Cerebral Palsy Day-23.pptx

Why to choose ICD, Delhi and its associated centers as your first choice when you are looking for a habilitation / rehabilitation centre for your child with special needs or differently able

ICD and its all collaborated/ partner centers are monitored by Dr. Mansoor Alam, the most experienced professional in India for children with developmental disorders. Dr. M Alam is considered one of the best consultants in India for High risk infant screening through GMA (Prechtl’s Method), Infant stimulation therapy, Early Intervention, Developmental therapy, Botox therapy and post procedures habilitation programs.
ICD provides you combination therapy or multimodal treatment which assures you better result. ICD’s combination treatment plan always includes medicines / injection therapy / surgery with advance habilitation therapies.
ICD with its international associate professionals have developed a unique treatment approach known as Neuro-Enhancing Treatment (NET). NET is considered one of the best treatment methods for children with cerebral palsy, spina bifida and Arthrogryposis. Neuro-Enhancing Positioning (NEP) is the backbone of NET and best method for achieving dissociation in cases of spastic and dystonic cerebral palsy. This is why ICD is considered the best treatment institute / centre / clinic for children with cerebral palsy
ICD’s integrated approach of treatment has successfully treated thousands of children with complex developmental issues from not only India but also from countries like Nepal, Bangladesh, Afghanistan, Pakistan, Sri Lanka, Iraq, Iran, Malaysia, Indonesia, Nigeria, Kenya, Kuwait, Oman, Qatar, Saudi Arabia, Dubai, South Africa, Sudan, UAE, Turkey, Uzbekistan, Vietnam, Singapore, Yemen, Uk, Australia, USA, Canada.
ICD has been the preferred partner for introducing newer therapies in India. ICD has already supported Allergan to introduce Botox, Medtronic to introduce Intrathecal Baclofen Pump, UFTD Delhi to start HBOT, Bike / Reviva Cell to introduce stem cell treatment in India.
Experiences have made ICD perfect. 20 + years of experience have enabled ICD to associate with more than 400 highly qualified and experienced professionals from different specializations.
ICD is best known for its proper screening, right diagnosis and holistic treatment planning. Always remember, right diagnosis means right treatment.
ICD is the only organization in India which can provide you all required assistive technology such as orthotics ( AFO/ Calipers/ Splints / Braces, etc), Mobility Aids( Walker / Rollator / Tripods / Wheel Chairs / Crawler, etc), Postural Aids ( CP Chair / Standing Frame / Corner Chair / Aligner / stretching aid, etc), Toys and Training materials, etc . In case of Ads and appliances, People says “You name it-we have it”
Thousands of articles, dozens of books have included ICD as their primary and trusted source for information for researches / case studies.

1. Cerebral Palsy Day Dr. Mansoor Alam Consultant Developmental Specialist Institute for Child Development, New Delhi

2. World Cerebral Palsy Day World Cerebral Palsy Day-6 th October Indian National Cerebral Palsy-3 rd October

3. Cerebral Palsy Day World Cerebral Palsy Day is observed on October 6. Cerebral Palsy is a lifelong disability with no known cure. The day celebrates lives of 17 million people living with Cerebral Palsy, bringing people living with cerebral palsy, their families, allies, supporters and organisations across more than 100 countries together . In 2012, Cerebral Palsy Alliance created World Cerebral Palsy Day on October 6. The day aims to ensure that children and adults with cerebral palsy have the same rights, access and opportunities as rest of the world.

4. Indian cerebral palsy day 3 rd October, every year In remembrance of Dr Perin K Mulla Feroze , a lady doctor from Mumbai.

5. Cerebral Palsy Day There are many different ways you can spread cerebral palsy awareness. One of the most popular ways to show your support for National Cerebral Palsy Month is to wear the colour   green Green is commonly associated with new life, growth, and nourishment, which seems fitting given the nature of cerebral palsy. Cerebral palsy manifests in childhood, and is often the result of serious birth injuries

6. Theme of CP Day-2023 The theme for the day is # MillionsOfReasons  – as cerebral palsy affects more than 17 million people worldwide, there are millions of reasons to support the day and make your voice heard on October 6 . World Cerebral Palsy Day  is a movement of people with cerebral palsy and their families, and the organisations that support them, in more than 75 countries . The World Cerebral Palsy Day vision is to ensure that children and adults with cerebral palsy have the same rights, access and opportunities as anyone else in our society.

7. Today… Quick facts about cerebral palsy (CP) Definition Causes of CP Risk factors Classification Diagnosis Assessments Treatment and Management F-words in CP Management

8. Quick facts CP is the most common physical disability in childhood CP occurs in approximately 1 in 400 live Births worldwide It is caused by an injury to the developing brain, which mostly happens before birth There is no single cause but researchers have identified a number of factors that may lead to the brain injury Babies can now be diagnosed as at ‘high risk of CP’ at three months of age or even before There are many evidence-based interventions for CP and new international clinical guidelines will soon be available.

9. Cerebral palsy Cerebral palsy (CP) is a physical disability that affects movement and posture CP is an umbrella term for a group of disorders that affects a person’s ability to move CP is due to damage to the developing brain before, during or after birth CP affects people in different ways. It can affect body movement, muscle control, muscle coordination, muscle tone, reflex, posture and balance. Although CP is a permanent life-long condition, some of these signs of cerebral palsy can improve or worsen over time People who have CP may also have visual, learning, hearing, speech, epilepsy and intellectual impairments.

10. The clinical picture of a person as a whole

11. Definition Cerebral palsy describes a group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.

12. Definition The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behavior, by epilepsy, and by secondary musculoskeletal disorders”

13. Cerebral Palsy Three part definition: A disorder of movement and Posture caused by a non-progressive Injury to the immature brain Change in muscle tone and posture, both at rest and with voluntary activity. First year or two of life – included in most definitions Upper age limit of post-natal brain insult- unclear

14. History Dr. Little was the first person who identified cerebral palsy. CP was earlier known as little diseases It is not widely known that Sigmund Freud (1889) was the leading European authority on CP of the late 19 th Century. He authored three Monographs on CP in the 1890’s. Freud was the first to point out that prematurity and birth asphyxia might reflect a fetus already damaged in-utero Even less well known is that William Osler wrote the only 19th century monograph on CP published in the US Osler’s special interest was in clinical expression and brain pathology

15. CP is classified in many ways to understand and deal the condition Based on the site of insult to the brain Based on involvement of body parts Based on severity of the damage to the brain 10/6/2023 16 Classification / Types of CP

16. Spastic Rigidity Dyskinetic Floppy Ataxia Mixed 10/6/2023 17 Classification Based on site of insult of the brain

17. Quadriplegia Triplegia Diplegia Hemiplegia Monoplegia 10/6/2023 18 Classification Based on involvement of body parts

18. Mild Moderate Severe Profound 10/6/2023 19 Classification Based on extent of damage in the brain Based on severity of the condition

19. Spastic hemiplegia CP Spastic diplegia CP Spastic quadriplegia CP Spastic triplegia CP Spastic monoplegia CP 10/6/2023 20 Different Forms of CP

20. Dystonic CP Athetoid CP Ataxic CP Hypotonic CP Mixed CP 10/6/2023 21 Different Forms of CP

21. Advance Classification Based on involvement of body parts Bilateral CP Bilateral Symmetrical CP Bilateral Asymmetrical CP Unilateral CP Unilateral Symmetrical CP Unilateral Asymmetrical CP

22. Advance Classification Based on Functional Ability Gross Motor Level- GMFCS (5 Functional Level) Mobility Level-FMS (5 Functional Level) Manual Ability Level-MACS (5 Functional Level) Visual Ability Level-VFCS (5 Functional Level) Communication Ability Level- CFCS (5 Functional Level) Feeding Ability Level- EDACS (5 Functional Level) Lowest Ability to Highest Ability Level-5: Lowest Ability Level Level-1: Highest Ability Level

23. General Features Infantile hemiplegia is a movement defect of one side of the body only, either the right side or the left. The disability is not always uniform. In the typical spastic form in the older child, the following patterns are seen. The upper limb is held with the arm adducted and internally rotated, The forearm flexed and pronated, the wrists flexed, and the fingers flexed with the thumb pressed into the palm. 10/6/2023 24 CP Spastic Hemiplegia

24. 10/6/2023 25 CP Spastic Hemiplegia

25. S ymmetrical or near symmetrical involvement the legs are more involved that the arms. The hips knees and ankles may flex and the child can sit in the tailor position on the base of his spine. The arms may be mildly, moderately or severely affected. Very mild cases of spastic diplegia may involve the legs and feet only. There may be a tendency to walk in planter flexion only. 10/6/2023 26 Cp spastic diplegia

26. 10/6/2023 27 Cerebral palsy spastic diplegia

27. These children show asymmetrical involvement; and the arms are more involved than the legs. The arms may be mildly, moderately or severely affected. If the arms are moderately affected, one hand is better than the other because the child will use one hand for play. 10/6/2023 28 Cp spastic triplegia

28. 10/6/2023 29 Cerebral palsy spastic triplegia

29. These children show symmetrical or near symmetrical involvement; and the arms are more involved than the legs. Both hands are severely involved and he finds difficulty in feeding himself and playing with toys. If a child with spastic quadriplegia is maintained in one position for the greater part of the day, particularly if it is a flexed posture, he may develop flexion contracture in muscles and in the capsules of joints. Severe deformities and joints dislocations can result. 10/6/2023 30 Cp spastic quadriplegia

30. 10/6/2023 31 Cp spastic quadriplegia

31. Dystonia  is a movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both.  Dystonia  in  cerebral palsy  ( CP ) presents as hypertonia, involuntary postures and movements, or a combination 10/6/2023 32 Cp dystonia

32. 10/6/2023 33 Cerebral palsy dystonia

33. Athetoid  cerebral palsy  is a type of  cerebral palsy  characterized by  athetosis , or uncontrolled movements. This lack of control usually causes a person with athetoid  cerebral palsy  to make erratic movements, especially when the person is in motion. 10/6/2023 34 Cp athetosis

34. 10/6/2023 35 Cerebral palsy athetosis

35. Ataxia  is the least common form of  cerebral palsy .  Ataxia  means 'without order' or 'incoordination'.  Ataxic  movements are characterized by clumsiness, imprecision, or instability. ...  Ataxia  causes an interruption of muscle control in the arms and legs, resulting in a lack of balance and coordination. 10/6/2023 36 Cp Ataxia

36. 10/6/2023 37 Cerebral palsy ataxia

37. Hypotonia  is diminished muscle tone. The infant or child with  hypotonic cerebral palsy  appears floppy -- like a rag doll. In early infancy,  hypotonia  can be easily seen by the inability of the infant to gain any head control when pulled by the arms to a sitting position (this symptom is often referred to as head lag). 10/6/2023 38 Cp hypotonia

38. 10/6/2023 39 Cerebral palsy hypotonia

39. Rigidity  –  is not seen in cases of cerebral palsy caused by prematurity; however it is a common feature in cerebral palsy caused by anoxia, such as in near drowning. Muscles that have rigidity feel heavy and like “a lead pipe” when they are moved passively. 10/6/2023 40 Cp rigidity

40. Mixed cerebral palsy  is a developmental disorder caused by brain damage that takes place before, during or shortly after birth. Those diagnosed with  mixed CP  have damage to the motor control centers in several parts of their brain. 10/6/2023 41 Mixed CP

41. 10/6/2023 42 Cerebral palsy mixed

42. The exact cause is unknown but it is believed that C.P occurs during pregnancy when the brain gets damaged or is underdeveloped . 10/6/2023 43 Causes of Cerebral Palsy

43. Causes of cerebral palsy Cerebral palsy (CP) is the result of a combination of events either before, during, or after birth that can lead to an injury in a baby’s developing brain There are multiple causes of CP –but a series of ‘causal pathways’, i.e. a sequence of events that combine to cause or accelerate injury to the developing brain. About 45% of children diagnosed with CP are born prematurely For most babies born at term with CP, the cause remains unknown Only a small percentage of CP is due to complications at birth (e.g. asphyxia or lack of oxygen).

44. Variety of perinatal, prenatal, and postnatal factors contribute, either singly or multifactorily to CP. Commonly thought to be due to birth asphyxia; now known to be due to existing prenatal brain abnormalities. Premature delivery is the single most important determinant of CP. In 24% of cases, no cause is found. 10/6/2023 45 Causes of cerebral palsy

45. Multifactorial but in most cases is unknown . Sometime Neuro-imaging may be entirely normal . An increasing amount of literature suggests a link between various prenatal, perinatal, and postnatal factors and CP Prenatal factors play a significant role in the etiology of CP. 10/6/2023 46 Causes of cerebral palsy

46. This disorder affects the Cerebrum. which controls voluntary movement such as thinking and emotions. The cerebral motor cortex (at the back of the frontal lobe) is usually damaged also. Cerebral Palsy may occur due to the damage of white matter (brain tissue). 10/6/2023 47 Where/How ?

47. Risk factors Risk factors do not cause CP. However, the presence of some risk factors may lead to an increased chance of a child being born with CP. Some risk factors for cerebral palsy have been identified. These include: premature birth (less than 37 weeks) low birth weight (small for gestational age) blood clotting problems (thrombophilia) an inability of the placenta to provide the developing foetus with oxygen and nutrients bacterial or viral infection of the mother, foetus or baby that directly or indirectly attacks the infant’s central nervous system prolonged loss of oxygen during the pregnancy or birthing process, or severe jaundice shortly after birth.

48. General Gestational Age < 32 weeks Birth Weight < 2500 Grams Maternal History Mental Retardation Seizure disorder Hyperthyroidism Two or more fetal loss Sibling with motor deficits 10/6/2023 49 Risk Factors associated with CP

49. During Gestation Twin gestation Fetal growth retardation Third Trimester bleeding Premature Placental Separation Choionitis Increased urine protein excretion Low placental weight 10/6/2023 50 Risk Factors associated with CP

50. Fetal Factors Abnormal fetal presentation Fetal malformation Fetal bradychardia Neonatal Seizures 10/6/2023 51 Risk Factors associated with CP

51. Diagnosis CP can sometimes be diagnosed early, so interventions can start as soon as possible Babies can now be assessed as being at ‘high risk of cerebral palsy’ as early as 3-5 months of age. The most sensitive tools are: General Movements Assessment in babies <20 weeks (corrected) - 95% predictive Neuroimaging Hammersmith Infant Neurological Assessment (HINE) - 90% predictive See CP: Diagnosis and Treatment poster at www.worldcpday.org

52. Diagnosis ( cont ) Diagnosis Making for CP

53. Diagnosis ( cont ) Assessing Motor Development Assessing Motor Development

54. Diagnosis ( cont ) Neuroimaging

55. Diagnosis Making Cerebral Palsy is a complex disorder so diagnosis making is always difficult. There is no specific test which can confirm the presence of CP. CP is diagnosed through observations, assessments and clinical investigations.

56. Diagnosis Making Delayed milestones, mostly with gross motors and fine motors Persistence of primitive reflexes No evidence of progressive disease / No loss of milestones achieved previously

57. Diagnosis Making There is motor delay- variation by more than 50% with abnormal movements and poor postural control A child with CP may have a combination of associated disorders such as Epilepsy, Visual deficits, Hearing Deficits, Drooling, Feeding problems, Poor Cognition, Poor speech, etc

58. Diagnosis Making Observation  and documentation ( Videography)of the child while the child is in static, dynamic and transitory postures during play, etc Documenting medical history starting from pregnancy. Medical issues related to prenatal, perinatal and postnatal to establish a good scientific basis of the diagnosis

59. Diagnosis Making Getting X-rays or Ultrasound (Skull / Hips / Spine), Getting MRI / CT scan of the Brain / Spine Getting EEG -to rule out epileptic syndrome

60. Diagnosis Making Getting Blood Tests -to rule out other diseases Getting Chromosomal Study -to rule out genetic disorder Getting Vision Test, Hearing Test, etc to have a baseline

61. Associated impairments Children with CP may also have a range of physical and cognitive impairments Children with CP always have some or the other associated disorders In a recent study of 100 Children with CP, 34 associated disorders has been found. Lesser the number of comorbid conditions-better the prognosis

62. Associated Disorders All children with CP have some or the other associated problems. There are three types of co morbidities have been identified. The three co morbidity categories are cocausal , complications, and co‐occurring. Cocausal : Disorders caused by the same injury to the developing brain that caused CP (i.e. epilepsy and cognitive impairment ) Complications : Disorders that are complications of the main CP condition (i.e. scoliosis and hip dislocation ) Co‐occurring : Disorders not caused by the injury to the developing brain, nor are complications of the main CP condition

63. Associated Disorders In actual sense these associated factors are considered the basis of prognosis (outcomes from the treatment). Coping with these disabilities may be even more of a challenge than coping with the motor impairments of cerebral palsy. There is a common saying  “Lesser the number of associated problems-more the chances of better future”.

64. Epilepsy / Seizures / Convulsions Children with CP can have focal / partial seizures, generalized seizures, petit mal / absence seizure, myoclonic seizure, tonic-atonic seizure (drop attacks), etc Management / Treatment Options Medicinal Treatments- Anti-epileptic Drugs (AED) based on the types of seizure   Neuro -surgery to remove the part of the brain responsible for the seizures (lobotomy)   Vagus Nerve Stimulation   Ketogenic -a special diet, etc

65. Visual Impairments-eye problems Children with CP may have cerebral visual impairment (CVI),  Eye Visual Impairment, Strabismus, Poor visual acuity (Myopia or Hypermetropia ), Nystagmus, Lazy eye, etc Treatment / Management options Visual Aids-Spectacles Eye Surgery Vision therapy

66. Hearing Impairments / Deficits Children with CP may have hearing loss (conductive hearing loss, sensorineural hearing loss), etc Treatment / Management Options Hearing aids Surgeries to correct malformation or injuries Cochlear implant  Auditory Training, etc

67. Speech impairments Children with CP can have problems such as aphasia, dyspraxia, dysprosody , dysarthria, stuttering, dysphagia , resonance disorders, etc Treatment / Management Options Use of Bliss Board  Speech and language therapy, etc

68. Feeding disorder Very common problems in the form sucking difficulties, swallowing difficulties, chewing difficulties, drooling etc Treatment / Management Options Combination therapy Nutritional modifications  GERD is managed with medication

69. Drooling-excessive production of saliva ( Sialorrhea ) Drooling can be in the form of posterior drooling or anterior drooling Treatment / Management Options 1.  Optimizing positions and conditions 2.  Oro-motor and oro -sensory   therapies 3.  Behavioral therapies 4.  Oral appliances 5.  Anti-cholinergic agents 6.  Botulinum toxin Injections 7.  Surgical intervention

70. Mental Retardation-Intellectual Disability-Low Intelligence-Low cognition 33% children with CP may have low / subnormal cognition or poor mental ability. They have average or lower than average IQ.  Treatment / Management Options  Medications Occupational therapy Cognitive therapy Special Education  Vocational / Life Skills training

71. Bladder Related Issues Children with CP have urinary incontinence or enuresis, Urinary infections, and indication issues Treatment / Management Options  Medicinal Management- Specialized Exercises- Kegel  Exercises Toilet Training Program

72. Bowel Related Issues Incidence: 40% to 57% children with CP may have bowel related issues  Treatment / Management Options  Medications Physical therapy

73. Constipations Incidence: Around 74% children with CP have constipation Treatment / Management Options 1. Encourage foods that contain fibres 2. Encourage a good intake of Fluids 3. Limit the period of idle sitting 4. Encourage to change posture regularly 5. Assist with medications to maintain good bowel habit

74. Dental Problems More than 50% children with CP have Dental problems in the forms of, mal-alignment of the upper and lower teeth, excessive gagging, gingivitis due to seizure medications, etc Treatment / Management Options  Dental care Oral hygiene, etc

75. Failure to Thrive Incidence:  as many as 33% - 40% children with CP may have failure to thrive situation Failure to thrive is a condition which is considered in children who are consistently underweight. Management / Treatment Options Special Diet-Nutritional supplements Managing other medical conditions

76. Obesity There is worldwide tendency of increasing prevalence of obesity in children. Treatment / Management Options Diet Modification Weight reduction program

77. Poor Muscle Growth Incidence: Very common in hemiplegic Cerebral Palsy Treatment / Management Options Nutritional supplements-Protein rich food Activity oriented exercises, etc  

78. Breathing Problems Incidence : Children with cerebral palsy are very prone to respiratory complications like upper respiratory infections (URTI), aspiration, and pneumonia. Breathing difficulties have been seen due to spinal curvature (scoliosis) Treatment / Management Options  Symptomatic medications Breathing exercises

79. Visual -Perception Impairments / Perceptual Disorder Incidence: About 50% Children with CP may have visuo -perceptual disorders Treatment / Management Options  Ophthalmological support Vision therapy  Occupational therapy Special education, etc

80. Delayed Maturation Incidence: Very rare. Sometimes puberty begins earlier but ends later in white children with CP, compared with general population Treatment / Management Options  Symptomatic medical and surgical management Transitional Management Sex education, etc

81. Abnormal sensations-sensory loss Incidence: Rare, mostly with hemiplegic CP Treatment / Management Options Medications  Physical therapy Occupational therapy, etc

82. Sensory dysfunction Incidence: Around 40% children may have sensory dysfunction Treatment / Management Options  Sensory Integration therapy

83. Hydrocephaly (Water in the brain) Incidence: Around 17.3%. Treatment / Management Options  Symptomatic medical management  Need based surgical procedures, insertion of shunt, Endoscopic third ventriculostomy ,

84. Microcephaly (Small size head) Incidence: Lot children with cerebral palsy may have Microcephaly. Around 26.5% Treatment / Management Options Regular monitoring Surgery may be helpful if there is craniosynostosis

85. Skin disorders Incidence: Skin infection and irritation is very common in CP Treatment / Management Options Symptomatic treatment Personal hygiene Skin care, etc

86. Behavioral Issues Incidence: 1 in 4 children with CP have behavioral disorders. Treatment / Management Options Behavioral therapy-ABA, BMT, CBT, etc  Medications

87. Congenital Heart Disorder Incidence: Very rare. Commonly PDA Treatment / Management Options  Symptomatic medical and surgical treatments

88. Hormonal Imbalance Incidence: Poor growth or delayed puberty due to multiple pituitary hormone deficiency hormone deficiency (MPHD) Treatment / Management Options  Hormonal Therapy

89. Sleep disturbance Incidence:   Difficulty in initiating and maintaining sleep, sleep wake transition, sleep breathing disorders, sleep bruxism, excessive day time sleeping, nightmares and sleep talking , etc Treatment / Management Options Modification environment like light system, temperature and bedding used for the child Maintaining  sleep diary and diet modification Medications, etc

90. Pain Incidence: Pain is very common with children with CP. Adults are more prone to pain due to poor postures and joint immobility Treatment / Management Options Medications-  Antispasmodic medications, Anticholinergic drugs Botox Injection Muscle massage,  acupuncture , ice packs and heat therapy, hydrotherapy, and cognitive behavioral therapy.

91. Issues with Secondary Sexual Characters Incidence: Very common with severely affected adults Treatment / Management Options Sex education Behavior therapy Medications, etc

92. Psychological Issues Incidence:  Mental health and psychological problems, in the forms of depression, anxiety and conduct disorders, generally triggered by pain, discomfort or sleep disturbances. Treatment / Management Options Psychotherapy  Medications

93. Associated impairments Children with CP may also have a range of physical and cognitive impairments 1 in 4 is unable to walk 1 in 4 is unable to talk 3 in 4 experience pain 1 in 4 has epilepsy 1 in 4 has a behaviour problem 1 in 2 has an intellectual disability 1 in 10 has a severe vision impairment 1 in 4 has bladder control problems 1 in 5 has a sleep disorder 1 in 5 has saliva control problems

94. Team Members Family Medical Management Team Habilitation Service Providers Life Cycle Approach Birth to one year One year to 3 years Three years to 6 years Six years to 13 years Thirteen years to 18 years Above 18 years Management and treatment team

95. Screening Team Neonatologist Child Specialist Developmental Pediatrician Medical Diagnosis Making and Medical Management Team Pediatric Neurologist Pediatric orthopedic Surgeon Pediatric Eye specialist Pediatric ENT Specialist Pediatric Cardiologist Pediatric Gastroenterologist Multidisciplinary Management Team

96. Pediatric Nephrologists Genetic Specialist Pediatric Dietitian-Nutritionist Pediatric Endocrinologist Pediatric Immunologist Pediatric Physiatrist Pediatric Plastic Surgeon Pediatric Pulmonologist Multidisciplinary Management Team

97. Habilitation Team Neonatotherapist Early Intervention Specialist Developmental Therapy Specialist Pediatric physiotherapist Pediatric Occupational Therapist Special Educator Speech and language Pathologist Psychologist / Behavior Therapist Multidisciplinary Management Team

98. Habilitation Team Pediatric Optometrist Pediatric Hearing Aids Technician Postural Aids Specialist Orthotician Mobility Aids Specialist Adaptive and assistive Aids Technician Apps and Games designers Multidisciplinary Management Team

99. Management Approaches Multidisciplinary Interdisciplinary Trans disciplinary

100. Thorough and accurate assessment of children with cerebral palsy by a multidisciplinary team is essential to ensure chosen interventions meet t he child’s needs. Most assessments measure a particular aspect of the child’s life. It can be Physical, Communication , Social-emotional or cognition The World Health Organization's International Classification of Functioning, Disability and Health (ICF) has been used to guide assessment. The ICF domains include body function and structure, participation, activity and personal and environmental factors. Assessments of Cerebral Palsy

101. International Classification of functioning, disability and health

102. Standardized assessments and outcome measures may be relevant to one or more domains of the ICF. A significant number of assessments are available and it is often necessary to use a combination of these. Assessments of Cerebral Palsy

103. Selection of assessment tools should be based on purpose, psychometrics and those most relevant to the area/s of difficulty. The functional ability classification scales should be used to guide assessment and intervention with all children diagnosed with cerebral palsy to facilitate communication and goal setting. Assessments of Cerebral Palsy

104. Communication ADL Mobility Ambulation ICF Model of Intervention for Habilitation

105. Further assessment should occur to ensure realistic goal setting, provide a baseline for intervention and for evaluation of intervention programs. Assessment Guidelines

106. History and observation Assessment of reflexes and reactions Assessment of functional level and motor development Assessment of muscle tone Assessment of muscle strength Assessment Protocols

107. Assessment of musculoskeletal system deformities Assessment of physical fitness Assessment of gait Assessment of balance Assessment of trunk impairment Assessment Protocols

108. Assessment of health-related quality of life Assessment of activities of daily life Assessments of upper extremity Cognition / Psychometric Assessments Speech and Communication Assessments Assessment Protocols

109. Detailed information should be received from the family or caretakers in all issues related to the children including Family history Prenatal, natal and postnatal period Chronologic and corrected age Associated problems Developmental story Adaptive equipment used Intervention approaches applied Medication taken Family Profile History and observation

110. Observational analysis is crucial to determine children’s functional skills, spontaneous motions and motion strategies, and the underlying fundamental problems. Thus, it can be decided in which field detailed assessment needs to be carried out. During observational analysis, children must be in a setting they can be with their family, and they can feel comfortable and safe. History and observation

111. There should be various toys and materials in the setting to reveal the children’s capacity and to draw their attention. The assessment room should not be crowded and noisy . Video recordings during observation are rather beneficial as well. History and observation

112. Observation of reflexes is important to illustrate the severity of the influence in the nervous system, and observation of balance and protective reactions is important to support motor developmental process. When these assessments are carried out, the corrected age of the children should be considered. It is known that primitive reflexes continue insistently or disappear later than normal or never occur in children with CP. Assessment of reflexes and reactions

113. It can be observed that symmetric tonic and asymmetric tonic neck reflexes still continue in adolescent stage in a case diagnosed with dyskinetic-type CP. Insistence of these reflexes can complicate the therapy. It may be necessary to make various adaptations in the treatment program when the primitive reflexes continue in advanced ages. At the same time, the assessment of protective reactions is important for determining a treatment program Assessment of reflexes and reactions

114. It is crucial to assess motor development, functional skills, and activity limitations for determining the current state of the children, and there are frequently used test batteries for this purpose. Gross Motor Function Measurement (GMFM) is a standardized measurement instrument frequently used to measure the change in gross motor function. Assessment of functional level and motor development

115. Gross Motor Function Classification System (GMFCS) The Gross Motor Function Classification System (GMFCS ) is a five level classification that describes the gross motor function of children with cerebral palsy on the basis of their self-initiated movement with particular emphasis on sitting , walking , and wheeled mobility. FUNCTIONAL MOTOR ABILITY

116. GMFCS

117. ( GMFCS) Levels Level-I: Walk independently Level-II: Walk independently with limitations Level-III: Use assistive devices such as elbow crutches or walking frames Level-IV: Require a wheelchair but may have some form of independent mobility such as a powered wheelchair or may assist with transfers Level-V: Require a wheelchair and are fully dependent in their mobility Gross Motor Function Classification System

118. The Functional Mobility Scale (FMS ) has been constructed to classify functional mobility in children 4 to 18 years, taking into account a range of assistive devices a child might use over three distances: five meters ( in and around the home), 50 meters (in and around (School /preschool ) and 500 meters ( in the community). The FMS is sensitive to detect change after Specialized interventions. Functional Mobility Scale (FMS)

119. FMS

120. Assessing Upper Limbs

121. Level-I: Handles objects easily Level-II: Handles most objects but with reduced speed and/or quality Level-III: Has some difficulty and needs help to modify or prepare activities Level-IV: Handles a limited selection of easily managed objects in adapted settings Level-V: Does not handle objects UPPER LIMB CLASSIFICATIONS Manual Ability Classification System (MACS )

122. MACS

123. Communication  is simply the act of transferring information from one place, person or group to another. Every  communication  involves (at least) one sender, a message and a recipient. This may sound simple, but  communication  is actually a very complex subject. Communications

124. Speech  is human vocal communication using language. Each language uses phonetic combinations of vowel and consonants sounds that form the sounds of its words Speech disorders  affect a person's ability to produce sounds that create words. ... Types of  speech disorder  include misarticulation, apraxia , and dysarthria . There are many possible causes of  speech disorders , including muscles weakness, brain injuries, degenerative  diseases , autism, and hearing loss. Speech

125. Speech and Communication Therapy

126. Level-I: Effective sender and/or receiver with familiar and unfamiliar partners Level-II: Effective but slower paced sender and/or receiver with familiar and unfamiliar partners Level-III: Effective sender and/or receiver with familiar Partners Level-IV: Inconsistent sender and/or receiver with familiar partners Level-V: Seldom effective sender and/or receiver even with familiar partners COMMUNICATION CLASSIFICATION Communication Function Classification System-CFCS

127. Level-I An effective communicator in most situations Can independently communicate a wide variety of messages/topics to familiar and unfamiliar people in most environments Functional Communication Classification System (FCCS)

128. Level-II An effective communicator in most situations, but does need some help Can communicate a variety of messages/ topics to familiar people but may experience some difficulties with unfamiliar people/topics and environments and may need prompts, such as, prompt questions, repetitions (to make themselves understood) and loudness An AAC user who requires assistance with set up, and/or programming; and whose listener may need some assistance with orientation/ interpretation of AAC strategies Functional Communication Classification System (FCCS)

129. Level-III An effective communicator in some situations. Can communicate a small range of messages/ topics to most familiar people Effective communicator with familiar people and activities and in familiar settings about their needs and wants, and things that are happening but require assistance with unfamiliar people/topics and environments Relies on a familiar communication partner to interpret AAC or speech attempts, and to prepare, set up and support communication Functional Communication Classification System (FCCS)

130. Level-IV Assistance is required in most situations, especially with unfamiliar people and environments. Communicates daily/routine needs and wants with familiar people Can initiate and attract attention but needs a familiar person who is familiar with their routine, recent /significant experiences and likes and dislikes, and to interpret their communication Responds to familiar voices, sounds and routines using body movement, facial expression and vocalisation Functional Communication Classification System (FCCS)

131. Level-V Communicates unintentionally with others, using movement and behavior Daily/routine needs and wants are interpreted by familiar people from observation of the individual’s emotional state, body movement and behavior Needs full assistance from a familiar person to observe, interpret movements and behaviors, anticipate, and problem solve based on their experience, training and observation Functional Communication Classification System (FCCS)

132. Academic Performance Adaptive Delay or Impairment Capacity to Learn/Learning Impairments Communication Level Emotional Status Health Intelligence Motor Abilities Social Ability Vision and Hearing Special Education Assessment

133. The assessments help to allocate the following service and supports to accommodate, modify or adapt a child’s needs: Program Modifications Related Services Special Accommodations Specially Designed Instruction Supplementary Aids Adapted Equipment Adapted Materials Assistive Technology Augmentative Communication Devices Special Education Assessment

134. The assessment of cognitive functioning is often challenging in students with motor impairment because the majority of tests require verbal and motor responses A careful consideration of the level of motor, communication, and/or visual or visual perception impairment in students with CP and motor impairments can inform assessors on the choice of cognitive assessment battery to use The use of Assistive Technology, together with alternative response modes (e.g., partner assisted scanning) is encouraged to enable access to standardized cognitive assessment. Special Education Assessment

135. For students with significant motor impairments for whom standardized cognitive assessments are not appropriate, the use of developmental scales, which assess progress along a continuum rather than providing comparative performance data with peers, may be an appropriate alternative Special Education Assessment

136. For students with severe motor impairments, it is important to conduct a functional skills assessment. A functional skills assessment targets the skills needed in a given environment and activity, and includes measures of social and adaptive functioning with a focus on basic life skills. It focuses on practical independent living skills. It also considers students’ functioning in their environments, and examines the process of learning and performance. Special Education Assessment

137. Based on the results of the assessment, intervention techniques are implemented and evaluated on a regular basis The following test accommodations are helpful in supporting students with significant motor impairments so as to obtain the best responses during the assessment session Body positioning is of specific relevance to students with significant motor impairments. Students should be positioned in a way that facilitates the support of the trunk and independent use of the arms and hands. This can be done via the use of an Adaptive Seating System. Appropriate positioning can reduce pain, permit better fine motor function, facilitate attention, reduce fatigue, and promote improved social interaction, thereby optimizing performance. Special Education Assessment

138. Students should be allowed to use assistive technology such as Augmentative and Alternative Communication (AAC) devices to enhance their functional communication. Information on the student’s communication style and modality should be determined before assessment. It may be helpful to involve the family, caregivers and therapists who work closely with the student to assist in understanding the student’s responses. Special Education Assessment

139. Please remember-

140. Treatment and management Treatment Medicines / Drugs Antispastic Anti-Epileptic Anti-drooling GERD Constipation Chemodenervation Phenol Botox

141. Treatment and management Orthopedic Surgery STR SEMLLARS OSSCS Ilizarov Percutaneous

142. Treatment and management Use of Implants Use of Intrathecal Baclofen Pump Use of Deep Brain Stimulation Use of VP Shunt Use of Neurosurgery Selective Dorsal Rhizotomy Gamma Knife Surgery

143. Treatment and management Use of Regenerative Medicines Hyperbaric Oxygen Therapy Stem Cell Therapy

144. Treatment and management Complementary and Alternative Medicines Homeopathy Unani Ayurveda Herbal Acupuncture Chinese Medicines Acupressure Magneto therapy Nutritional Therapy

145. Treatment and management Management Habilitation and Rehabilitation Services Infant Stimulation Therapy Early Intervention Play Therapy Developmental Therapy Physiotherapy Occupational Therapy Speech Therapy Cognitive Therapy / Special Education Behavioral Therapy Assistive Technology

146. F-Words

147. Thank you all For More Information, Please contact me at Institute for Child Development C-27, Malviya Nagar New Delhi-110017 Landline Number: 011-41012124 Mobile / Whatsapp Number: 7838809241 Mail ID: [email protected] Website : www.icddelhi.org