Cerebral Palsy: PT assessment and Management

neurological physiotherapy, cerebral palsy rehabilitation, APGAR Score

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, speech, bowel-bladder, & orthopedic deformities

4. Criteria of diagnosis Neuromotor control deficit that alters movement or posture S tatic brain lesion A cquisition 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 a sphyxia 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. M onoplegia is one single limb being affected. D iplegia : 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 1/3 rd of spastic diplegics , strabismus may be present

15. H emiplegia The most ambulatory of all forms, although they generally have dynamic equinus on affected side T riplegia : three limbs affected usually both LL & one UL Q uadriplegia : 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

23. pathology Periventricular leukomalacia (PVL) is the most common finding in CP C orticospinal 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)

24. 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

25. 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

26. 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, hemiballismic , rigid

27. 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

28. risk babies Biological risk Established risk Environmental & social risk

29. Biological risk Birth weight of 1500g or less Gestational age of 32 weeks or less Small for gestational age (less & 10 th 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

30. 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

31. 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)

32. 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

33. 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

34. 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

35. 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

36. Post natal screening Starts in the immediate neonatal period & during the first two years To find biochemical defects Hearing & visual problems

37. Clinical methods (at birth) Examination of weight, height, head circumference Gestational age Musculoskeletal defects Testicular descent At 6 weeks repeat test

38. 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

39. Electronic scanning USG, CT Scan, MRI To find out AVM, hemorrhage, cyst, leucodystrophies etc

40. 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.

41. 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

42. 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)

43. Management Medical Surgical Rehabilitative

44. 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

45. 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). 2 ndary complication caused by spastic muscles generating abnormal forces on bones

46. 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

47. 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.

48. 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

49. 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

50. Prediction of ambulation

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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 W hat motivates his action – particular situation, person or special plaything Communication of the child W ith the parents Whether child initiates or responds with gestures, sounds, hand or finger pointing, eye pointing or uses words and speech

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. Cranial nerve integrity Strabismus or squint (Occulo motor nerve) Visual defects (optic nerve) Auditory defects (auditory nerve) Feeding & swallowing problems (lower cranial nerves) etc.

66. Special senses Visual & auditory defects Tactile & vestibular hyposensitivity or hypersensitivity

67. 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

68. Motor integrity Abnormalities of tone Spasticity, hypotonicity, dystonia etc Muscular weakness Loss of voluntary control Decreased co ordination

69. Reflex integrity Abnormal DTR Abnormal Superficial reflexes Abnormal primitive reflexes may be persistent ATNR, Extensor thrust, gallant reflex etc

70. ROM & flexibility Decreased in the ROM of the involved limbs Tightness & contracture in hip adductors, hamstrings, calf are very common

71. Anthropometric measurement Height or length decreased (growth retardation) Weight – decreased (thin & lean) or obese Head circumference – decreased (growth retardation or microcephaly), increased (hydrocephalus)

72. 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

73. 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

74. 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

75. 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

76. 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

77. 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

78. 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

79. Posture Poor posture in all types of CP Kypho -Scoliosis, knock knee & flexion deformity & inverted flat foot are commonly seen

80. 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

81. 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

82. Functional capacity Varies from complete dependence to complete independent

83. Pt management

84. Infancy (first stage – birth to 3 years)

85. 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

86. 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

87. 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

88. 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

89. 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

90. 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

91. 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

92. 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

93. 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

94. 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

95. 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

96. 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.

97. 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.

98. 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

99. 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.

100. 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

101. Preschool period

102. Main aim is to reduce the primary impairments & prevent the secondary impairments

103. 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

104. 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

105. Reduce spasticity Positioning in anti synergistic pattern Stretching of tight structures MFR ROM exercise Rhythmic rotations Splinting & serial casting Dorsal rhizotomy Botox injection

106. 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

107. 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

108. 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

109. 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

110. 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

111. School age & adolescence

112. 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

113. 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

114. Barriers s/a transportation, finances, time preferences & involvement, interest should also be considered carefully Injury prevention will limit impairment & disability

115. Transition to adulthood

116. 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

117. 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

118. Characteristics Score Score 1 Score 2 Acronym Skin color / Complexion Blue or pale all over Blue at extremities body pink ( acrocyanosis ) No cyanosis- body & extremities pink A ppearance Pulse rate Absent <100 ≥100 P ulse Reflexirritability No response to stimulation grimace/feeble cry when stimulated cry or pull away when stimulated G rimace Muscle tone None some flexion flexed arms & legs that resist extension A ctivity Breathing Absent weak, irregular, gasping strong, lusty cry R espiration Apgar score

119. 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.