/ ci sa
moment
ari
l
y mov ement  Uses“mama toy
&papa”
 cr
uises  Wav
esby
e-by
e

14mos.  Walksalone,  Pi
l
es2cubes  Usesspoonw/ Usessi
ngl
e Under
stands  Stageof
armsinhigh overpr
onat
ion word si
mplecommands AutonomyVS
guardormid  Scri
bbles &spil
li
ng Shameand
guard spontaneousl
y Doubt(1-
3y/
o)
 Remov
es
 Widebase,  Holdscrayoni
n gar
ment I
ssueof
excessivehi
p& ful
llengt
hin hol
dingon&
kneeflexi
on pal
m l
ett
inggo

 Footcont
acton
enti
resol
e

 Sli
ghtv
algus
knees&feet

18mos.  Armsatl
ow  Cr
uder
elease I
mitates  Poi
ntst
o  Preoper
ati
onal 
guar
d housework namedbody peri
od(2-7y/
o)
 Holdscr
ayonbut par
ts
 Mature &inpalm  Carr
ies,hugs  Ablet
oevokean
support
ingbase doll I
denti
fi
esone obj
ectorev
ent
&heelstri
ke  Dumpsr ai
sini
na pi
ctur
e notpr
esent
bot
tle  Dri
nkfrom cup
 Seatsel
fin neatl
y  Says“no”and
chai
r j
argonwords

 Walks
backwar
d

2y
r  Begi
nsr
unni
ng  Handdomi nance  Pull
sgar ment  Two-wor
d Chi
ldi
scapabl
e
i
susual phr
ases of
:
 Wal ksup&  Usesspoon
downst air  Buil
deight-cube well  Ref
erst f  Def
osel erred
alonew/no- tower byname i
mitat
ion
alternat
ingfeet  Opensdoor&
 Placespencil tur
ningknob  Fol
lows  Sy
mbol
i
cpl
ay
 Jumpsonbot h shaftb/nthumb si
mple
feetinplace &f i
nger
s  Toil
ettrai
ning di
rect
ion  Dr
awingof
usuall
ybegin gr
aphi
cimage

3y
r  Runswel
l  Usesoverhead  Toi
lett
rai
ned  Three-wor
d  Stageof
thr
owwi t
hA- P day&night sentences I
niti
ati
veVS
 Wal
ksupstai
rs arm &tr
unk guil
t
w/al
ter
nat
ing motion  Unbutt
ons,  Giv
esful
l
f
eet washesand name  Dealswit
h
dri
eshands& i
ssueofgeni
tal
face I
denti
fi
essel
f sexual
it
y
asboyorgi
rl
  Recogni
zes3
col
ors

4y
r  Walksdown  Handlesapencil
st
airsw/ byfi
nger&wr i
st
al
ternat
ingf
eet act
ionli
keadult
s

 Hopsonone  Copi
esacr
oss
f
oot
 Thr
owsov
erhead
 Plant
ararches
devel
oping  Cut
swith
sci
ssor
s
 Situpfrom
supineposit
ion
w/ orot
ati
ng

5y
r  Ski
ps  Drawsmanw/  Cr
eat
ivepl
ay  Fl
uentspeech  Stageof
head,bodyand i
ndustryVS
 Ti
ptoes extr
emiti
es  Compet
it
ive  Givename, i
nferi
orly(5yr
pl
ay addressand toadolescence
 Balances10  Throwsw/ age
seconeach di
agonalar
m&  Usesf
orkfor
foot bodyrot
ati
on st
abbi
ngfood

 Cat
chesw/hand  Dressesw/ o
supervisi
on
exceptt y
ing
shoelace

6y
r  Ri
desbi
cycl
e  Pr
intal
phabet  Teacheri
san Periodof
i
mpor t
ant concrete
 Rol
l
erskat
es  Matur
ecatch& author
it
yto operati
onal
t
hrowofball chi
ld thought(7to
adolescence)
 Usesfor
k capablefor
appr
opri
atel
y l
ogicalthi
nking

 Ti
eshoel
ace

7y
r  Continui
ng  Eat
sw/f
ork&
ref
inementof kni
fe
ski
lls
 Combshai
r

 Responsi
blef
or
grooming
 I
NFANTI
LEREFLEXES

A.Pr
imi
ti
veRef
lexes
Ref
lex Onset I
ntegr
ati
on St
imul
us React
ion

Fl
exorWi
thdr
awal 28wksof 1-
2mos. Noxi
ousst
imul
usi
nsol
e Massf
lex
ionI
/Ll
owerext
remi
ty
gest
ati
on off
oot

Cr
ossedExt
ensi
on 28wksof 1-
2mos. Noxi
ousst
imulusi
nthe Massext
ensi
onofC/
Llower
gest
ati
on bal
loft
hefoot ext
remi
ty

Tr
act
ion 28wksof 2-
5mos. Pul
lswi
thb/
lupper Massf
lex
ionofB/
Lupper
gest
ati
on ext
remi
ty exr
emi
ty

Mor
o 28wksof 5-
6mos. Suddenneckext
ensi
on Arm ext
ensi
on&abduct
ion
gest
ati
on fol
l
owedbyf l
exi
on&adducti
on

St
art
le Bi
rt
h Per
sist Loudsound Arm ext
ensi
on&abduct
ion
fol
l
owedbyf l
exi
on&adducti
on

Pal
margr
asp Bi
rt
h 4-
6mos. Maint
ainedpr
essur
eon Fl
exi
onoft
hef
inger
s
pal
m

Pl
ant
argr
asp 28wksof 9mos. Maint
ainedpr
essur
eon Fl
exi
onoft
het
oes
gest
ati
on sol
e

Root
ing 28wksof 4mos. St
roki
ngofl
ater
aloft
he Mouthdev
iat
etot
hesi
teof
gest
ati
on mouth st
roke

B.Toni
cRef
lexes
Ref
lex Onset I
ntegr
ati
on St
imul
us React
ion

Posi
ti
vesuppor
ti
ng Bi
rt
h 6mos. Weightbear
ingont
he Legext
ensi
onforsuppor
ti
ng
sol
e par
ti
albodywei
ght

Asymmetri
cTonic Bi
rt
h 6-
7mos. Headtur
ningort
il
ti
ngt
o Chi
nsi
de-ext
ensi
onoft
hear
m
NeckRef
lex(ATNR) t
heside
Occi
putsi
de-f
lexi
onoft
hear
m

Symmetr
icToni
c 4-
6mos. 8-
12mos. a.Neckf
lexi
on a.Ar
mfl
exi
onw/l
egext
ensi
on
NeckRef
lex(
STNR)
b.Neckext
ensi
on b.Ar
m ext
ensi
onw/l
egf
lexi
on

Toni
cLaby
rint
hine Bi
rt
h 6mos. Headposit
ioni
nspace a.
supi
ne-ext
ensort
one
45°angl
e
b.
prone-f
lexort
one
a.supi
ne

b.pr
one

C.Mi
dbr
ainRef
lexes
Ref
lex Onset I
ntegr
ati
on St
imul
us React
ion
Equi
l
ibr
ium React
ion Supi
neandsi
tt
ing:
7-8 Per
sist
s Til
tthepost
ureonan Lat
eralf
lexi
onont
he
mos. vesti
bul
arbal
l opposi
teside

St
andi
ng:
12-
21mos.

NeckonBody 4-
6mos. 5y
/o Headr
otat
ion Bodywi
l
lfol
l
ow
React
ion

BodyonBody 4-
6mos. 5y
/o 1segmentwi
l
lrot
ate Theothersegment
React
ion wil
lfol
low

Par
achut
e Si
tt
ing:
4-6mos. Per
sist
s Pusht
hepat
ient Abduct
ionand
ext
ensi
onofthe
St
andi
ng:
6-9mos. opposi
tel
imb

Dir
ect
ionofpr
otect
ive
ext
ension:

For
war
d:5-
6mos.

Lat
eral
:6-
7mos.

Post
eri
or:
9-10mos.

PEDI
ATRI
CSEVALUATI
ON

 newbor
ntoadolescence
 0mos.to18-
21y /o(Ameri
can)
 0mos.to12y/o(Fil
ipi
no)

I
. HI
STORYTAKING
 int
ervi
ew
 forcor
rectdi
agnosi
s

A.Pr
enat
alhi
stor
y(bef
orebi
rt
h)

1.Her
edi
tar
ydiseases
a.Mother
 hear tdisease
 dy str
ophi es
 genet i
cdi sorders
o Down’ ssy ndr
ome
o Edwar d’ssyndrome
o Wi lli
am’ssy ndrome
b.Fat
her
 cancer
 lungdi sease
 psy choticdisease
 2.Radi
ati
on
 duri he1stt
ngt ri
mest
er

3.Mat
ernal
Inf
ect
ion

 STORCH
 Syphil
i
s
 Toxoplasmosi
s
 Rubell
a
 Cytomegalovi
rus
 Herpeszoster

4.Pr
ematur
it
y
 Normal
:38-
42weeksofgestat
ion
 Pr
emature:
<37weeks
 CP(Spast
icdi
plegi
a)

5.Hemor
rhage
 mot herandchi
l
d

6.Anoxi
a
 absenceofoxy geninthebr
ain
 i schemicbrai
ndamage
7.Kerni
cterus
 deposi ti
onofBili
rubi
ninthebrai
n(Basal
Gangl
i
a)
 CP( Athet
hosi
s)

TRI
AD:
 hearingloss
 athethosis
 Parinaud’ssyndr
ome

B.Per
inat
alhi
stor
y

1.Mannerofdel
i
very
2.Hi
stor
yofLabor
a.pr ol
ongedlabor(Anoxi
a)-damagetotheCNS
b.basedonno.ofGr avi
da(dur
ati
onofpregnancy
)
i. Primigravi
da-<18hrs.(
fi
rstpr
egnancy)
i
i. Mul ti
grav
ida-<12hrs.

3.APGARtest
 donebyt
heDoct
or(Pedi
atr
ici
an)
 fi
rst5mi
nut
esaf
terdel
iv
ery

APGARSCORI
NG
0 1 2

Appear
ance Cy
anot
ic Li
mbs-bl
uish Pi
nki
sh
 Body
-pi
nki
sh

Pul
se

(N:
130-
140 Absent
/(-
) <100bpm >100bpm
bpm)

Gr
imace Nor
eact
ion Mini
mal Cr
ies
gr
imace
(
ref
lexes)

Act
ivi
ty Nomov
ement Sl
i
ghtf
lexi
on Fl
exedposi
ti
on

(
muscl
etone)

Respi
rat
ion No Sl
ight Cr
ies
abdominal
/chest movementof
mov
ement abdominal

Tot
al: 0 t
o 10

Goodprognosis : 7to8scor
e
Needrespi
rat
orysuperv
isi
on:5t
o6scor
e
Needventi
lat
orysuper
visi
on:0t
o4scor
e

C.Postnat
al hi
stor
y
1.Tr auma
 catchingababy
2.Infection
 meni ngit
is
 encephaliti
s
3.Toxi ci
ty
 poisoning(6-8y
/o)

I
I. GROWTHANDDEVELOPMENT

A.Gr
owt
h

1.Headci
rcumf
erence
 N:35cm (newbor
n)
 ṗ4mos. :
41cm +6cm
 ṗ6mos. :
41cm +12cm
 adult :
51cm +10cm

 Brai
nstopsdevel
opingatt
heageof5y /
o
 Maturi
tyofachil
d’sbr
aini
sunti
l7y earsofage
 insul
ttothebrai
nat<5y /
o : CP
 insul
ttothebrai
nat>7y /
o : TBI
 Anencephal
y: absenceofthebrai
nunderECG
 2.Wei
ght
 N:3,
400g/3.
4kg
 Under
wei
ght:
<1500t
o2000g/1.
5to2kg

3.Hei
ght
 N:50cm

4.Ot
herMusculoskeletalf
indi
ngs
a.Scoliosis(abnormal)
b.Genuv arus(Bowleg) :
0to3y/
o
c. Genuv algus(Knockknees) :
3to5y/
o(Br
addom)
:
2to8y/
o
d.Pespl anus( f
latfoot
) :
0to18mos.
e. Pescav us(abnormal)

B.Dev
elopment
alTasks
 usedtoassessment
aldev
elopmentofachi
l
d

1.Emot
ionalScaleTest
 Er i
kErikson

2.SpeechDevel
opmentScal
e
o Good :1wordat2y/o
o Fair :soundat2y/
o
o Poor :nosoundat3y/o

3.Mot
orDev
elopment
a.Ambulati
on
 refl
exes(
inf
ant
)

b.OnsetofSi
tt
ing
o Good :
cansitat2y/
o
o Fair :
cansitat3y/
o
o Poor :
can’
tsitat4y/
o

c. St
ati
cBal
ance
o 0 :absent
o 1 :assumepositi
on
o 2 :assume&mai ntai
nposi
ti
on
o 3 :assume&mai ntai
nposi
ti
onw/shi
ft
o 4 :assume&mai ntai
nposi
ti
onw/shi
ft
;can
bechal
lenged

d.Tol
erance
o Good :
>hour
o Fai r(
+):
45t
o60min
o Fai r :
30to45mi
n
o Poor( +) :
15to30mi
n
o Poor :
<15min
 e. Gai
tPat
ter
n
 N: 3y/o
 Mat ur
egai
t:7y
/o

f
. Ey
eTracki
ng
 N:3mos.
 canseest
imul
usat180°r
ange

BookRef
erences:

 Braddom,Randal lL.Phy sicalMedicine& Rehabi l

it
aton,3rd Edi
i t
ion,pp1243-
12560
 DeLisa,Joel A.Rehabi l
itat
ionMedi ci
ne:Pr i
nciplesandPr acti
ce,3rdEdit
ion
 O’Sull
i
van, SusanB.&Schmi t
z,ThomasJ.Phy sicalRehabil
itat
ion,5thEdition,
pp
7195-201
 Snell
,RichardS.MDGr ossAnat omy ,1stedi
tion
 Santos,PabloPT- OTRev i
ew
 delMundo,Fe,Est rada,Fel i
xA. ,Ocampo,Per la D.and Nav arro,Xer xesR.
TextbookofPedi atri
csandChi l
dHeal t
h,4thEdition,pp1093-1100
 Behrman, Richar dE.,Kli
egman, RobertM.andJenson, HalB.NelsonText bookof
t
h
Pediatr
ics,17 Edi t
ion,pp2023-2025
 Cunningham,MacDonal d,Gant ,LevenoandGi l
stap Wi
r l
l
iamsObst etr
ics,19th
Edit
ion,pp998- 1003
PARTI
I
PTI
NITI
ALEVALUATI
ON
GENERALI
NFORMATI
ON

Patient’sname :
M.A.
Age :
15y /o
Sex :
Mal e
Addr ess :
Pagdalagan,
CSFLU
Civ
il status :
Single
Cit
izenshi p :
Fil
ipi
no
Handedness :
®
Occupat ion :
none
Rel
igi on :
RomanCat holi
c
Refer r
ingMD :
Dr.B
Referr
ingUni
t :
OPD
RehabMD :
Dr.A
DateofConsult
ati
on :
Febr
uary3,2011
DateofRefer
ral :
DateofIni
ti
alEval
uat
ion :
Diagnosi
s :
CP,spast
icquadr
ipl
egi
a

SUBJECTI
VEI
NFORMATI
ON

C/
c:(
Inf
ormant
:Pt
’smot
her)
Pt℅muscl
eweaknessandspast
ici
tyon(
B)UE/
LE

HPI:
I
nfor
mant
:Pt
’smot
her

Presentcondi ti
onst artedapproximat el
y10y ear
sPTI Ewhenpthadanumbi lical
i
nfect ionaf t
erbirth.Pt ’
smot herst at
edt hattheyr ushedhi mt oITRMCaf teranor mal
deliveryathomeandwasseenandev al
uatedbyadoct or.Theptwast hendi agnosed
hav i
ngsept i
car thri
tis2°t oumbi li
calinfect
ion.Theptunder wentsev er
almedi cat
ions
thrui njecti
onsindi ff
erentar easofhi sbodyev eni ntheskull.Theptt henconsul ted
anotherdoct orfrom samehospi talaft
ersev eralyearsfrom previ
ousconsultati
onsdue
to abnor mal i
ti
esi ngr owthanddev elopmentoft hept .Ptunder gonesev eraltests
(unrecal l
ed)andt hendi agnosedbyDr .Bhav i
ngCP,spast icquadri
plegi
a.Ptwast hen
referredt oPhysical Rehabil
itationunderDr .Aforf ur
therevaluati
onandt r
eatment .

PMHx:

(
+) Hospi
tal
i
zat
ion(
Unr
ecal
l
eddat
e,Sept
icar
thr
it
is)

(
+) Umbi
l
ical
inf
ect
ion

(
-) DM

(
-) Hear
tdi
sease

FMHx:

Fat
her Mot
her

HTN (
+) (
+)

DM (
-) (
+)

Lungdi
sease (
+) (
-)
PSEHx:

(-
)alcoholi
cdr i
nker
(-
)cigaret
tesmoker
Sedentaryli
festyl
e
Homesi t
uation:Ptli
vesinabungal
ow t
ypeofhousewi
thhi
spar
ent
sandsi
x
si
bli
ngs.
BR─DR=≈10st eps
BR─LR=≈10st eps
BR─CR=≈7st eps

OBJECTI
VEFI
NDI
NGS

VS: BP: 110/

70mmHg
PR: 63bpm
RR: 15cpm
T: 36.
8°C

OI
:
 bedbound
 unreli
abl epat i
ent
 ectomor ph
 (+)scaron( L)l at
er alknee
 (+)trophicski nchangeson®f ace
 (+)callusfor mat i
onon®l ater
alankl
e
 (+)atrophyon( B)UE/ LE
 (+)protrudedt ongue
 (+)promi nentcoccy x
 (+)wr i
sthy per extended
 (+)®l ateral fl
exionoft hetr
unk
 (+)®hi pext ernall
yr otated
 (+)(L)hi pinternallyrotated
 (+)inverted( L)&®f oot
 (+)®bi gtoef lexed
 (-
)post ural dev i
ation
 (-
)gai tdeviat i
on

Pal
pat
ion:
 nor mothermic
 hy pert
onicinall4’
s
 ( +)spast
icit
ygrade3on(
B)LE,
grade2on(
B)UE
 ( -
)tenderness
 ( -
)musclespasm
 ( -
)edema
Neur
ologi
calEval
uati
on:
SA/Sensor
yTest i
ng:N/A(unrel
iabl
ept)
STD’
sused:pinforpain,
brushforli
ghtt
ouch,
thumbf
ordeeppr
essur
e.

DTR’
s:N/
A

R L

Legend:
Grade0 aref
lexia
Grade1+ hyporeflexia
Grade2+ normor eflexi
a
Grade3+ hyperreflexia
Grade4+ cl
onus

ROM:
All
maj
orj
oint
sof(
B)UE/
LEar
ewi
thLOM,
act
ivel
yandpassi
vel
ydone.

Fi
ndi
ngs: LOM on(B)UE/
LE
Si
gni
fi
cance: LOM 2°t
ospasti
cit
y

MMT:
All
maj
ormuscl
esof(
B)UE/
LEar
egr
ossl
ygr
adedof2/
5.

Fi
ndi
ngs:Muscl
eweaknesson(B)UE/
LE
Si
gni
fi
cance:Muscl
eweakness2°t
oparal
ysi
s

ST:
N/A

Fi
ndi
ngs:
Si
gni
fi
cance:

PA:
N/A

Fi
ndi
ngs:
Si
gni
fi
cance:

GA:
N/A

Fi
ndi
ngs:
Si
gni
fi
cance:
ADL:

TheFunct
ional
IndependenceMeasur
e(FI
M)
FI
M LEVELS

NoHel
per

7Compl
eteI
ndependence(
Timel
y,Saf
ety
)

6Modi
fi
edI
ndependence(
Dev
ice)

Hel
per-Modi
fi
edDependence

5Super
visi
on(
Subj
ect
=100%)

4Mi
nimal
Assi
stance(
Subj
ect
=75%ormor
e)

3Moder
ateAssi
stance(
Subj
ect
=50%ormor
e)

Hel
per-Compl
eteDependence

2Maxi
mal
Assi
stance(
Subj
ect
=25%ormor
e)

1Tot
alAssi
stanceornott
est
abl
e(Subj
ectl
esst
han25%)

ADMI
SSI
ON DI
SCHARGE GOAL

SELF-
CARE

A. Eat
ing 1

B. Gr
oomi
ng 1

C. Bat
hing 1

D. Dr
essi
ng-
Upper 1

E. Dr
essi
ng-
Lower 1

F. Toi
l
eti
ng 1

SPHI
NCTERCONTROL

G. Bl
adder 1

H.Bowel 1

TRANSFERS

I
. Bed,
Chai
r,Wheel
chai
r 1

J. Toi
l
et 1
 K. Tub,
Shower 1

LOCOMOTI
ON

L. Wal
k/Wheel
chai
r Wheel
chai
r

M.St
air
s 1

COMMUNI
CATI
ON

N.Compr
ehensi
on 1

O. Expr
essi
on 1

SOCI
ALI
NTEGRATI
ON

P. Soci
alI
nter
act
ion 1

Q. Pr
obl
em Sol
vi
ng 1

R. Memor
y 1

Fi
ndings:Tot
alassi
stanceornottest
abl
e
Signi
fi
cance:Ptisdependenti nallaspect
sofADL’
sast
o sel
f-
car
e,bedmobi
l
ity
,
tr
ansferandambulat
ion

ASSESSMENTPART

PtGoal
:tor
educespast
ici
tyandi
ncr
easemuscl
est
rengt
h

Pr
oblem Li
st:
1.Dependenti nall aspectsofADL’s
2.Muscl eweaknesson( B)UE/LEċgr ade2/5
3.Muscl eat rophyon( B)UE/LE
4.Spast i
citygr ade3on( B)LE,grade2on( B)UE
5.Scaron( L)l ateralknee
6.Trophi cskinchangeson®f ace(f
ungi)
7.Callusf ormat ionon®l at
eralankl
e
8.Protrudedt ongue
9.Promi nentcoccy x
10.®l ateralflexionoft hetr
unk
11.®hi pext er nall
yr otated
12.(L)hipi nt
er nall
yr otated
13.i
nv erted(L)&®f oot
14.®bi gt oef lexed
15.Wr i
sthy per extended
LTG:(
1year)
1.to attaini ndependency on ADL’ s as t
o self
-car
e,mobi l
i
ty,transfer
,and
ambulat i
on
2.toregainmuscl est r
engthon( B)UE/ LEf
rom gr
ade3/5to5/5
3.toi
mpr ovemuscl eintegri
tyon( B)UE/LE
4.toeli
mi natespastici
tyon( B)UEf rom gr
ade1+/5to0/5,
(B)LEfrom grade1/5t
o
0/5
5.toeli
mi natescaron( L)later
alknee
6.toeli
mi natefungion®f ace
7.toeli
mi natecall
uson®l ateralankle
8.toi
mpr ovebodypost ure

STG:(
6Txsession)
1.to ↑levelofindependencyon ADL’ sast o self
-car
e,mobil
it
y,t
ransf
er,and
ambulati
on
2.to↑musclestrengthon( B)UE/ LEfr
om grade2/5t o3/5
3.to↓muscleatrophyon( B)UE/ LE
4.to↓spasti
cit
yon( B)UEf rom grade3/5to1+/5, (
B)LEf r
om gr
ade2/
5t o1/5
5.to↓scaron(L)later
alknee
6.to↓fungion®f ace
7.to↓call
uson®l at
eral
ankl e

PLAN

PTMx:
1.AAROMEt
o(B)UE&LE

2.AROMEt
o(B)UE&LE

3.FESt
o(B)LE

4.GPSt
o(B)UE&LE

5.PNFt
o(B)UE&LEt
o↓spast
ici
ty&↑st
rengt
h

6.Roodsi
nst
abi
l
ityt
echni
quet
o(B)UE&LEt
o↓spast
ici
ty

7.Bi
cycl
eEr
gomet
eron(
B)UE&LE

8.St
rengt
heni
ngex’
sto(
B)hi
pabduct
ors

9.St
ret
chi
ngex’
sto(
B)hi
padduct
ors

Suggest
edPTMx:
1.HIP
a.Pr
opernut
ri
ti
ont
ogai
nwei
ght
 b.Pr
operbedposi
ti
oni
ng(
reposi
ti
onptev
ery2hr
s)t
opr
eventbedul
cer
s

2.HEP
a.ROM exer
ciseson(
B)UE/
LEi
nal
lpl
anes