 1.

CEREBRAL PALSY
 2. Definition  It is defined as a group of
disorders resulting from permanent non
progressive cerebral dysfunction developing
before maturation of CNS affecting the
locomotor system  It is non-contagious motor
conditions that cause physical disability in
human development
 3.  Although brain lesions that result in CP are
not progressive, clinical picture of CP may
change with time  In addition to primary
impairments in gross & fine motor function,
there may be associated problems with
cognition, seizures, vision, swallowing, s peech,
bowel-bladder, & orthopedic deformities
 4. Criteria of diagnosis ◦ Neuromotor control
deficit that alters movement or posture ◦ Static
brain lesion ◦ Acquisition of brain injury either
before birth or in first years of life
 5. History  Formerly known as "Cerebral
Paralysis,“ ◦ First identified by English surgeon
 William Little in 1860. (Little’s disease) ◦
Believed that asphyxia during birth is chief
cause  In 1897, Sigmund Freud, suggested that
difficult birth was not the cause but only a
symptom of other effects on fetal development
 National Institute of Neurological Disorders &
Stroke (NINDS) in 1980s suggested that only a
small number of cases of CP are caused by lack
of oxygen during birth
 6. Epidemiology  The incidence of CP is about
2 per 1000 live births  The incidence is higher
in males than in females  Other associated
problems include ◦ Mental disadvantage (IQ <
50): 31% ◦ Active seizures: 21% ◦ Mental
disadvantage (IQ < 50) and not walking: 20% ◦
Blindness: 11%
 7.  During past 3 decades considerable
advances made in obstetric & neonatal care, but
there has been no change in incident of CP 
The population of children with CP may be
increasing due to premature infants who are
 surviving in greater numbers, higher incidence 
in normal-weight term infants (3), and longer
survival  overall.
 8. Causes of CP  Prenatal (70%)  Peri-natal (5-
10%)  Post natal
 9. Prenatal  Maternal infections E.g. rubella,
herpes simplex  Inflammation of placenta
(chorion amnionitis)  Rh incompatibility 
Diabetes during pregnancy  Genetic causes 
Exposure to radiations  Maternal jaundice
 10. Peri- natal  Prematurity- immature
respiratory & cardiac function  Asphyxia 
Maconeum aspiration  Birth trauma 
Disproportion  Breech delivery  Rapid delivery
 Low birth weight  Coagulopathy
 11. Post natal  Brain damage secondary to
cerebral hemorrhage, trauma, infection or
anoxia  Motor vehicle accidents  Shaken baby
syndrome  Drowning  Lead exposure 
Meningitis  Encephalitis
 12.  Additional risk factors for CP include ◦
Kernicterus ◦ methyl mercury exposure ◦ genetic
causes
 13. Classification of CP  Depending on the
topographical distribution ◦ Monoplegic ◦
Diplegic/ Paraplegic ◦ Triplegic ◦ Hemiplegic ◦
Tetraplegic / Double hemiplegia
 14.  Monoplegia is one single limb being
affected.  Diplegia: LE affected, with little to no
upper-body spasticity. ◦ The most common form
of spastic forms ◦ Most people with spastic
diplegia are fully ambulatory, but are "tight" &
have scissors gait ◦ Flexed knees & hips to
varying degrees, & moderate to severe
adduction are present ◦ Often nearsighted &
intelligence is unaffected ◦ In 1/3rd of spastic
diplegics, strabismus may be present
 15.  Hemiplegia ◦ The most ambulatory of all
forms, although they generally have dynamic
equinus on affected side  Triplegia: three limbs
affected usually both LL & one UL 
 Quadriplegia: all four limbs more or less equally
affected. ◦ Least likely to be able to walk ◦ Some
children also have hemiparetic tremors
(hemiballismus), & impairs normal movement
 16.  Depending on tone or movement patterns
(physiologic) ◦ Spastic ◦ Athetoid/ dyskinetic ◦
Ataxic ◦ Flaccid/ Hypotonic ◦ Mixed
 17. Spastic CP  It is the most common type of
CP, occurring in 70% to 80% of all cases.  The
cerebral cortex is affected  Moreover, spastic
CP accompanies any of the other types of CP in
30% of all cases  It can be monoplegia,
diplegia, triplegia, hemiplegia or quadriplegia.
 18. Athetoid/ dyskinetic CP  It is mixed muscle
tone  Often show involuntary motions  The
damage occurs to extrapyramidal motor system
& pyramidal tract  It occurs in 10% to 20% of all
cases  In newborn infants, high bilirubin levels
in blood, if left untreated, can lead to brain
damage in certain areas (kernicterus).  This
may also lead to Athetoid CP
 19. Ataxic CP  It is caused by damage to
cerebellum  They are least common types of
CP, occurring only in 10% of all cases  Some of
these individuals have hypotonia and tremors
 20. Hypotonic CP  Hypotonic CP have
musculature that is limp, and can move only a
little or not at all (Floppy child)  The location of
damage is wide spread in the CNS  Although
physical therapy is usually attempted to
strengthen muscles it is not always
fundamentally effective.
 21. Mixed CP  Signs & symptoms of spastic CP
is seen with any other type of CP ◦ Most
commonly mixed with Athetoid
 22.  Depending on functional level (Gross
Motor Function Classification System) ◦ It
classifies acc. to age categorized activity level
 24. pathology  Periventricular
leukomalacia (PVL) is the most common finding
in CP  Corticospinal tract fibers to LL are medial
to those of UL in periventricular white matter. ◦
 Thus children with PVL typically have spastic
diplegia (common type of CP)
 25.  Bilirubin encephalopathy in basal ganglia
is seen in athetoid CP following a diagnosis of
kernicterus  Focal cortical infarcts involving
both grey & white matter are found in patients
with hemiparesis, & are typically related to MCA
strokes  Brain malformations can be found on
neuroimaging in approximately 10% of children
 26. Signs & symptoms (spastic)  Hypertonia 
Exaggerated reflexes & +ve barbinskis  Clonus 
Poor voluntary movement  Scissoring gait 
Low intelligence & loss of memory  Epilepsy 
Synergistic pattern  Contracture, deformity &
wasting ◦ Adduction & IR of shoulder ◦ Flexion
of elbow & pronation of forearm ◦ Wrist flexion
& thumb inside hand ◦ Flexion & adduction of
hip ◦ Knee flexion ◦ PF of ankle
 27. Extrapyramidal CP  May affect limb, face,
tongue & speech  Characterized by continuous
muscular worm like movement  Postural
 instability  Decreased movement in prone
position  Fluctuation of tone from high to low 
Reflexes are usually normal & muscles are able
to contract  Decreased stability  Difficulty to
look up  Emotional liability  Arms are more
affected  Sucking & feeding problems  Delayed
head & trunk control  May be either
quadriplegic or rarely hemiplegic  Subtypes -
dystonic, athetoid, choroid, h emiballismic, rigid
 28. Ataxic / hypotonic  Inco-ordination 
Intension tremor  Hypotonia  Nystagmus 
Diminished reflexes  Speech, visual, hearing &
perceptual problems  Joint hypermobility 
Dysmetria  Incontinence  Postural instability 
Gait disturbances  Imbalance & lack of trunk
control  Unsteadiness 
 29. risk babies  Biological risk  Established risk
 Environmental & social risk
 30. Biological risk  Birth weight of 1500g or
less  Gestational age of 32 weeks or less  Small
for gestational age (less & 10th percentile of
 weight)  Ventilator requirement for 36 hours or
more  Intracranial hemorrhage  muscle tone
abnormalities  Recurrent neonatal seizures (3
or more)  Feeding dysfunction  Symptomatic
(TORCH)  Meningitis  Asphyxia with apgar
score <3 in 1 min after birth or <6 in 5 min after
birth
 31. Established risk  Hydrocephalus
 Microcephaly  Chromosomal abnormalities 
Musculoskeletal abnormalities (CDH, AMC, limb
deficiencies)  Multiple births more than twins 
Brachial plexus injuries  Myelodysplasia 
Congenital myopathies  Inborn errors of
metabolism  HIV infection
 32. Environmental/ social risk  Single parent 
Parental age less than 17  Poor quality infant
parent attachment  Maternal drug or alcohol
abuse  Behavioral state abnormalities (lethargy,
irritability)
 33. Detection of risk babies  Principles ◦ There
should be definite objective ◦ Some form of
 action should be possible if the test is positive ◦
The population should be defined ◦ Test should
be sensitive ◦ Test should be specific ◦ Screening
should start at foetal life & continue into early
childhood  Some test are for all children but
some are for those who are known to be at risk
 34. Prenatal screening  Routine check up for
mother during pregnancy is beneficial for the
mother & the foetus  Health education ◦ Diet
advice (avoid tobacco & alcohol) ◦ Exercise on
prescription ◦ Sleep & working habits
 35.  Clinical examination ◦ Breast condition ◦
Height of uterus ◦ Position of foetus ◦ BP ◦
Samples of blood & urine  For special test
condition sought are ◦ Phenylketonuria ◦
Glycosuria ◦ Albuminuria ◦ Rh incompatibility ◦
Congenital syphillis ◦ Rubella, AIDS ◦ Neural tube
defect
 36.  Special test for screening ◦ USG from 8-12
weeks  For the assessment of the gestational
period  Congenital abnormalities in various
 organ defect ◦ Amniocentesis from 16-18 weeks
of pregnancy  To find chromosomal defect, if
the test is positive terminate pregnancy ◦
Chorionic villus sampling technique in 8-11
weeks of pregnancy  For chromosomal study
 37. Post natal screening  Starts in the
immediate neonatal period & during the first
two years ◦ To find biochemical defects ◦
Hearing & visual problems
 38.  Clinical methods (at birth) ◦ Examination
of weight, height, head circumference ◦
Gestational age ◦ Musculoskeletal defects ◦
Testicular descent ◦ At 6 weeks repeat test
 39.  Chemical methods ◦ Blood sample from
heel prick at 2-5 days of age & repeated where
necessary  Respiratory conditions, cardiac
pathology, haemoglobinopathies can be
detected  Neuromuscular pathologies (cpk
level)  Metabolic disorders  Gene
abnormalities
 40.  Electronic scanning ◦ USG, CT Scan, MRI 
To find out AVM, hemorrhage, cyst,
leucodystrophies etc
 41. Diagnosis  The diagnosis of CP depends on
patient's history & on the basis of significant
delay in gross & fine motor function, with
abnormalities in tone, posture, & movement on
neurological examination.  Once diagnosed
with CP, further diagnostic tests are optional.
 42.  MRI is preferred over CT due to diagnostic
yield & safety.  The CT or MRI also reveals
treatable conditions, such as hydrocephalus,
AVM, subdural hematomas etc.  Diagnosis,
classification, & treatment are often based on
abnormalities in tone  Apgar scores have
sometimes been used as one factor to predict
whether or not an individual will develop CP
 43. Diagnostic tools  Movement Assessment of
Infants (MAI): able to predict CP at 4 months
(identifies motor delay)  Alberta Infant Motor
Scale (AIMS) is able to predict CP at 6 months
 (Identifies motor delays & measures changes in
motor performance over time)  Bayley scale is
able to predict CP at 1 year (Identifies devt
delay in gross & fine motor, & cognitive
domains)
 44. Management  Medical  Surgical
 Rehabilitative
 45. Drugs  Oral medications such as baclofen,
diazepam, and trihexyphenidyl as well as
therapeutic botulinum toxin (Botox)  Children
with dystonic CP have dopa- responsive
dystonia, with improved motor function using
levodopa  Children with basal ganglia/thalamic
injury from perinatal asphyxia may develop
improved expressive speech & hand use with
trihexyphenidyl
 46. Surgery  Dorsal rhizotomy reduces
spasticity  Joint & Tendon release most often
performed on hips, knees, & ankles.  The
insertion of a baclofen pump usually during
young adolescence. ◦ usually placed in left
 abdomen - a pump that is connected to spinal
cord, ◦ sends bits of Baclofen to relax muscle 
Bony correction E.g. femur (termed femoral
anteversion or antetorsion) & tibia (tibial
torsion). 2ndary complication caused by spastic
muscles generating abnormal forces on bones
 47. Prognosis  CP is not a progressive but the
symptoms can become more severe over time 
Prognosis depends on intensity of therapy
during early childhood  Tend to develop
arthritis at a younger age than normal because
of pressure placed on joints by excessively
toned & stiff muscles
 48.  Intellectual level among people with CP
varies from genius to intellectually impaired ◦ (it
is important to not underestimate a person with
CP and to give them every opportunity to learn)
 The ability to live independently with CP varies
widely depending on severity of each case. ◦
Some individuals with CP are dependent for all
ADL. ◦ Some can lead semi-independent lives,
 needing support only for certain activities. ◦ Still
others can live in complete independence.
 49.  Persons with CP can expect to have a
normal life expectancy  Survival is associated
with the ability to ambulate, roll, & self-feed 
As the condition does not directly affect
reproductive function, some have children &
parent successfully  There is no evidence of
increased chance of a person with CP having a
child with CP
 50. Notable persons  Abbey Curran, American
beauty queen with CP who represented Iowa at
Miss USA 2008 and was the first contestant to
compete with a disability
 51. Prediction of ambulation
 52. Pt assessment  Subjective Examination: ◦
Obtained from parents especially mother or
from relatives and through case-sheet. ◦
General details includes  Name  Age & Sex 
Address  When did the mother first noticed the
 dysfunctions ◦ Siblings having same type of
symptoms
 53. PT assessment  History ◦ Review of
complications of pregnancy & delivery, birth
weight, gestation, any neonatal & perinatal
difficulties, feeding problems, and other health-
related problems ◦ Developmental milestones
 54.  Prenatal History ◦ Age of mother ◦
Consanguity marriage ◦ Any drugs taken during
pregnancy ◦ Any trauma & stress ◦ Any addiction
– smoking or alcoholism ◦ History of TORCH
infection ◦ History of previous abortions, still
born or death after birth ◦ Multiple pregnancies
◦ Status & cast of the mother
 55.  Perinatal History ◦ Place of delivery ◦
History preterm or post-term delivery ◦ History
of asphyxia at birth ◦ History of prolonged
labour pain ◦ Type of delivery (Forceps, vacuum
delivery) ◦ Presentation of child (Breech) ◦
Condition of mother at the time of delivery
 56.  Postnatal History ◦ Delayed birth cry ◦
Weight of the child at birth ◦ History of trauma
to brain during the first 2 years of life ◦ History
of neonatal meningitis, jaundice, hypoglycemia,
Hydrocephalus or Microcephaly ◦ Nutritional
habits of the child (malnutrition), Feeding
difficulties ◦ Any medical, surgical or
physiotherapy treatment taken before ◦ What
treatment was used? ◦ Was the treatment
effective or not? ◦ What was the ability level of
child at that time? ◦ What obstructs the child
from progress? ◦ Apgar Score from the case-
sheet
 57. On Observation:  Behaviour of the child ◦
Whether child is alert, irritable or fearful in the
session or during particular activities ◦ Child
becomes fatigued easily or not during activity ◦
What motivates his action – particular situation,
person or special plaything  Communication of
the child ◦ With the parents ◦ Whether child
initiates or responds with gestures, sounds,
 hand or finger pointing, eye pointing or uses
words and speech
 58.  Other observations ◦ Involuntary
movements ◦ Deformities & contracture ◦ Scar
may be present ◦ Trophic changes may also be
seen due to poor positioning ◦ Postural faults ◦
Gait abnormalities ◦ Use of external appliances
 59.  Attention span ◦ What catches child’s
attention ◦ For how much time child’s attention
is maintained on particular thing ◦ How does
parent assist him to maintain attention ◦ What
distracts the child ◦ Does child follows
suggestions to move or promptings to act
 60. ◦ Position of the child  Which position does
the child prefer to be in?  Can child get into
that position on his own or with help?  With
assistance, child makes any effort to go in that
position  Symmetry of the child (actively or
passively maintained)  If involuntary
movements present, then in which positions
these movements are decreased or increased
 61. ◦ Postural control & alignment  How much
parental support is given  Postural stabilization
and counterpoising in all postures  Proper &
equal weight bearing  If the child’s center of
gravity appears to be unusually high, resulting in
floating legs and poor ability to raise head
against gravity  Fear of fall in child due to poor
balance
 62. ◦ Use of limbs & hands  Limb patterns in
changing or going into position as well as using
them in position ◦ Attitudes of limbs during
playing & in all positions  Whether one or both
hands are used, type of grasp and release 
Accuracy of reach and hand actions  Any
involuntary movements, tremors or spasms,
which interfere with actions, are present
 63. ◦ Sensory aspects  Observe child’s use of
vision, hearing, of touch, smell and temperature
in relevant tasks  Does child enjoys particular
sensations  Whether child enjoys being moved
or having position changed ◦ Form of
 Locomotion  How child is carried  Any use of
wheelchair or walking aids  Which daily
activities motivates child to roll, creep, crawl,
bottom shuffle or walk
 64. ◦ Deformities  Any part of body, which
remains in particular position in all postures &
in the movements  The positional preferences
typically seen in spastic cerebral palsies are for
mid positions of body –  In the UL  Shoulder
protraction or retraction, adduction and internal
rotation, Elbow flexion, Forearm pronation,
Wrist & Fingers flexion  In the LL  Hip semi-
flexion, internal rotation and adduction, Knee
semi-flexion, Ankle plantar flexion, Foot
pronation or supination, Toes flexion  Athetoid
or dystonic posturing usually incorporates
extremes of movement such as total flexion or
extension  Windswept Deformity of hip – One
hip flexed, abducted and externally rotated;
other hip flexed, adducted and internally
rotated and in danger of posterior dislocation
 65.  Higher cognitive function ◦ Drowsy &
lethargic ◦ Decrease in intellectual function ◦
Mental retardation (mild to profound) ◦
Attention deficit & easily distractible ◦ Poor
memory ◦ Poor comprehension of speech &
language
 66.  Cranial nerve integrity ◦ Strabismus or
squint (Occulo motor nerve) ◦ Visual defects
(optic nerve) ◦ Auditory defects (auditory nerve)
◦ Feeding & swallowing problems (lower cranial
nerves) etc.
 67.  Special senses ◦ Visual & auditory defects ◦
Tactile & vestibular hyposensitivity or
hypersensitivity
 68. On examination  Sensory Assessment ◦ It is
difficult to assess sensation in babies and young
children with severe multiple impairments. ◦ If
any hearing or visual or psychological
abnormalities are present then assessment
done by specialist is required
 69.  Motor integrity ◦ Abnormalities of tone 
Spasticity, hypotonicity, dystonia etc ◦ Muscular
weakness ◦ Loss of voluntary control ◦
Decreased co ordination
 70.  Reflex integrity ◦ Abnormal DTR ◦
Abnormal Superficial reflexes ◦ Abnormal
primitive reflexes may be persistent  ATNR,
Extensor thrust, gallant reflex etc
 71.  ROM & flexibility ◦ Decreased in the ROM
of the involved limbs ◦ Tightness & contracture
in hip adductors, hamstrings, calf are very
common
 72.  Anthropometric measurement ◦ Height or
length decreased (growth retardation) ◦ Weight
– decreased (thin & lean) or obese ◦ Head
circumference – decreased (growth retardation
or microcephaly), increased (hydrocephalus)
 73. ◦ Growth Parameters  Height - Until 24 to
36 months of age, length in recumbency is
measured using an infantometer. After the age
of 2 years standing height is recorded by a
 stadiometer Weight kg Pounds At birth 3.25 7 3-
6 months Age in months +9/2 Age in months +
11 1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17
7-12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7
+5
 74. Weight kg Pounds At birth 3.25 7 3-6
months Age in months +9/2 Age in months + 11
1-6 yrs Age in years x 2 + 8 (Age in yrs x 5)+17 7-
12 yrs [(age in yrs x 7) + 5] /2 Age in years x 7 + 5
 Weight
 75.  Head circumference of the child - ◦ The
tape is used to measure occipitofrontal head
circumference from external occipital
protuberance to glabella Head cicumference Cm
At birth 35 3 months 40 1 yr 45 2 yrs 48 12 yrs
52
 76. Developmental milestones 
Age Developmental Milestones  4 to 6 weeks
Social smile  3 months Head holding  6
months Sits with support  7 months Sits
without support  5 to 6 months Reaches out
 for bright object & gets it  6 to 7 months
Transfers object from one hand to other  6 to 7
months Starts imitating cough  8 to 10 months
Crawls
 77.  10 to 11 months Creeps  9 months
Standing holding furniture  12 months Walks
holding furniture  10 to 11 months Stands
without support  13 months Walks without
much of a support  12 months Says one word
with meaning  13 months Says three words
with meaning  15 to 18 months Joints 2 or 3
words into sentence
 78.  13 months Feeds self with spoon  15 to
18 months Climbs stair  15 to 18 months Takes
shoes and socks off  24 months Puts shoes and
socks on  24 months Takes some clothes off  3
to 4 years Dresses self fully  2 years Dry by day
 3 years Dry by night  3 years Knows full name
and sex  3 years Rides tricycle
 79.  Joint Range of Motion (active & passive) ◦
Active head and trunk flexion, extension,
 rotation observed during head raise in prone,
supine, sitting, standing developmental
channels ◦ Active shoulder elevation, abduction,
rotation, flexion and extension movements are
observed during functional examination of
creeping, reaching and other arm movements ◦
Active elbow flexion and extension observed
during child’s reach to parts of body or toys ◦
Active wrist and hand movements will be
observed during function development ◦ Active
hip flexion and extension will be observed
during all functions ◦ Active knee flexion and
extension seen with active hip flexion extension
◦ Foot movements are also check during
functional development
 80.  Posture ◦ Poor posture in all types of CP ◦
Kypho-Scoliosis, knock knee & flexion deformity
& inverted flat foot are commonly seen
 81.  Balance & gait ◦ Compromised static &
dynamic balance ◦ Balance severely affected in
athetoid & ataxic CP ◦ Independent walking is
 rarely achieved by spastic quadriplegic &
athetoid CP,  few diplegic CP can walk with
aids,  hemiplegic CP can achieve independent
walking
 82.  Bowel & bladder involvement ◦ If the child
is able to communicate & understand, training
can be helpful ◦ In profound MR and those
unable to communicate have dependent
functions
 83.  Functional capacity ◦ Varies from complete
dependence to complete independent
 84. PT MANAGEMENT
 85. INFANCY (FIRST STAGE – BIRTH TO 3 YEARS)
 86. PT aims  Family education  Handling &
care  Promote infant & parent interaction 
Encourage development of functional skills &
play  Promote sensory motor development 
Establish head & neck control  Attain &
maintain upright position
 87. Family education  Educate families about
CP  Provide support in their acceptance of child
 Goal setting & programming should be done
with family  Be realistic about the prognosis &
efficacy of PT while remaining hopeful 
Honesty & commitment towards child 
Listening to parental concerns & recognizing
personal values & strength
 88. Handling & care  Promote parents ease,
skill & confidence in handling child  Positioning,
feeding & carrying techniques should be taught
 Promote symmetry, limit abnormal posturing
& facilitate functional motor activity  Use
variety of movement & posture to promote
sensory function  Include position to allow
lengthening of spastic or hypoextensive muscles
 Use positions to improve functional voluntary
movement of limbs
 89. Mother & child relationship  Activities
should be done on mother's lap, close to body
& face so that her touch & stroking & talking to
 baby not only help motor development but also
body image, movement enjoyment by baby &
demonstrate love & security  Weaning of child
to a PT should be carefully done after mother-
child bonding & confidence is established
 90.  Introducing more than one therapist or
developmental worker may be disconcerting to
child & even parents  Not to overload with
exercises, but rather use corrective movements
& postures within ADL of child
 91. Feeding & respiration  Position in a
propped up sitting for feeding  For greater hip
stability & symmetry during feeding position in
a high chair with adaptation  Head & neck
position should be in neutral rotation & slight
flexion to facilitate swallowing  Deep
respiration can be facilitated before feeding by
applying pressure in the thorax or the
abdominal area
 92. Facilitate sensory-motor development
(body image)  Reaching, rolling, sitting,
 crawling & transitional movements like standing
& pre walking are facilitated ◦ Promotes spatial
perception, body awareness & mobility,
facilitate play, social interaction & exploration of
environment  Use of equipments that
facilitates function when impairment is
preventing development E.g. sitting on adapted
chair
 93.  Practice midline play, reach for feet, suck
on fingers  Do not give too many stimuli at
once  Carefully introduce different surfaces for
child to roll on, creep, crawl, & walk on with
bare feet  Always give child time to experience
tactile & auditory stimuli & let him reach & find
out about himself whenever possible
 94. Improve proprioceptive &
vestibular function  They are compensatory
stimuli for visual impairment & also develop
body image  Touch, pressure & resistance can
be correctly given to stimulate movement giving
clues as to direction & degree of muscle action.
  Do not use Rx with handling or other
proprioceptive stimuli from behind as leaning
back will facilitate extensor thrusts
 95. Visual development  Can be easily
integrated with methods for head control, hand
function & all balance & locomotor activities 
Relate appropriate level of visual ability with
child's motor programme.  Also one may have
to accept unusual head position & other
patterns which make it possible for the child to
use residual vision  Use favorite toys or colors
to facilitate visual function
 96. Language development  Talk & clearly
label body parts used  Delay is normal for a
child who cannot yet understand meaning of
sounds, words & conversation  Use simple &
easy words with appropriate examples &
models  Communication is also fostered
through motor actions, touch & body language
relevant to sign system of a child
 97. Facilitating motor development 
Postural stability of the head when ◦ lying prone
(0-3 months) ◦ on forearms (3 months) ◦ on
hands and on hands and knees (6 months), ◦
during crawling, half-kneeling hand support (9-
11 months) ◦ in the bear-walk (12 months) in
normal developmental levels.
 98.  Acceptance of prone position. ◦ Accustom
child to prone  on soft surfaces, sponge rubber,
inflatable mattress, in warm water, over large
soft ball, over your lap  rock and sway a baby
held in prone suspension.
 99.  Postural stability of the shoulder girdle ◦
weight on forearms (3 months), ◦ on hands (6
months), ◦ on hands & knees & arms held
stretched forward along the ground to hold a
toy at 5-6 months also include postural stability.
 Pivot prone with arms held extended in air
activates stabilizers (8-10 months). 
Maintenance of half-kneeling lean or upright
 kneeling (lean on hands) or grasp a support - 9-
12 months stimulates shoulder girdle stability
 100.  Postural stability of pelvis ◦ On knees
with hips at right angles (4 months) ◦ on elbows
& knees & on hands and knees (4-6 months), ◦
on half-kneeling and upright kneeling with
support (9-12 months) in normal motor levels.
 101. Maintaining an upright position  Use of
adapted chairs & standing frame  Use of
orthosis can be delayed until some voluntary
movement is gained  Sitting on swiss ball,
vestibular board etc can be given to improve
challenges
 102. PRESCHOOL PERIOD
 103.  Main aim is to reduce the primary
impairments & prevent the secondary
impairments
 104. Increase force generation (strengthening)
 Creating demands in both concentric &
eccentric work ◦ Transitional movements against
gravity, ball gymnastics etc.  If a child has some
 voluntary control in muscle group, capacity for
strengthening exists  Use of electrical
stimulation or by strengthening within
synergistic movement patterns
 105.  Ambulatory children with CP have
capacity to strengthen muscles, although poor
isolated control or inadequate length  To
participate in a strength-training program, child
must be able to comprehend & to consistently
produce a maximal or near-maximal effort
 106. Reduce spasticity  Positioning in anti
synergistic pattern  Stretching of tight
structures  MFR  ROM exercise  Rhythmic
rotations  Splinting & serial casting  Dorsal
rhizotomy  Botox injection
 107. Increase mobility & flexibility  ROM
exercise  Maintain length of muscle by regular
stretching & splinting ◦ Prolonged stretching of 6
hours a day with the threshold at which the
muscle began to resist a stretch  Strengthening
exercise of prime movers of a joint
 108. Prevent deformity  Serial Casting
techniques  Orthosis & night splints  Lycra
splinting & taping techniques ◦ Skin reactions
should be carefully assessed  Allignment of the
body in a variety of positions in which they can
optimally function, travel & sleep
 109. Improve physical activity  Exercise should
be intensive, challenging & meaningful &
involve integration of skills into function 
Movement should be goal oriented &
interesting to maintain motivation ◦ Kicking a
soccer ball  Feedback is important &
feedforward is also considered  CIMT also
improves function in hemiplegic CP  Oromotor
rehabilitation should also be provided
 110. Improve ambulatory capacity 
Weight bearing, promoting dissociation, &
improving balance  Walkers & crutches may be
used ◦ Posterior walkers encourages more
upright posture during gait  Treadmill training
or body weight support treadmill training 
 Adapted tricycle, wheelchair or motorized
wheelchair may improve mobility in more
disabled children
 111. Improve play  Play is the primary
productive activity of children it should be
motivating & pleasurable  Motivates social
skills, perception conceptual, intellectual &
language skills  Appropriate toys & play
methods should be suggested  Parents should
encourage to let children enjoy their typical play
activities s/a rolling downhill or getting dirty
 112. SCHOOL AGE & ADOLESCENCE
 113. Improve activity, mobility & endurance 
Gait training can be continued throughout
school age with other conjunction s/a spasticity
mgt  Architectural modification may be
required s/a ramps or rails  Orthosis increases
energy expenditure  Regular exercise, proper
diet & nutrition & participation in recreational
activities is encouraged
 114. School & community participation
 Positioning, lifting & transfer techniques
should be taught to the school personnel 
Opportunities should be given to participate in
community & recreational activities  Adapted
games & athletic competition & team
participation improves self esteem  Introduce
to Community fitness program
 115.  Barriers s/a transportation, finances,
time preferences & involvement, interest should
also be considered carefully  Injury prevention
will limit impairment & disability
 116. TRANSITION TO ADULTHOOD
 117. Improve functional skills  Maintain &
improve cardiovascular fitness  Weight control,
maintain integrity of joints & muscles, help
prevent osteoporosis  Fitness clubs, swimming,
wheelchair aerobics & adapted sports are
options  Disability certificate should be
provided to reimburse handicap facilities &
 compensations  Introduce to help lines &
community care centers
 118. Transition planning  Vocational training &
occupational training should be provided 
Living arrangement, personal mgt including
birth control, social skill & household
management should be made available 
Continuation of professional health service
should be done
 119. Characteristics Score 0 Score 1 Score 2
Acronym Skin color/ Complexion Blue or pale all
over Blue at extremities body pink
(acrocyanosis) No cyanosis- body & extremities
pink Appearance Pulse rate Absent <100 ≥100
Pulse Reflexirritability No response to
stimulation grimace/feeble cry when stimulated
cry or pull away when stimulated Grimace
Muscle tone None some flexion flexed arms &
legs that resist extension Activity Breathing
Absent weak, irregular, gasping strong, lusty cry
Respiration Apgar score
 120. Scoring  Test is done at 1 & 5 min after
birth, & repeated later if score is/ & remain low
◦ 3 & below- critically low, ◦ 4 to 6 - fairly low ◦ 7
to 10- generally normal.  A low score on 1
minute -requires medical attention  If score
remains below 3 at times s/a 10, 15, or 30 min,
there is a risk that child will suffer longer-term
neurological damage.  Purpose of Apgar test is
to determine quickly whether a newborn needs
immediate medical care or not & not designed
to make long-term predictions  A score of 10 is
uncommon due to prevalence of transient
cyanosis, & is not substantially different from a
score of 9. ◦ Transient cyanosis is common,
particularly in babies born at high altitude.