CP-Care - Module 2 - Basic principles treatment and care

IO2 module 2
Basic Principles of
Treatment and Care
CP-CARE - 2016-1-TR01-KA202-035094
(01.12.2016 – 30.11.2019)

Unit 1 - Basic Principles of Treatment

The goal in the treatment of cerebral palsy
is to reach the highest possible functional
level for the child.
It is intended to prevent the deformities
that may occur, to develop existing skills,
to teach new skills, to prevent abnormal
movements and related disorders.

 The basic principles in the treatments for
these purposes are as follows :
Daily life skills should be supported
and be functional.
Individual differences and clinical
condition should be observed.

The child must be active during
the applications.
Biomechanical principles should be
considered.

◦ Sensory-perceptional-
motor integration is very
important in terms of
achieving independence.
◦ Supportive equipment
should be used for the
individual when
necessary.

Basic Principles of Cerebral Palsy Care-
Optimal Settings

Improving the quality of
life of the individual with
cerebral palsy, ensuring
social cohesion, health,
care and prevention
problems must be
solved.

In this regard,
 Legal arrangements for persons with Cerebral Palsy
are designed to ensure that persons with disabilities
live their lives, health care, basic care services.
 See IO1 report (http://cpcare.eu/en/downloads/) for
relevant legislation.

In this regard,
 The protection of the dignity of individuals,
 Individuals with adequate support in the living
environment are more likely to
feel more confident
attitudes and behaviors are
more positive
less likely to meet health and
care-related problems

General Principles
 It shouldn’t be
overprotective
◦ Daily activities should
not be helped unless
they really need help,
and should be
allowed to be
independent

The child should be
encouraged to have
independence.
Should be encouraged
for every small or huge
activity that can be
done independently.

The child should
be helped to be
properly
positioned during
the day.
If necessary,
assistive devices
can be used for
sitting and
standing.

 Be patient and observer!
Cerebral palsy care and
treatment is a long
process. It may take
time for the child to
develop and progress.

 Repetition and diversity are important
aspects.
Repetition of the activities
that the child can do during
the day and doing it in
various forms is important
for the development.

 Parents should have good time with the child.
It is important to act in a way that
encourages and delights the child in
care and treatment.
It can be done in a game if
necessary.
It should not be forgotten that
success will increase as the level of
participation of the child increases.

Negative Factors Affecting Care
Not getting the idea of the
individual
Noise, heat, light and
ventilation conditions in
maintenance environment

Negative Factors Affecting Care
Not paying attention to the privacy of the
individual and not taking security measures
The use of medical terms
The negativity of between the caregivers

Points to Consider in Care
 If a medical or technical explanation is required,
these should be explained
on the basis of the
understanding of the
individual with cerebral
palsy
complex terminology
should not be used

Heat, light, ventilation
conditions must be taken into
account during maintenance.
Care should be taken to
ensure that the area of care
and treatment is not crowded.

The privacy of the disabled individual should be protected
The Disabled individual may want to be with someone
who is trusted or loved during care, and must be
understanding for it

The individual should be encouraged to cooperate in
decisions regarding their own care
To emphasize that there is a partnership between the
individual and the caregiver, the "we" language should be
used instead of the "I" language. Like "we talk and
decide."

Points to Consider in Care
If the habits of the individual are not medically
harmless, support should be given and, if necessary,
guidance should be given.

References
1. Bülent Elbasan, Pediatrik Fizyoterapi Rehabilitasyon, İstanbul Tıp
Kitabevleri, 2017
2. https://www.childbirthinjuries.com/cerebral-palsy/treatment/therapy/
3. https://www.mayoclinic.org/diseases-conditions/cerebral-
palsy/diagnosis-treatment/drc-20354005
4. http://www.felc-romatizma.com/serebral-palsi/ailelere-serebral-palsi-
kilavuzu/ Japanese Society for Rehabilitation of Persons with Disabilities
(JSRPD)

Unit 2 – Facilitation of Normal
Development

 Facilitation makes it possible
to reveal the posture and
movement in an easy way.
 It means that the movement
is facilitated, and it is included
in the treatment as "possible
to do", "to do what needs to
be done".
 Definition of Facilitation

 The therapist makes
the movement easier
for the child, makes it
fun and safe.

 On this count, the
child likes to move
and feels the
movement.

Principles of the Facilitation
The child's movements should be
observed within the functional
pattern.
Function-specific and active range
of motion should be assessed.

 Range of motion, alignment and sensory
systems should be prepared.
http://metaco.co.uk/wp-content/uploads/IMG_2562.jpg

 It should be helped
to initiate, maintain
and / or terminate
the movement.

The movement
must be fluent
The result of the
motion should be
analysed
Movement must
be repeated in
various forms

http://www.christopherharold.com/guide-
makes-huge-difference/
Ensure that the child learns the mistakes
made during the movement
Hand contacts must be reduced gradually
for functional movement

Approximation
 It is the pressure
applied to the joint to
bring the bones closer
together.
Types of facilitation

Intermittent joint compression
Pressure applied to the
joint intermittently.

Light Touch
 Very light touch applied to the skin. It can
be used for guiding movement or
positioning purposes.
https://i.ytimg.com/vi/dF1DW38Rz3Q/maxresdefault.jpg

References
1. Bülent Elbasan, Pediatrik Fizyoterapi Rehabilitasyon, İstanbul Tıp Kitabevleri, 2017
2. Bobath Kavramı, Nörolojik Rehabilitasyonda Teori ve Klinik Uygulama, Çeviri editörleri: Prof. Dr. Ayşe
Karaduman, Prof. Dr. Sibel Aksu Yıldırım, Prof. Dr. Öznur Tunca Yılmaz, Pelikan Yayınevi, 2012
3. VELICKOVIĆ, T. D. (2002). Basic Principles of the Neurodevelopmental treatment (NDT) Bobath. life, 4, 9-
11.
4. Bobath, K., & Bobath, B. (1964). The facilitation of normal postural reactions and movements in the
treatment of cerebral palsy. Physiotherapy, 50, 246-262.
5. Zanon, M. A., Porfírio, G. J., & Riera, R. (2015). Neurodevelopmental treatment approaches for children
with cerebral palsy. The Cochrane Library.
6. Neurological Disabilities: Assessment and Treatment, Susan E. Bennett, James L. Karnes, Lippincott
Williams & Wilkins, 1998, (p:57-60)
7. Camacho, R., McCauley, B., & Szczech Moser, C. (2016). Pediatric neurodevelopmental treatment. Journal
of Occupational Therapy, Schools, & Early Intervention, 9(4), 305-320.

Unit 3 – Caring for clients with
Cerebral Palsy

 Position for feeding Cerebral Palsy

 The position of the child and the feeder is
important during feeding.
If the feeder is in
front of the child, in
midline, this will
facilitate the
communication with
the child

Create a quiet environment and slowly introduce an element of
distraction when the child’s ability progresses - start with
background sounds like radio.
Use different food texture, temperature and taste to improve
sensory responses but before make sure to assess careful which
texture maybe potential cause of aspiration
The child should be able to clear the food before taking a new
spoon and should recover breath - give the child time
The quantity of the food on the spoon should be enough but safe
for the child to handle

 Some adapted equipment may help children in
achieving independence during meal time, for
example angled spoon, scoop plates etc.

Changing diaper of a client with Cerebral
Palsy
Change each child's diaper when wet or
soiled.
Change clothing also if necessary. Keep a
supply of clean diapers near changing
table, but out of the children's reach.
Wash and dry each child's bottom during each
diaper change with an individual sanitary
wash cloth or paper towel or diaper wipe

After putting on the clean diaper, wash the child's
hands with soap and water and dry with individual cloth
towel or paper towel.
Place used diaper in a closed container that is lined
with a leak proof or impervious liner. Diapers must
be removed daily.
Disposable diapers must be taken to an outdoor
garbage can with a lid.
Cloth diapers and soiled clothing must be returned to
the child's parent or washed at the center.

Sanitize the area used for changing child's
diaper with soap and water, followed by a
disinfectant solution.
Wash your hands with soap and water
immediately after each diaper change.
If you use disposable gloves, discard them
first.

How to put on-off the orthotics
This section is provided from “MOBILE TRAINING FOR HOME AND HEALTH CAREGIVERS
FOR PEOPLE WITH DISABILITIES AND OLDER PEOPLE” (M-CARE) GA № 539913- LLP- 1-
2013- 1- TR- LEONARDO- LMP Project

Putting on your client’s ankle foot orthosis
(AFO)
Orthosis: an externally applied device used to modify the
structural and functional characteristics of the neuromuscular
and skeletal system
Step 1 – Get the leg ready
Put on a
knee-high,
plain cotton
sock
Smooth out
any wrinkles
Bend the hip
and knee
Stretch the ankle
muscle by pulling down
on the heel and
pushing up at the toes
Never put the
AFO on a
straight leg

Step 2 – Place foot in AFO
With one hand, keep the
knee and ankle bent at a
90 degree angle.
With the other
hand, hold the AFO
with the straps
open.
Start with the heel
firmly touching the
toe plate of the
AFO.
Slide the heel all the way
down and back into the
AFO

Step 3 – Fasten the straps
Keep the heel firmly in the
AFO with your thumb.
Thread the ankle strap through
the loop and fasten it.
Pull the sock out from under
the ankle strap to take out any
wrinkles.
Fasten the top strap.

Step 4 - Stop and check!
The sock has no wrinkles.
The straps are done up to the proper
tightness.
There is no space behind the heel.
The tips of the toes are just inside
the edge of the toe plate.
http://www.hamiltonhealthsciences.ca/documents/
Patient%20Education/OrthosisPuttingOnChild-
lw.pdf
http://www.hamiltonhealthsciences.ca/docume
nts/Patient%20Education/OrthosisPuttingOnChi
ld-lw.pdf

Be Careful!
The AFO must pass all these checks to be
comfortable and prevent skin pressure
problems.
If the AFO ‘fails’ any of these checks, take it
off and start again at Step 1.

Caring in Daily Living Activities
How to put on
and take off a
shirt, trousers
How to feed
or eat
Hygiene
principles

 Choose a good position. Decide the
position in which your child is most
steady, with or without support. This will
make dressing and undressing easier for
him.
 Involve your child. Involve your child
every time you dress or undress him. Give
him clear instructions or show him how to
straighten his arms and legs. This will
help him to cooperate with you as he
grows older.

Start with
simpler
clothing
• Always start with a simple item of clothing like a
loose shirt with front buttons open.
• He will find it easier to take it off and put it on.
This will make teaching and learning more
successful.
Teach
undressing
first
• First teach your child to take off his clothes as it is
much easier than learning to put them on

Start early
• Normally parents help their
children to dress and undress till
they are four or five years old.
But if your child is handicapped,
start teaching him as early as
possible since it will take him
more time to learn the skill.

Buy or make clothes one size
larger.
•Whenever you get your child new
clothes always make sure that
they are one size larger.
•Shoes must be of the correct
size, otherwise the child will find
it difficult to walk.

 Children with cerebral palsy are facing a
number of disease threats that are not
caused by infection.

The following
items should
be considered
in the care of
the child
Washing hands
Nail cutting
Different
positioning during
the day (if the
child is not
mobile)
Hair cleaning
Cleaning of
orthoses
Skin care

The following items should be
considered in the care of the
child
• Control of allergic reactions
• Cleaning of open wounds
• Cleaning bed and linen
• Caring for clothes and shoes
• Changing the diaper regularly in
cases of urinary incontinence

 For additional daily care support please
visit www.pcgcare.eu

References
1. https://www.braceworks.ca/2015/05/13/devices/lower-limbs/afo/a-
schedule-for-wearing-your-brace/
2. https://healthbeat.spectrumhealth.org/innovations-compression/
3. www.pcgcare.eu
4. http://www.asksource.info/pdf/A932_dressingforthechild_1995.pdf
5. http://www.cerebralpalsy.org/information/mobility/orthotics
6. https://www.physio-pedia.com/Feeding_the_Child_with_Cerebral_Palsy
7. http://www.cerebralpalsycenter.org/wp-
content/uploads/2014/04/Diapering-Guidelines.pdf

Unit 4 - Cerebral Palsy and Communication

 Children with cerebral
palsy may have difficulty
in using words.
 In their daily lives, they
may not be able to use
many words that their
peers say.
https://beautyboysj2sgq3.onion.link/2017/12/all-i-want-for-christmas/
Solving Communication Barriers

 They may have difficulty expressing
themselves
 They may have difficulty sharing
experiences like excitement, fear,
discomfort.

Although speech is important, it may be difficult
for children to express themselves if their
vocabulary is inadequate.
Children with cerebral palsy may have
difficulty interacting with the environment as
a result of vision or hearing problems.

Any supportive/assistive
technology to aid the
communication is addressed in
Module 3, Unit 2

 Communication hints:
◦ Shake hands
◦ Identify yourself
◦ Speaking in group
◦ Listen for clarifications
◦ Treat adults as adults
◦ Listen carefully
◦ Be patient
◦ Ask short questions
◦ Repetition
◦ Eye level
◦ Look directly
◦ Lip read
◦ Common expressions
Photo by Stuart Miles,
http://www.freedigitalphotos.net/

When introduced to a person
with CP, it is appropriate to
offer to shake hands.
Shaking hands with
the left hand is an
acceptable greeting.

When meeting a CP child who is visually impaired,
always identify yourself and others who may be
with you (doctors, nurses, educators).

When speaking in a group, remember to identify the
person to whom you are speaking in case you have
people with visual impairments.

If you offer
assistance,
wait until
the offer is
accepted
Then ask for
additional
clarifications

 Listen attentively when you're talking with a child
who has difficulty speaking.

 Be patient and wait for the child to finish, rather than
correcting or speaking for the person.

 If necessary, ask short questions that require
short answers, a nod or shake of the head.

Never pretend to understand if you are having
difficulty doing so.
Instead, repeat what you have understood
and allow the child to respond.
Always while speaking with a child on a wheel
chair, place yourself at eye level in front of that
child to make the conversation easier.

References
1. http://www.cerebralpalsy.org/information/communication/communicating-effectively
2. http://news.psu.edu/story/313680/2014/04/28/academics/speech-language-and-hearing-
clinic-helps-people-face-communication
3. https://www.brainchildmag.com/tag/cerebral-palsy/
4. http://www.nfcacares.org/who_are_family_caregivers/
5. http://www.nfcacares.org/pdfs/AARPSurveyFinal.pdf
6. http://www.womenshealth.gov/faq/caregiver-stress.cfm#a
7. http://www.womenshealth.gov/faq/caregiver-stress.cfm#a
8. http://aspe.hhs.gov/daltcp/reports/ltcwork.htm
9. http://www.healthcalculators.org/calculators/caregiver.asp
10. http://www.co.rock.wi.us/Dept/Aging/CaregiverBooks.htm
11. http://seniorliving.about.com/od/lifetransitionsaging/a/agingwellbooks.htm
12. http://www.caregivingcafe.com/blog/wp-content/uploads
13. http://seniorcarepartners.wordpress.com/our-caregivers/

Unit 5 - Medication for Cerebral
Palsy

Oral medications plays an important role in the
treatment of cerebral palsy (CP).
The function can be increased in children with
CP with oral medication.
With oral medication:
• Muscle over activity is reduced (spasticity, hypertonicity)
• Involuntary movements are reduced (dyskinetic
movements)
• Muscle spasm is decreased
• The seizures are controlled.
Go to: Module 0 Unit 5

Oral medications for seizures
It's the oldest medication in use.
Especially in infancy, it is preferred
due to its low side effect profile.
Its use is restricted in adolescence
due to side effects.
Phenobarbital
(Luminal or luminaletten)

It is the most commonly used medication.
It is effective in many types of epilepsy.
The initial side effects are sleeping and relaxation.
These side effects are less noticeable after the body's
adaptation process.
There may be effects on liver function tests and blood
count.
Carbamazepine
(Tegretol, Karazepin, Carbaleks )

It is a broad-spectrum epilepsy drug.
Depending on the dose, side effects such as shivering, hair
loss may be seen.
The sedative effect is not significant.
The most important side effect is liver damage and bone
marrow suppression, especially in small children.
It is encountered in roughly 1/1000 children.
Valproate
(Depakine, Convulex)

It's a new generation epilepsy drug.
Common side effects are sleep,
imbalance and sedation.
Other side effects are kidney stones, non-
sweating and weight loss.
Topiramate
(Topamax)

It is a new generation drug.
Apart from sedative effects, there is no
significant side effects.
It is generally used in resistant epilepsies.
Levetiracetam
(Keppra)

Despite efficacy in selected patients in childhood,
there is little evidence for spasticity treatment.
Sedation and hypotonic are side effects.
Sudden discontinuation may result in hyperthermia,
worsening of spasticity, seizures, and altered mental status.
Baclofen
(Lioresal)

Its use in children is limited.
It is a single muscle relaxant effects directly on the skeletal
muscle cell.
Dantrolene is generally effective in serious spasticity.
The most common side effect of dantrolene is general
muscle weakness.
Liver dysfunction, sleepiness and fatigue are other side
effects.
Dantrolene

Although there is evidence that tizanidine in
spinal cord injuries and MS are beneficial, there is
not enough research in the child.
It is especially recommended for reducing
spasms and improving night comfort.
The most common side effect is sedation.
Sleepiness, hypotension, liver toxicity are other
side effects.
Tizanidine
(Sirdalud, Devalud)

Oral medications for spasticity
There is limited evidence of the benefit
of treating spastic children.
Common side effects are sleepiness,
ataxia, and mental performance
deterioration.
Diazepam

Dopaminergic Medicine for
Cerebral Palsy
It is used in children with CP with dystonia.
Since it takes time for positive response to occur,
it is recommended to continue to levodopa until 6
months.
Side effects include nausea, vomiting, sleep
disturbances, weight gain, and worsening of the
movement pattern.
L-DOPA
(levodopa)

Other additional diseases and
medication
Gastrointestinal problems
Reflux
• H2-receptor antagonist
• Inhibits gastric acid production
Cimetidine
• It is a histamine H2 receptor
antagonist that inhibits gastric acid
production and is widely used in the
treatment of peptic ulcer and
gastroesophageal reflux disease.
Nizatidine

Gastrointestinal problems
Constipation
• It is a medicine that is used in
constipation treatment for a short
time.
Magnesium
hydroxide
• It works by pulling water into the
column.
Lactulose
Solution
• They act by increasing the
amount of water secreted in the
intestine.
Osmotic
laxatives
(Miralax)

Attention deficit and hyperactivity disorder
Methylphenidate hydrochloride
(Ritalin)
• It is used to increase attention and
concentration.
• It is the central nervous system
stimulant.
• Used in children and adolescents
between 6 and 18 years of age.

Attention deficit and hyperactivity disorder
Atomoxetine
(Atominex, Attex, Strattera)
• It is a sympathomimetic that
affects the central nervous
system.
• It is prescribed by psychiatrist or
paediatric neurologist in 6-25
years old patients.

References
1. http://sinancomu.info/ilaclar.html
2. http://www.drdenizdogan.com/2012/06/kas-gevsetici-
ilaclar.html
3. Baker, S. S., Liptak, G. S., Colletti, R. B., Croffie, J. M., Di
Lorenzo, C., Ector, W., & Nurko, S. (1999). Constipation in
infants and children: evaluation and treatment. Journal of
pediatric gastroenterology and nutrition, 29(5), 612-626.
4. Gremse, D. A. (2004). GERD in the pediatric patient:
management considerations. Medscape General
Medicine, 6(2)
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3353606/
6. http://www.ilacabak.com/ilacgoster.php?Id=7495

Unit 6 - Botolinium Toxin A (Botox) and
Cerebral Palsy

Cerebral Palsy (CP) is a complicated
motor disorder requiring a
multidisciplinary approach.
Botulinum neurotoxins are an
important aspect of the treatment of
CP.
Botulinum neurotoxins are used for
20 years in movement disorders
related to CP.
In addition to many treatment
methods, botox application must be
applied when necessary.

What is Botulinium Toxine?
Botulinum toxin A is the most commonly used in children
with CP.
Seven subgroups of this toxin have been identified.
Among these, Botulinum A and B are used for therapeutic
purposes.
BOTOX is the brand name of a toxin produced by the
bacterium Clostridium botulinum

 Botox, stopping the release of
acetylcholine at the
neuromuscular junction,
slows down muscle
contraction.
 Botox reduces muscles tone
and improves arm and leg
movements in children with
CP.

Botox is administered by an orthopedist into the muscle,
muscle relaxation begins within 48-72 hours and the
effect lasts 3-6 months.
Side effects are very rare:
• Pain during injection,
• Infection
• Haemorrhage
• Feeling of coldness in the
injection site
• Allergic reactions
• Weakness and fatigue

• Patient selection is very important. Spastic children
without constant contractures are the group of
patients most benefiting from injection.
• While the treatment response of dyskinetic patients
varies, the atetoid group does not benefit from this
treatment.
• Botox can be applied from a minimum of 18 months of
age.
• No upper limit is specified.

Objectives of Botulinum Toxin A
application:
To develop walking in spastic diplegic and
hemiplegic children
Minimize adductor tone in children with hip
dislocation
Reduce spasms and pain in spastic dystonic
patients
Reducing tonus in psoas
Facilitating physiotherapy by reducing
spasticity.

 After botox injection physical therapy is of great
importance.
After botox injection with physical therapy:
 Agonist and antagonist muscles must be
strengthened
 Selective movement to be gained
 Alignment must be ensured
 Joint range of motion should be
increased
 Postural and trunk control should be
increased
 Proper gait patterns should be ensured

References
1. Başarır M., & Özek M. M., Spastiste ve Tedavisi. Türk Nöroşirürji
Dergisi, 2013, 23(2): 158-173.
2. Strobl, W., Theologis, T., Brunner, R., Kocer, S., Viehweger, E.,
Pascual-Pascual, I., & Placzek, R., Best clinical practice in
botulinum toxin treatment for children with cerebral
palsy. Toxins, 2015, 7(5): 1629-1648.
3. https://www.hakanbuzoglu.com/botoxun-etkimekanizmasi-nedir

Unit 7 - Selective Dorsal Rhizotomy and
Cerebral Palsy

 There are a variety of surgical procedures that can be used
to increase the functioning of the children with Cerebral
Palsy (CP).
 One of these surgical procedures is selective dorsal
rhizotomy.

In selective dorsal rhizotomy (SDR), the
nerve fibres forming the posterior roots
between the second lumbar vertebra and the
second sacral segments of the spinal cord
are separated and stimulated by electrical
current.
Normally, when these fibers are stimulated,
there is no activation in the muscles.
When these fibers are stimulated in children
with cerebral palsy, muscle activity occurs.
For this reason, these nerve fibers are
considered abnormal and cut off. This
surgical procedure is called SDR.
With SDR, the fibers from the posterior root
are cut at a certain distance.
The motor fibers remain intact.

Indications for SDR
• Diplegic children between 4 and 8 years old are ideal
for this procedure.
• There is no effects on athetosis or dystonia.
 To be a diplegic child
 Moving independently
 Non-fixed contractures
 Have a good balance and trunk control
 Have a good selective motor control

 SDR is effective on spasticity.
 The main effect of the SDR is on the spasticity of the legs
and it can cause very little gain in the upper extremity.
 Since every child with CP does not benefit from this
surgery, the choice must be made very carefully.

Physiotherapy before and after SDR
• The strength and flexibility of
the muscles should be
increased.
Before the SDR
• Muscle strengthening
• Providing trunk control
• Increasing of joint range of
motion
• Ensuring the alignment is
necessary.
After the SDR

Complications of SDR
◦ Urinary or faecal incontinence
◦ Significant weakness in lower extremity
◦ Escape from cerebrospinal fluid (fistula development)
◦ Infection
◦ Sensory loss
◦ Hip instability

References
1. Başarır M., & Özek M. M., Spastiste ve Tedavisi. Türk
Nöroşirürji Dergisi, 2013, 23(2): 158-173.
2. Steinbok, P., Selective dorsal rhizotomy for spastic
cerebral palsy: a review. Child's nervous system,
2007, 23(9): 981-990.

Unit 8 - Orthopaedic Surgeries and
Cerebral Palsy

Pathologies seen in musculoskeletal system in cerebral
palsy (CP):
Muscle-tendon shorts / contractures
Joint contractures (ROM-restraint)
Joint instabilities
Torsional bone deformity.
A number of orthopedic surgeries have been
performed to prevent or treat the musculoskeletal
pathologies summarized above. In this respect, it is
aimed to maximize the movement and the quality
of life of the child with CP.

 Orthopaedic surgery is not the treatment of the underlying
illness, but rather the improvement of the individual's
independence by increasing his functions and abilities.
Alignment of the extremities
Daily living/ Function/Mobility/Gait/Better communication

 Orthopaedic surgeries in children with CP are divided into
soft tissue (tendon-muscle) and bone surgery. Soft tissue
surgeons are divided into tendon and muscle.
Orthopaedic Surgeries
Tendon Muscle Bone
Lengthening Lengthening Osteotomy
Transfer Facial surgeries Arthrodesis
Tenatomy Resections
Arthroplasty

Soft tissue surgeries
With muscle lengthening operations, it is aimed to
extend some of the tendons, or part of the tendon
itself, to increase the range of motion in the joints
that are released and affected by the muscles.
For example, in a child walking at the tip of the
toe, the heel will be able to hit the ground with
the extension of the Achilles tendon.
Knee movement will be provided by stretching the
hamstring tendons, which are stretched in a child
who bends the knee.

https://www.pexels.com/s
earch/surgery/
Sometimes the task of the muscles working with tendon
transfers in children with CP, and is diverted to another
direction.
For example, in the case of limited forearm supination, the
pronator muscle is removed from the adhered position,
changed direction, and attached to a different location to
provide supination.

If appropriate, children with CP can also be
referred for bone surgery
Hip problems are common in children with CP.
Increased spasticity tends to cause hip dysplasia
(especially in diplegia and tetraplegia)

A child with CP is normal when the hips
are born and problems develop as the
child grows, especially when the spasticity
is under the influence of abnormal forces
caused by it.
This does not only affect walking, it also
causes the child's toilet and perineal
difficulty, asymmetry, scoliosis and pain.
For this reason, bone correction surgeons
have an important place in children with
CP.

Bone surgery
 Osteotomy
◦ Derotation
osteotomy is called
osteotomies to
change the torsion
of the bone to the
appropriate angular
position.

Arthrodesis
 Bone or joint fusion surgery
called arthrodesis is
performed to provide
function and relieve pain in
the wrists, ankles, wrists,
fingers, thumbs or spinal
cord.
 In arthrodesis, the two bones
of the joints are fused, and
the joint is completely
separated from the bones.

Upper extremity surgeries
The aim is to improve the function and improve the
cosmetic appearance.
• Spastic hemiplegic and tetraplegic patients are more
frequent.
• Among the surgical options, dynamic transfers, muscle-
tendon extensions, joint stabilizations and muscle balance
correction can be said.

Lower extremity surgeries
The main goal on the lower extremity is to improve
the walking.
• Equine foot and subluxation in the hip are the most common
problem in children with CP
• It is also important in lower extremity surgeons to prevent
situations where pain may be the cause even in children with
impaired walking or very little possibility of walking.
• Hip operations, adductor, hamstring, gastrocnemius lengthening
operations are the most commonly performed operations in the
lower extremity.

The Timing of Surgery
Orthopedic surgery is very difficult to give a
definite answer to when it should be done or when
we can get the best results.
Because a special treatment scheme is often
needed for each patient.
Especially, muscle-tendon lengthening surgery can
be done very early and can lead to repetition.

The Timing for Surgery
In general, when corrective osteotomies are
performed on bones above 7 years of age, success
is greater and recurrences are less frequent.
In addition, at this age, the way the child is
walking becomes more pronounced. For this
reason, it is generally best to wait 7 years for bone
and muscle surgery in terms of surgical timing.

References
1. Yıldız, C., Kılınçoğlu, V., Yurttaş, Y., & Başbozkurt, M. Serebral Paralizide
Ortopedik Tedavi Prensipleri: Genel Bakış. TOTBİD, 2009, 8(1-2):25-29.
2. https://avicenna-klinik.com/tr/hastaliklar-ve terapileri/eklemler/eklem-
sabitleme-artrodez/
3. https://www.hemensaglik.com/makale/artrit-tedavisinde-eklem-fuzyon-
ameliyati-artrodez
4. Bülent Elbasan, Pediatrik Fizyoterapi Rehabilitasyon, İstanbul Tıp
Kitabevleri, 2017

Unit 9 - Serial Casting and Cerebral
Palsy

• One of the negative effects of spasticity in children with
cerebral palsy (CP) is the shortening of muscles.
• Muscle shortening causes contractures in the future.
• In the presence of contracture, limitation of joint range of
motion is observed, and restriction in daily life occurs.
• One of the important treatments that can be used in the
treatment of contracture and joint limitation in children
with CP is serial casting.

In serial casting, a series of
cast is applied and removed
at regular intervals.
With each application of cast,
the range of motion of the
joint is increased gradually.
What is Serial Casting?

 Serial casting allows a muscle to remain immobilized in an
extended position, thereby increasing the extensibility of
the muscle and surrounding soft tissue structures.
The mechanism of action of serial casting is achieved by
both increasing the length and number of sarcomeres in the
target muscle.
The purpose of the serial casting in children with CP is to
correct the deformity, prolong contractures and reduce
spasticity.

Serial casting can be applied alone in children with CP, as
well as botox in addition.
Although there are various opinions about the period of
casting, casting should be done for 5-7 days and casting
should be removed for 1 day. This should be done for 3-4
weeks.

Thus, the desired effect is obtained
This is the most important point regarding the
series casting.
The muscle to be applied should be the
maximum length during casting.
When selecting serial casting in CP?

Serial casting should be performed by
orthopedic physician.
The cast should be done after the
maximum range clearance is
completed.
At the end of each week, physical
stretching and mobilization should be
done with physical therapy.
An orthosis must be used to maintain
the range of motion after casting.

When selecting serial casting in children with CP,
the following should not be present:
Small wound
on the skin
Edema Sensory loss
Cognitive
impairment
Contraindications

Other contraindications
Open wound
Unhealed fractures
Presence of external fixator
Circulatory problems
Acute inflammation

References
1. Stoeckmann, T. (2001). Casting for the person with
spasticity. Topics in stroke rehabilitation, 8(1), 27-35.
2. Booth, M. Y., Yates, C. C., Edgar, T. S., & Bandy, W. D.
(2003). Serial casting vs combined intervention with
botulinum toxin A and serial casting in the treatment of
spastic equinus in children. Pediatric Physical
Therapy, 15(4), 216-220.
3. http://www.lisebiyoloji.com/destek-hareket.html

Unit 10 - Other Alternative And
Complementary Therapies

Complementary and alternative therapies are methods used
in many disease groups and also preferred by parents and
health professionals in paediatric diseases.
As the severity of the disease or disorder increases, it
appears that families are more willing to use these methods.

 It is a medical treatment method
applied by breathing 100%
oxygen in completely closed
pressure rooms.
anita-whyibelieve.blogspot.com.tr/p/hyperbarics.html www.oxygenunderpressure.com
www.centralfloridahyperbarics.com
Hyperbaric Oxygen Therapy (HBOT)

o There are two types of rooms, one for single person and
one for multi-people rooms.
o The type of treatment to be performed in the hyperbaric
room is determined by the current state of the patients.

o The average duration of treatment is 60-90 minutes.
o The number of applications can range from 3-5
sessions to 50-60 sessions.

 The area in which the affected nerves are
located are exposed to an increased amount
of oxygen:
To help to prevent cell death
to protect the working nerves
to allow oxygen to reach the tissues more easily,
to increase endurance against mycoplasma

o Oxygen is converted into ozone using a machine
(ozone generator) and is then used for
treatment.
Ozone Therapy

o It is an effective method in the treatment of
neurological problems such as cerebral palsy.
Increases the oxygenation
in the brain
Improves blood circulation
Generates relaxation
Helps to reduce pain
Increases resistance to
mycoplasma.

 There are various application methods:
Inhalation (Respiration)
Intraarticular Ozone Therapy (With Needle Into Joint)
Minor Ozone Therapy
3-5 ml of blood is taken from the
patient
The blood is then ozone enriched
The blood is injected back into the
patient's vein,
Major Ozone Therapy
50-100 ml of blood is taken from
the patient
The blood is then ozone enriched
The blood is injected back into the
patient's vein

 The frequency and duration of ozone therapy depends
on the level of the disease and the type of the
disease.
 When approximately 10 sessions are used, each
session varies from 3 to 30 minutes.

Acupuncture
More than 365 acupuncture points are defined in
the body.
Acupuncture needles are applied at this point.
Acupuncture also includes electro acupuncture,
laser acupuncture, acupressure and cupping.
Go to: Module 6 Unit 6

Acupuncture is used in adults as well as in children.
Acupuncture is beneficial in children with cerebral palsy,
such as functional improvement, increased GMFS score,
increased sleep quality, increased function in activities such
as walking, running, jumping.

Disadvantages Of Acupuncture
Although acupuncture is widely used in children, children's fear of
needles and pain make it difficult for children to apply acupuncture.
Non-sterile acupuncture needles can cause infection.
Bleeding and needle pain are side effects of acupuncture.
Pneumothorax is also one of the most serious complications that
can be seen after acupuncture.

Reflexology
Reflexology is the technique of applying pressure to the reflex
zones in the feet, hands and ears to create specific effects in
any part of the body and organs.
These reflex zones act as a sensor and represent different parts
of the body.

Benefits of Reflexology
Reduce pain
Increases blood circulation
Physical, emotional and
spiritual healing
Hormonal balance
Contributes to the overall
relaxation of the body
Improve overall
health status

How is Reflexology Applied?The patient is asked to sit or lie in a
comfortable position.
Beginning with stretch and pat motions
on ankle-foot for warm-up can help the
client to relax.
Techniques such as thumb movement,
finger movement, scrubbing, squeezing
and pat movements are used for
massage of the related region.

 Treatment sessions range from 10 minutes to 45
minutes.
 The number of sessions is determined by the health
status, physical characteristics and age of the person
being treated.

 In addition to foot reflexology, ear and face
reflexology applications have been on the agenda in
recent years.

Unit 11 - Management of Pain in
Cerebral Palsy

Pain in children with developmental
problems such as cerebral palsy
(CP) is a common problem.
Mechanism of Pain in CP
Loss of motivation, depression, anxiety
formation: it can lead to decreased
productivity and quality of life.
Ongoing pain in children with CP has harmful
and destructive effects in all areas of life.

Causes related to musculoskeletal system:
Structural changes caused by posture disorders
Disturbances that develop over time in the foot
and ankle
Orthopedic problems such as hip dislocation
Muscle shorts
Backbone curvatures

Causes related to the
nervous-muscle system:
Nerve jams
Over use of unaffected parts
Involuntary contractions of muscles of
children with SP: circulatory, respiratory and
digestive systems

Digestive system and nutrition
related factors:
Difficulty in swallowing
Stomach problems such as reflux,
gastritis and ulcer
Constipation and nutrition with tubing
Obesity can cause pain by causing
damage to joints

Surgical causes:
Muscle relaxation, tendon extension
Placement of muscle relaxant drug releasing devices
Bone surgeons
Surgeons for spinal curvature
Muscle relaxant drug injection can also cause pain

Toothache:
 Dental and jaw joint pain has been reported in
children with CP.

Pain originated from
rehabilitation:
Stretching, strengthening exercises
Series casting
Electrical muscle stimulation
!!Do change orthoses, splints and
positioning devices on time !!!

o Since the children affected by CP have different locations
and severity, different ways of preventing their pain are
observed.
o In the program that will be created under the physicians
and physiotherapists for the prevention of pain:
Medication
Surgery
Physiotherapy
is involved.
Prevention of Pain in CP

oDrugs that doctors often prefer to use are:
Medication and Other Medical Interventions in Pain
To decrease the hardness of the steel and the
involuntary movements
To increase bowel activity
To reduce the depression
To reduce the severity and frequency of
seizures seen with CP

Surgery is the last preferred method of treatment.
Often used:
Orthopedic Surgery: Extension of the muscles and
structures that connects muscle to the bone, surgeries
such as bone structure deterioration.
Spine Surgery: It is aimed to remove the problems of
correction of the spine and related problems.
Selective Dorsal Rhizotomy: involves the cutting or
repositioning of overactive nerves.

Physiotherapy in Pain treatment
In improving
the
movements
Inhibiting the
formation of joint
dislocations
In the
development of
self-confidence
In ensuring
balance and
coordination
In protecting
and improving
muscle strength
and flexibility

Objectives of physiotherapy interventions:
Releasing pain
Increasing muscle strength
Increasing balance reactions
Increasing range of motion
Improving daily living activities
Improving overall quality of life
Improving position/alignment

Manual Methods Electro physical
Agents
Exercises
Massage TENS PNF
Mobilization
techniques
US Strengthening
Cold pack Stretching
Hot pack Yoga
Biofeedback
Go to: Module 4 Unit 1, 2
Module 6 Unit 1

References
1. Characteristic of pain in children and youth with cerebral
palsy. Official Journal of The American Academy of
Paediatrics. July,2013.
2. www.bobathterapistleri.org/serebral-palsi-ve-agri2,60,1.
3. https://www.cerebralpalsyguidance.com/cerebral-
palsy/associated-disorders/pain/
4. https://www.aacpdm.org/UserFiles/file/fact-sheet-pain-
011516.pdf
5. https://www.medscape.com/viewarticle/491005_3
6. www.cerebralpalsy.org/information/pain-management

Unit 12 - Transcranial Electromagnetic
Stimulation

Transcranial Magnetic Stimulation (TMS) Therapy is used to
reorganize, activate and ameliorate the activity in that area by
targeting specific areas of the brain.
Part of the brain is exposed to the magnetic field so that it is
stimulated or suppressed.
Medical usage of Transcranial Magnetic Stimulation

An electromagnetic coil is placed in the
head skin near the forehead.
It creates a very short and painless
magnetic field in the brain.
Stimulates the muscles by giving a
momentary, violent warning, thus
accelerating motor development.
It is usually used in patients with unilateral
CP.

TMS is applied to the opposite
hemisphere in these patients, which
usually corresponds to the healthy side
of the body.
Approximately 1200 stimulus are given
to each session. The treatment lasts 20
minutes.
The patient does not feel pain during
treatment.

• It is a new and promising treatment used in stroke
patients in recent years. It is also promising for patients
with cerebral palsy.

The muscle tone
in the hands of
the patient is
reduced if there
is muscle
tension in the
arm.
With TMS, the intact
brain is suppressed
and the function of the
hand that the patient
forgets to use
increases.

There are minor side effects such as:
Adverse Effects of TMS
Headache
Sensitization in the skin
Tingling or spasm in facial muscles
Slight drowsiness
Noise disturbance during treatment

References
1. www.tmstedavi.net/makale.asp?id=32&durum=0
2. Gupta M, Rajak B.L. Transcranial Magnetic Stimulation
Therapy in Spastic Cerebral Palsy Children Improves
Motor Activity. November,2016.
3. http://manyetikstimulasyon.com/serebral-palsili-
hastalarda-tms-tedavisi.html
4. https://npistanbul.com/manyetik-uyarim-tedavisi-ttmu
5. https://www.mayoclinic.org/tests-
procedures/transcranial-magnetic-stimulation/about/pac-
20384625
6. https://www.hopkinsmedicine.org/psychiatry/specialty_ar
eas/brain_stimulation/tms/index.html

CP-Care project partners
 Gazi University (Turkey)
 PhoenixKM BVBA (Belgium)
 Bilge Special Education And Rehabilitation
Clinic (Turkey)
 Spastic Children Foundation Of Turkey
(Turkey)
 Serçev- Association For Children With
Cerebral Palsy (Turkey)
 Asociacion Espanola De Fisioterapeutas
(Spain)
 National Association Of Professionals Working
With People With Disabilities (Bulgaria)

CP-CARE curriculum, learning material,
handbook by www.cpcare.eu is licensed
under a Creative Commons Attribution-Non
Commercial 3.0 Unported License.
Based on a work at www.cpcare.eu
Permissions beyond the scope of this
license may be available at www. cpcare.eu
This project (CP-CARE - 2016-1-TR01-
KA202-035094) has been funded with
support from the European Commission.
This communication reflects the views only
of the author, and the Commission cannot
be held responsible for any use which may
be made of the information contained
therein.

CP-Care - Module 2 - Basic principles treatment and care

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