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Children with Hypertonia. What is Cerebral Palsy (CP)?. A group of disorders impacting the development of movement and posture Results in activity limitation Accompanied by disturbances of: Sensation Cognition Communication Perception Possibly behavior and/or seizure disorder.

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what is cerebral palsy cp
What is Cerebral Palsy (CP)?
  • A group of disorders impacting the development of movement and posture
  • Results in activity limitation
  • Accompanied by disturbances of:
    • Sensation
    • Cognition
    • Communication
    • Perception
    • Possibly behavior and/or seizure disorder

(Campbell S 2000, Miller F 2005, Bax M 2005 )

what is cerebral palsy cp3
What is Cerebral Palsy (CP)?
  • Caused by a non-progressive defect or lesion occurring in an immature brain
  • Insult occurs before or after birth
  • Single or multiple locations

(Campbell S 2000, Miller F 2005, Bax M 2005 )

categories of cp
Categories of CP
  • Spastic or Hypertonic CP
    • Hemiplegia
    • Diplegia
    • Quadriplegia
  • Ataxia
  • Athetosis
  • Hypotonia
ndt enablement classification model of health and disability
M R Franjoine & M P Haynes

+ Domains-

Dimensions

NDT Enablement Classification Model of Health and Disability

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

ndt enablement classification model of health and disability6
M R Franjoine & M P Haynes

+ Domains-

Dimensions

NDT Enablement Classification Model of Health and Disability

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

body structure and functions
Body Structure and Functions
  • Spastic Diplegia 41.5
  • Spastic Hemiplegia 36.4%
  • Dyskinesia or Athetosis 10%
  • Spastic Quadriplegia 7.3%
  • Ataxia 5%

(Campbell S 2000)

body structure and functions8
Body Structure and Functions
  • Lesion(s) impacts:
    • the motor cortex

and/or

    • white matter projections to and from cortical sensorimotor areas of the brain

Causes:

    • Unknown prenatal condition
    • Asphyxia
    • Prematurity
      • Intracranial bleeds, infection, medical conditions

(Campbell S 2000)

body structure and functions9
Body Structure and Functions
  • Cognition
  • Neuromuscular System
  • Sensory System
  • Musculoskeletal System
  • Regulatory
  • Gastrointestinal
  • Cardiopulmonary
  • Integumentary
cognition
Cognition

VARIABLE

CHILD BY CHILD

Dependent on:

  • Lesion(s)
  • Secondary effects of various systems
  • Seizures
  • Access to environment
neuromuscular system
Neuromuscular System

What is muscle “tone”?

  • Amount of tension in a resting muscle
  • Resists being lengthened
  • Has neural components
  • Has mechanical and elastic components; muscle and connective tissue

(Lundy-Ekman 2002, Kandel 2000)

neuromuscular system12
Neuromuscular System

What is Hypertonicity?

  • Abnormally high resting tension
  • An abnormally high resistance to being lengthened
  • Still has both neural and mechanical components
  • The tonic component of hypertonus

(Crenna 1998, Lundy-Ekman 2002, Kandel 2000)

neuromuscular system13
Neuromuscular System

What is Spasticity?

  • Resistance to rapid muscle stretch
  • Velocity dependent
  • The phasic component of hypertonus
  • Often associated with:
    • Upper Motor Neuron Syndrome (UMNS)
    • Hyperactive deep tendon reflexes
    • Clonus

(Kandel 2000)

neuromuscular system primary impairments
Neuromuscular System --Primary Impairments
  • Impaired Muscle Activation

Excessive Co-activation

  • Impaired Muscle Synergies
  • Inability to Initiate, Sustain, Terminate
typical
Typical
  • Co-activation
    • Simultaneous activation of agonists and antagonists at a joint influencing movement in the same plane
    • Normally used to increase joint stability or for proximal stability to support precise distal movements
    • Allows for graded movement
atypical
Atypical
  • Excessive Co-activation
    • Decreases movement speed
    • Limits flexibility of movement responses
    • Increased energy costs and fatigue
typical18
Typical
  • Muscle Synergies
    • A group of muscles working together across multiple joints and organized to act as a functional unit
    • Simplifies the work of the CNS
    • Strengthens with repetition
atypical19
Atypical
  • Impaired Muscle Synergies
    • Based on limited movement repertoires
    • Difficult to vary or adapt to meet the requirements of different tasks
    • Produces stereotypical movement patterns
atypical20
Atypical
  • Impaired Muscle Synergies
    • Movements are limited in amount and frequency
    • Movements tend to be in more limited ranges
typical22
Typical
  • Initiate, Sustain, Terminate
    • Quick response of muscles to the decision to move
    • Easily maintain posture against gravity
    • Relax muscles
    • Quick response of muscles to the decision to cease movement
atypical23
Atypical
  • Difficulty with Initiate, Sustain, Terminate
    • Delay between desire to activate and ability to initiate muscular movement (latency)
    • Difficulty holding against gravity…especially postural muscles
    • Can’t turn off muscles in time
neuromuscular system25
Neuromuscular System
  • Impaired Motor Execution
  • Impaired Modulation and Scaling of Forces
  • Impaired Timing and Sequencing
  • Excessive overflow of Intra-Interlimb contractions
typical26
Typical
  • Modulation and Scaling of Forces
    • Controlled acceleration or deceleration
    • Using the proper amount of force
    • Constant balancing of agonists and antagonists during movement
atypical27
Atypical
  • Impaired Modulation and Scaling of Forces
    • Inability to slow down as they approach a target
    • Reduces accuracy (overshoots)
    • Particular difficulties grading grip
typical29
Typical
  • Timing and Sequencing
atypical30
Atypical
  • Impaired Timing and Sequencing
    • Unable to turn on and off muscles or patterns of muscles at the appropriate times
      • i.e. agonist and antagonist coordination
      • i.e. the hamstrings during gait
    • Incorrect sequence of activation for a task
typical32
Typical
  • Overflow of Intra-Interlimb contractions
    • When learning a new skill
    • With increased effort
    • Within a limb or elsewhere in the body
    • Decreases as proficiency is gained
    • Can be actively overridden
atypical33
Atypical
  • Excessive overflow of Intra-Interlimb contractions
    • Bobaths described “associated movements”
      • i.e. while grasping with one arm, will posture with the other
      • i.e. when flexing the hip, the ankle dorsiflexes
    • Occur at times similar to typical but with a generally lower threshold
    • Decreases the capacity for isolated control during effort
neuromuscular system35
Neuromuscular System
  • Impaired Force Generation
    • Strength: the ability to contract a muscle to a sufficient degree to impact the task
      • Can be masked by tone and spasticity
      • Primary—impaired input from motor pathways
      • Secondary– atrophy and resultant fiber type and connective tissue changes
    • Postural
    • Movement system
neuromuscular system37
Neuromuscular System
  • Anticipatory Postural Control
    • TYPICAL:
      • Postural set prior to initiating a task or movement
    • ATYPICAL:
      • Posture is not linked to movement
      • Fail to anticipate postural needs prior to a movement or task
      • Fail to generate adequate proximal posture for distal function
neuromuscular system39
Neuromuscular System
  • Poverty of Movement
    • TYPICAL:
      • Large variety of movement repertoires to chose from
      • Can easily adapt and modify repertoires for the task
      • Movements are fluid, flexible, and complex
    • ATYPICAL:
      • Movement repertoires are limited in number
      • “Stereotypic”
      • Repertoires are difficult to change
      • Adapt poorly to various tasks
neuromuscular system40
Neuromuscular System
  • Fractionated or Dissociated Movements
    • TYPICAL:
      • “Isolated movement” or “dissociated movement”
    • ATYPICAL:
      • Difficulty isolating movement
        • Segment to segment
        • Inter-limb
        • Intra-limb
        • Limbs from trunk
sensory system
Sensory System

Vision

  • Vestibular
  • Somatosensory
vision
Vision
  • Varies greatly
    • Cortical blindness to refractory errors
    • Strabismus (eyes not properly aligned)
          • Esotropia (the eye turns in)
          • Exotropia (the eye turns out)
    • Nystagmus
    • Visual tracking problems
    • Field cuts
vision44
Vision
  • Ghasia, Brunstrom, Gordon & Tychsen, 2008
    • GMFCS levels I and II
      • Similar to typically developing children
      • Strabismus
      • Amblyopia (lazy eye)
    • GMFCS levels III to V
      • More severe deficits
      • Deficits not observed in typically developing children i.e. dyskinetic strabismus and Cerebral Visual Impairment
vestibular
Vestibular
  • Difficult to separate from vision and postural control
  • More impact seen in SQ than SD
somatosensory
Somatosensory
  • Clearly atypical yet difficult to truly assess
    • Propioception
    • Kinesthetic awareness
    • 2 point discrimination
    • Stereognosis
sensory processing
Sensory Processing
  • “ the ability of the nervous system to perceive, interpret, modulate, and organize sensory input for use in generating or adapting motor responses… (Miller & Lane 2000)
musculoskeletal system
Musculoskeletal System
  • Considerable secondary impairments
    • Bone:
      • Boney deformities 2° atypical muscle pull
      • Decreased bone density of long bones (FX)
musculoskeletal system49
Musculoskeletal System
  • Considerable secondary impairments
    • Dislocations:
      • 2° to atypical muscle pull and atypical bone shape formation
      • Impacts many joints from jaw to foot
    • Scoliosis and rib cage deformities
musculoskeletal system50
Musculoskeletal System
  • Considerable secondary impairments
    • Muscle:
      • Shortening and contracture
      • Fiber type shift
      • Weakness
    • Connective tissue:
      • Increased stiffness due to atypical matrix within muscle
      • Over-lengthening or shortening of tendons
ndt enablement classification model of health and disability51
M R Franjoine & M P Haynes

+ Domains-

Dimensions

NDT Enablement Classification Model of Health and Disability

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

motor functions
Motor Functions
  • Effective Posture and Movement
  • Ineffective Posture and Movement
posture and movement
Posture and Movement
  • Alignment of body segments
  • COM over BOS
  • Weight shift
  • Quality of movement (fast, slow)

“Observable conditions that are neither functional limitations nor system impairments” (Howle 2002)

general characteristics of posture in children with sq
General Characteristics of Posture in Children with SQ
  • Little variation
  • Influenced by limited joint range
  • Tone influenced by position in space
  • High tone extremities, low tone trunk
general characteristics of posture in children with sq56
General Characteristics of Posture in Children with SQ
  • Uses increased tone to gain stability
  • Eyes adjust to posture rather than posture being driven by vision
general characteristics of movement in children with sq
General Characteristics of Movement in Children with SQ
  • Limited amount
  • Limited variety
  • Stiffen extremities to attain postural stability
  • Poor dissociation
general characteristics of movement in children with sq58
General Characteristics of Movement in Children with SQ
  • Trunk moves with either flexors or extensors
  • Most active movement is in sagittal plane
  • Difficulty organizing movements in

relation to the BOS

  • Uses eyes and mouth to increase postural stability
prone
Prone
  • Posture
    • Difficult position
      • Pulled into gravity
      • Flexor tone is biased (typical)
      • Lack of joint range
  • Movement
    • Asymmetrical neck hyperextension

OR

    • Not enough antigravity strength to lift head
supine
Supine
  • Posture
    • Preferred position
      • Stable
      • Have the possibility of viewing the world
      • Extensors are biased (typical)
  • Movement
    • Sometimes can kick reciprocally
    • Push with neck hyperextension asymmetrically and may arch with body
sitting
Sitting
  • Posture
    • Very unstable position
    • Narrow base
    • Stabilization efforts create non-functional alignment of hips, spine, neck, and head
  • Movement
    • Too unstable to seek movement
    • Increased full body stiffness when movement is initiated
quadruped
Quadruped
  • Posture
    • Rarely can hold without assistance
  • Movement
    • Often can’t move at all
    • May pull with both arms—”combat crawl”
    • Occasional child may “bunny hop”
standing and walking
Standing and Walking
  • Posture
    • Placed in standing
    • Base too narrow--adducted legs and

plantar-flexed ankles

  • Movement
    • Stiffens whole body to gain stability
    • May support weight stiffly and then both “give”
    • Some may have reciprocal movements of legs
ndt enablement classification model of health and disability69
M R Franjoine & M P Haynes

+ Domains-

Dimensions

NDT Enablement Classification Model of Health and Disability

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

ndt enablement classification model of health and disability71
M R Franjoine & M P Haynes

+ Domains-

Dimensions

NDT Enablement Classification Model of Health and Disability

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

participation
Participation
  • Inclusion in family activities and outings difficult
  • Special classroom or mainstreamed with full-time paraprofessional
  • Participation is often limited due to:
    • Lack of interaction and communication with others
    • Wheelchair access
    • Transportation that accommodates WC
treatment strategies
Treatment Strategies
  • Address decreased ROM
    • Lengthen
      • Incorporate into your activities
      • Accompany with activation

and/or

    • Compensate
  • Work upright whenever possible
treatment strategies74
Treatment Strategies
  • Help establish an appropriate BOS
    • Usually need to widen
  • ALIGNMENT!
    • In relation to BOS
    • Segment to segment
    • Decrease asymmetries
  • Activate the trunk to free the extremities
    • Balanced flexors and extensors in the trunk
    • Work in the frontal and transverse planes
treatment strategies75
Treatment Strategies
  • Keep them moving!
    • May need large ranges to know where they are

BUT

    • They can only control small ranges themselves
  • Repetition
    • Motor learning
    • Strength
treatment comments
Treatment Comments
  • Empower these children!!!
  • Treat age appropriately despite motor abilities
  • Treat upright whenever possible
    • Forget the developmental sequence!!!
  • Attend to ALL the systems…Many impact their health and quality of life
  • Have a long term perspective
general characteristics of posture in children with sd
General Characteristics of Posture in Children with SD
  • Upper extremities show more variability than LEs
  • UE posturing may increase in unstable situations
  • Uses UEs for support in upright instead of trunk
general characteristics of posture in children with sd79
General Characteristics of Posture in Children with SD
  • LEs: Hip adduction, internal rotation, knee flexion, ankle plantar-flexion
  • LEs influenced by limited joint range
general characteristics of movement in children with sd
General Characteristics of Movement in Children with SD
  • Active children
  • Pull themselves around with their arms
  • Poor dissociation of LEs from trunk and from each other
general characteristics of movement in children with sd81
General Characteristics of Movement in Children with SD
  • Most active movement is in sagittal plane
  • Quadruped and walking progression is achieved by moving the COM outside the BOS
  • Walking speed is achieved by using LE spasticity instead of strength
prone82
Prone
  • Posture
    • Tends to stay on elbows until going to 4s
    • Lack of joint range at hips increases anterior tilt of pelvis and stresses T-L joint
  • Movement
    • Lateral weightshifts are limited
    • Pulls with arms to move forward
    • Pushes with arms and keeps legs stiff to roll
supine84
Supine
  • Posture
    • Plays with hands
    • LEs are stiff in hip flexion/adduction, internal rotation, knee flexion, ankle plantar-flexion
  • Movement
    • Reciprocal kicking, poorly graded
    • Very mild children may have hands to knee and hands to feet play
    • Move into and out of position using UEs
sitting86
Sitting
  • Posture
    • Like to sit
    • Narrow base is unstable so they seek “W” sit
    • Support with UEs
  • Movement
    • Get into and out of sitting in the sagittal plane
    • In “W” sitting, use both hands for play
kneel
Kneel
  • Posture
    • Hips flexed, anterior tilt to pelvis, lumbar lordosis
    • UEs either used for support or posture to increase trunk stability
    • Ankles often dorsiflex
  • Movement
    • Use this as a transition position to extend both legs and attain standing
    • Stay in sagittal plane, lateral weight shifts difficult
quadruped90
Quadruped
  • Posture
    • Difficulty controlling midrange hip and knee ranges so “sits” on heels
  • Movement
    • “Bunny Hop”
    • Moves both UEs together then both LEs together
standing and walking92
Standing and Walking
  • Posture
    • Base narrow--adducted legs and plantar-flexed ankles
    • Supports on UEs
    • Often “sinks” to foot flat during quiet standing
    • Can’t stand still
standing and walking93
Standing and Walking
  • Movement
    • Reciprocal movements of LEs—often abrupt
    • Difficulty dissociating LEs from each other
    • LE posturing may increase during gait
    • Difficulty with lateral weight-shift so often use trunk
ndt enablement classification model of health and disability96
M R Franjoine & M P Haynes

+ Domains-

Dimensions

NDT Enablement Classification Model of Health and Disability

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

ndt enablement classification model of health and disability98
M R Franjoine & M P Haynes

+ Domains-

Dimensions

NDT Enablement Classification Model of Health and Disability

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

participation99
Participation
  • Function well as a member of the family though may difficulty keeping up with siblings
  • Special classroom or mainstreamed.
  • Participation is often limited due to:
    • Fatigue
    • Speed and balance
    • Crutch, Walker, and WC access
    • Community accessabilty
    • Acceptance of peers
treatment strategies100
Treatment Strategies
  • Address decreased ROM
    • Lengthen
      • Incorporate into your activities
      • Accompany with activation

and/or

    • Compensate
  • Help establish an appropriate BOS
    • Usually need to widen
treatment strategies101
Treatment Strategies
  • ALIGNMENT!
    • In relation to BOS
    • Segment to segment
    • Decrease asymmetries
  • Get the trunk moving over the hip
    • Balanced flexors and extensors in the trunk
    • Work in the frontal and transverse planes
treatment strategies102
Treatment Strategies
  • Keep the LEs dissociated from each other
  • Work for midrange control and eccentric control
  • Repetition
    • Motor learning
    • Strength
treatment comments103
Treatment Comments
  • Protect their hands and other joints
  • Remember biomechanics when they get on their feet
  • Increased function increases risk of deformities
  • Have a long term perspective