Cerebral Palsy

Question 1

Skills needed in supine

Answer 1

bridging: 3-6 months
head stabilization in midline: 4-5 months
rolls over: 6 months
lies straight, symmetrical: 8 months
pulls self to sitting: 9-12 months

Question 2

features to develop in supine

Answer 2

○ Head and neck control
○ Shoulder control
○ Pelvic control
○ Counterpoising of limbs
○ Rising reaction and actions

Question 3

expected in supine: 0-3 months

Answer 3

dimunition of headlag
asymmetrical supine
kicking movement

Question 4

problems in supine: 0-3 months

Answer 4

○ Delayed diminution of head lag
○ Abnormal performance
■ Opisthotonus
■ Legs in FAbER
■ Strap hanger
■ Hip dislocation
■ Pull to sit = LE ext & add

Question 5

treatment in supine: 0-3 months

Answer 5

facilitate head raising in supine (for head lag)
objects on pts tummy
place child halfway down against a wedge

inhibit normal posturing
activities in prone, sidelying, or sitting
facilitate head flexion
midline play
positioning

Question 6

expected in supine 4-6 months

Answer 6

● Exhibits head stabilization in midline and off the surface
● Shows head rising/righting; overcomes head lag
○ When pulled to sit, pt can already correct and tuck
their chin
● Does pelvic bridging
● Brings feet to mouth or chin
○ With manual manipulation

Question 7

problems in supine 4-6 months

Answer 7

○ Patient cannot bring hands to midline – lack in
symmetry
■ If not corrected, manipulation of objects and
integration of visual to tactile manipulation
would be difficult.
○ Persistence of head lag in pull to sit
○ Inability to do bridging
○ Abnormal performance (LE in EAdIR)
○ Inability to roll

Question 8

treatment in supine 4-6 months

Answer 8

no midline play:(can start in sidelying) arm reach towards midline

head lag: inhibit abnormal posturing

no bridging: Facilitate bridging activities by integrating play therapy – progress by doing holds then resistance

inability to roll: integrate activities to facilitate rolling and turning; hammocks, supine to sidelying, segmental rotations, rolling from prone to supine

Question 9

expected in supine 6-9 months

Answer 9

Rolls, assumes to sitting
● Lies straight and symmetrical

Question 10

problems in supine 6-9 months

Answer 10

Inability to roll over or pull himself towards sitting
○ Persistent abnormal posturing

Question 11

treatment in supine 6-9 months

Answer 11

facilitate head raising and rolling
rolling: pull to sit

facilitate use of arms to roll

Question 12

skills needed in prone

Answer 12

● Rolls from prone to supine: 3-6 months
● Weight bears on hands and knees: 6-9 months
● Assumes supported kneeling: 11 months
● Head raises and hold: 0-3 months
● Assumes crawl position: 9-11 months

Question 13

in order to achieve prone milestones, pt should already have the ff

Answer 13

○ Head control
○ Shoulder control
○ Counterpoising of neck
○ Counterpoising of arm and leg
○ Pelvic control
○ Tilt, equilibrium and protective reaction

Question 14

expected in 0-3 months prone

Answer 14

● Lifts head at 0-45 deg in 2 months and 0-90 deg in 3-4
months
● Starts weight bearing on the forearm when doing prone
on elbows
● Turns head from side to side to explore and collect visual
inputs from the environment

Question 15

problems in 0-3 months prone

Answer 15

○ Baby does not like prone position
■ Difficulty in breathing
■ Difficulty in moving/extending the head
● Neck extensors are not yet well developed
■ Difficulty in using the hands
● WB on the elbows or forearm
● Hands could still be confined at the side
■ Increase in flexor tone
○ Delayed development of head control
○ Abnormal performance
■ Abnormal muscle tone
■ Asymmetric posture

Question 16

treatment strategies for 0-3 months prone

Answer 16

issues on prone: gradually increase tolerance ( don’t force)

delayed head control: facilitate neck ext

abnormal performance: correction of abnormal posture
integration of reflexes

Question 17

expected 4-6 months prone

Answer 17

● Weight bears on forearm or elbows or on forearm and
knees; In preparation for crawling
● Weight bears on forearms and able to weight shift for
overhead reach
● Rolls from prone to supine in 4 months

Question 18

problems 4-6 months prone

Answer 18

○ Inability to rise on to knees, on forearms and knees
■ Associated with emergence of mermaid crawl or
commando crawl
○ Inability to roll over from prone → supine

Question 19

treatment 4-6 months prone

Answer 19

facilitate assumption of position –> apply joint pounding/compression
play therapy; make them play in position for a long time to develop tolerance
activities rolling form prone to supine

Question 20

expected 6-9 months prone

Answer 20

● Weight bears on hands/prone on hands and on hands
and knees (quadruped)
● Does overhead reach while weight bearing unilaterally
○ Weight shift to one side and do reaching
● Does pivot prone
● Crawls: From commando and mermaid crawling
● Pulls to stand with support

Question 21

problems 6-9 months prone

Answer 21

○ Difficulty in weight bearing and static-dynamic
activities
■ Associated with lack of head and SH girdle
stability
○ Persistence of mermaid crawl or commando crawl
■ Associated with child pulling self forward on a
flexed arm or LE may be too stiff in extension,
adduction, and IR → cannot crawl with the LE

Question 22

treatment 6-9 months prone

Answer 22

difficulty weight bearing: weight shifting activities (can apply joint pounding or compression in POH or quadruped)
asymmetric WB

address mermaid/commando crawling: assist child to do reciprocal arm and leg patterns

Question 23

expected 9-12 months prone

Answer 23

● Half knees and leans on hands for support
● Kneels with arm support
● Bear walks or elephant walks (hip and knee extended)
● Pulls to stand through half kneeling
● Stands up through quadruped

Question 24

problems 9-12 months prone

Answer 24

○ Delayed in reciprocal crawling
■ Present as bunny hopping because still cannot
do reciprocal progression of arms and legs
○ Difficulty in maintaining half kneeling position
○ Inability to rise on hands and knees to stand
○ Inability to change positions from prone → sitting or
prone → squatting
○ Absence of equilibrium and protective reactions

Question 25

treatments 9-12 months prone

Answer 25

address tightness and P pelvic control facilitate changing positions half kneeling --> kneeling --> manual resistance to hip/shoulder girdle then apply play facilitate WB and stability over shoulder and pelvis half kneeling then facilitate standing vestib ball or rocker board for absence of protective reaction

Question 26

need to be developed in sitting

Answer 26

● Sits alone: 6-9 months ● Develops cervical and lumbar lordosis: 7-9 months ● Sits in various positions: 9-12 months ● Develops tilting reactions: 6-9 months ● Sits lean on hands: 4-6 months

Question 27

need to be developed to achieve sitting milestones

Answer 27

○ Head control ○ Shoulder control ○ Trunk control ○ Pelvic control ○ Counterpoising for head and limb movements ○ Rising from sitting ■ Towards the end of sitting development ○ Equilibrium and protective reaction

Question 28

general sitting problems

Answer 28

abnormal posture muscle imbalance involuntary movement

Question 29

expected 3-6 months sitting

Answer 29

Sits and leans on hands ● Sits with support gradually removed ● Sits on chair with back and arms support

Question 30

problems 3-6 months sitting

Answer 30

Delayed motor development either in supported seating or manifested with impaired balance with head movements Persistence of abnormal postures and malalignment

Question 31

treatment 3-6 months sitting

Answer 31

delayed development: sitting with support or quadruped sitting pushing and pulling in sitting POE or POH c unilateral hand and overhead activities push against therapist's hand once they can elevate arm to horizontal kyphosis: adjust head table higher to maintain upright posture scolio: train overhead reach on the arm of the side of concavity facilitate ant pelvic tilt facilitate side sitting or tailor sitting avoid W sitting sitting w feet flat

Question 32

expected 6-9 months sitting

Answer 32

sits indep sits and reaches out for objects (unilat --> bilat) develops protective reactions

Question 33

problems 6-9 months sitting

Answer 33

delay in milestones

Question 34

treatment 6-9 months sitting

Answer 34

promote sitting and overhead reaching gentle, quick, slow pushes in supported and unsupported sitting with counterpoise encourage upright sitting pelvis stabilization

Question 35

expected 9-12 months sitting

Answer 35

● Sits and plays without hand support ● Sits in various positions ● Rises from and goes back to sitting position

Question 36

problems 9-12 months sitting

Answer 36

inability to sit steadily for >10 mins impaired balance in transitional positions absence of equilibrium and protective reaction

Question 37

treatments 9-12 months sitting

Answer 37

○ Inability to sit steadily for >10 minutes ■ When this manifests, can do push & pull exercises, integrate overhead reaching activitiesc different arm patterns (PNF), and hand movements as well ■ Can also facilitate assumption of many different positions possible like assumption to side sitting, sitting c one knee bent, crooked sitting, short sitting, long sitting, or sitting dangling (however, sitting dangling should be initially avoided since we want to put the pt’s foot on the ground) ○ Impaired balance in transitional positions ■ Can be trained with the child in mid wing changing postures into and out of sitting (e.g. supine → prone → sitting, STS from chair or floor, coming to stand over a bolster) ● STS from chair/floor/wheelchair/tricycle (of various heights and widths) ○ Absence of equilibrium and protective reaction ■ Can be addressed by doing protective equilibrium reactions in sitting → can use rocking chairs, swings, see-saws, inflatable toys, and bolsters to facilitate this reaction ■ Can train the child to extend and prop arms side to side in various sitting positions

Question 38

skills needed in standing

Answer 38

○ Cruises: 9-12 months ○ Stands, holding on to furniture: 7-9 months ○ Anterior tilts pelvis for stability: 9-12 months ○ Shows sinking or astasia with head control: 3-6 months ○ Flings out arms in protective extension: 12-24 months

Question 39

features needed to develop milestones in standing:

Answer 39

○ Symmetrical weight bearing on both feet ○ Head and trunk control ○ Pelvic control ○ Counterpoising in standing ■ Counteract and balance forces ○ Stability in weight-shifting and lateral sway ○ Equilibrium and protective reactions

Question 40

expected standing 3-9 months

Answer 40

● Pulls to stand ● Exhibits trunk supported standing and bouncing in standing ● Shows supported standing and weight bearing of legs ● Stands and holds on to furniture or with pelvic support ● Stands and starts to weight shift → in preparation for walking

Question 41

problems standing 3-9 months

Answer 41

delayed weight bearing poor stab and abnormal posture persistent primitive reflex absence of equilibrium and protective reaction

Question 42

treatment standing 3-9 months

Answer 42

○ Address and promote stability → train the pt by tilting the pelvis forward and backward, sideways to maintain upright posture ○ Promote weight shifting → lifting one leg at a time so the pt can learn the necessary activities for balancing out the weight on each of the extremities

Question 43

expected standing 9-12 months

Answer 43

● Stands alone - weight shifts ● Cruises ● Walks

Question 44

problems standing 9-12 months

Answer 44

○ Delayed motor development ■ Either pt cannot stand alone, can stand but holds on to something, unable to weight shift, unable to cruise/walk ○ Abnormal postures and gait deviations

Question 45

treatment standing 9-12 months

Answer 45

○ Improve stability initially to promote bilateral symmetrical weight bearing in standing → integrate activities (e.g. play therapy) for the pt to stand symmetrically ○ Can promote mobility as a progression by doing overhead reaching, lifting one leg in preparation for stepping ○ For cruising, we can use horizontal bars and we can instruct pt to walk sideways ○ For walking, we can instruct pt to hold on parallel bars or use of walking frames (for example, like a mini push cart for the pt to hold on for support)

Question 46

moro and startle

Answer 46

● Problems: ○ Interfere with protective extension response, sitting balance and balance reaction ● Treatment: ○ Train the head with vertical stability in upright positioning ○ Weight bearing on UE - POE, POH ○ Facilitate equilibrium and protective reactions

Question 47

palmar grasp

Answer 47

● Problems: ○ Interferes with manipulative skills (transfers of objects, voluntary release) ● Treatment: ○ Facilitate finger extension and inhibit finger flexion ■ E.g. placing hard objects in the palm so the hand won't be fully closed ○ Weight bearing through POE - POH in quadruped position

Question 48

galant's trunk incurvation

Answer 48

● Problems: ○ Interferes with the development of trunk stability and sitting balance ○ Can later on lead to scoliosis ● Treatment: ○ Position body in the midline and facilitate (B) paraspinal muscles bilaterally (give facilitatory stimulus at the same time) ○ Stretching of the muscles of the concave side

Question 49

crossed extension, extensor thrust, flexor withdrawal, and stepping

Answer 49

● Problems: ○ Interfere with LE movement and reciprocation ○ Can later on lead to pt’s inability to crawl, hypersensitivity to tactile inputs, deformities, and contractures and later on, inability to walk ● Treatment: ○ Weight bearing with joint compression through the pelvic and hip ○ Facilitate hip abduction and inhibit hip/LE adduction ○ Desensitize soles of the foot through deep pressure and weight bearing activities ■ So the pt won’t react or won’t have manifestations of reflexes

Question 50

positive supporting reflex

Answer 50

● Problems: ○ Manifest and affect the pt to be unable to do reciprocal flexion and extension movements of the LE ○ Can lead to poor standing balance, low standing base, inability to walk ○ When the feet is on the floor, the pt can have genu recurvatum ○ No reciprocal movements ● Treatment: ○ Break the total extension patterns of the limbs ■ Supine: hold on to the sole of the foot and move the legs reciprocally ● Promote flexion extension of the LE ■ Standing: move the legs alternately forward and backward

Question 51

negative supporting

Answer 51

● Problems: ○ Persistence of negative supporting reflex would lead to flaccid patients ■ E.g. let pt stand upright, since flaccid, their tendency is to sink (like a jell-O) ○ Astasia - upright sinking d/t flaccid ○ Abasia - inability to propel the LE or simulate walking (reciprocal movements of LE) ○ Interferes with supporting responses in the LE ● Treatment: ○ Graded sensory inputs on the sole of the foot ○ Promote weight bearing with joint compression to facilitate positive supporting reflex ○ Facilitate facilitation of co-contraction muscles in the proximal joints

Question 52

ATNR

Answer 52

○ Affects pt’s ability to roll from supine to prone ○ Interfere with crawling and creeping (can’t WB on the flexed side), balance, bilateral activities and midline play, poor eye-hand coordination ○ Manifest abnormalities of head postures during activities ○ Abnormal head posture → can have scoliosis, hip subluxation/dislocation, and contractures ● Treatment: ○ Promotion of activities of the head with the head in midline and neck in extension ○ Perform bilateral symmetrical activities with head on the side ○ Rolling in a barrel ■ Promotes changes in head position and inhibits the UE from extending ○ Performing quadruped, rock back and forth then reach forward ○ Activities in sidelying to prevent head rotation and promote midline orientation

Question 53

STNR

Answer 53

● Problems: ○ Present with lack of trunk rotation ○ Lead to poor sitting postures ○ Interfere with smooth reciprocal movements ■ E.g. inability to do one hand activities, weight shifting, crawling, creeping, and walking ○ Interfere with balance ○ Manifest with heel sitting, bunny hopping, hip and knee flexion contractures, and absence of balance and protective reactions ● Treatment: ○ Prone on hands then progressed to quadruped with elbows extended ○ Roll back and forth with neck extension and flexion ○ Prone scooter board/gym ball ■ Arms forward, feet off the floor ■ Balancing while on the hands and feet then the knees are extended ○ Isolated movements in various positions ○ Weight shifting 0 RIGHTING REACTIONS

Question 54

tonic labryinthine

Answer 54

● Prone and Supine ● Problems: ○ Persistence of this reflex will result in the limitation of the visual field, contractures, abnormal vestibular inputs, and interference with the development of head writhing, and gross motor skills such as rolling, sitting, and creeping. ○ Increased flexor tone in prone ■ Cannot do antigravity movements in prone ○ Increased extensor tone in prone ■ Anti-gravity movements are difficult in supine ■ Opisphotonic posture ■ Trouble orienting, no head raising ● Treatment: ○ Activities are done in sidelying to eliminate the effect of gravity ○ Perform antigravity movements in supine like flexion activities ■ Pull to sit to facilitate (B) SCM ■ Supine activities, reach foot ○ Perform antigravity movements in prone like extension activities ■ Prone scooter board, weight shifting, and reaching forward ■ Prone on elbows and prone on hands with facilitation of neck and back extension by tapping

Question 55

neck righting

Answer 55

● Problems: ○ Persistence of this reflex would manifest in interference of segmental rolling. Patient cannot roll segmentally and cannot dissociate upper trunk to pelvis. ● Treatment: ○ Log-rolling initially then segmental rolling as a progression ■ Shoulder first, then, the pelvis, then, the extremities ○ Counter-rotation of the trunk ○ Bilateral limb movements to cross over the midline ○ Quadruped activities

Question 56

associated reactions

Answer 56

● Problems: ○ Persistence of this reflex would manifest with difficulty with isolated movements, general increase in muscle tension, and interference with bilateral hand function ● Treatment: ○ Simple tasks done initially with unilateral movements and movements in the cardinal plane ■ Don't place excessive resistance initially because it will lead to facilitation of the counteraction of the opposite extremity

Question 57

plantar grasp

Answer 57

● Problems: ○ Persistence of this reflex would manifest with interfere with the ability to STS especially when the feet are on the ground, will not be able to perform weight shifting, and not be able to develop the mature balance reactions appropriately ● Treatment: ○ Facilitation of toe extension, inhibit toe flexion ○ WB and joint compression in standing

Question 58

head righting

Answer 58

● Problems: ○ ○ Inhibits development of balance and protective extension ○ Absence of this reflex would result with the interference of the visual process and other sensory inputs. ● Treatment: ○ Slow tilting activities ○ Balance activities in all developmental positions ○ Rolling with the head off the floor using rubber tires or bolsters ○ Prone swings, prone on elbow, prone over the ball, prone scooters

Question 59

body righting

Answer 59

○ Absence of this reflex would result to difficulty of the child to perform segmental trunk movements (difficulty in trunk rotation), limitation in flexibility in all the gross and fine motor skills, poor weight shifting abilities ● Treatment: ○ Similar exercises in Head Righting ○ Integrate segmental rolling ○ Facilitation of balance and protective reactions

Question 60

protective extension

Answer 60

● Problems: ○ Absence of this reflex would result to increase likelihood to injury especially during falls (cannot catch or break the fall), becomes apprehensive in moving in space, interfere with shoulder girdle stability and UE function ● Treatment: ○ Prone on bolster (prone on hands) → Prone on ball ○ Vestibular stimulation ■ Simulate falling on hands from kneeling

Question 61

equilibrium or tilting

Answer 61

● Problems: ○ Absence of this reflex would interfere with balance and flexibility, apprehension in moving in space (gross motor), reaction of the patient with positional changes will be very slow, affect emotional tone (emotional lability), decrease attention span, lead to poor postural basis for all fine motor tasks ● Treatment: ○ Facilitation of trunk and head righting ■ Slow tilting in all positions initially ○ Promote in supine – rolling to side lying to sitting on a ball ○ Platform swings or any movable equipments ■ And later on perform challenging activities in standing