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Definition
A sensorimotor nonprogressive disorder that affects the control of posture and movement.
Lack of oxygen before, during or shortly after the birth process.
Congenital c.p and acquired c.p
Although the brain lesion is unchanging, from clinical point of view signs and symptoms do change together with children’s development and maturation of the CNS.
2.08 per 1000 school age children in Euroupin 2002 with approximately one third to half of children with cerebral palsy of low birth weight.
The classical distribution of symptoms
Spastic quadriplegia
All four involved with a mixture of spasticity & dyskinesia
Severe motor disability Can not sit or walk independently
Spastic diplegia
Increased tone in the legs but little or no involvement in the arms.
Walk with or without aids W kneeling posture in preference
to long sitting
Spastic hemiplegia
Most walk independently Wide variation in the function of
the affected arm and hand
Classification according to the impairment (McCarthy(
Spastic (70%) Dyskinetic (20% - 25%) Ataxic (5%– 7%) Hypotonic Mix
Classification
Motor type , Cortical lesion Dystonic or Atetoid Non Progressive Ataxia Mixed of spasticity, ataxia,
dystonia Rigidity
Fay Classification
Spastic paralysis,non-spastic, atonic
Atetosis (mid brain) Tremor & rigidity (basal ganglia) Ataxia High spinal (Medulla) Mixed
Aetiology Birth asphyxia Low birth weight Hypoxia, vascular accidents,
infections and toxicity Familial influences Teratogens like toxoplasmosis,
rubella, CMV &herpes simplex Iodine deficiency and consanguinity
Functional Mobility scale
1. Uses wheelchair, stroller or buggy: May stand for transfers and may do some stepping supported by another person or using a walker/frame.
FMS
2. Uses K-Walker or other walking frame: without help from another person
3. Uses two crutch: without help from another person
4. Uses one crutch or two sticks: without help from another person
FMS
5.Independent on level surfaces: does not use walking aids or need help from another person. If uses furniture, walls, fences, shop fronts for support please use 4 as the appropriate description
FMS6. Independent on
all surfaces: does not use any walking aids or need any help from another person when walking, running, climbing and climbing stairs.
Walking distance Rating (1-6)Walking 5 meters(eg, in bedroom or other room)
Walking 50 meters(eg, at school, in the classroom and playground)
Walking 5oo meters( eg, in the shopping mall or street)
GMFC
5 level system Severity of motor involvement
based on age, motor ability and use of assistive technology
Natural history
Child below normal size Poor motor and cognitive skills Deformities of joints and bones Associated complications; epilepsy,
visual impairment, musculoskeletal deformities, growth delay, sleep disturbance and reduced life expectancy
Epilepsy
Higher incidences in quadriplegia than dyskinesia and spastic diplegia esp, preterm infants
Epilepsy is linked with an increased risk of sensory & cognitive impairment
Seizures lead to developmental regression
Sensory impairment
Visual impairment (7% to 9%) Visual impairment leads to
uncontrolled trunk and head Lack of proprioceptive & tactile
system Diminished anticipatory control
Nutritional factors and ability to walk are significant factors in decreased bone mineral density
Difficulty in swallowing and chewing
Reflux result in aspiration and consequent chest infection
Sleep disturbance due to:
Sleep hypoxemia Upper airway obstruction Decreased melatonin level Nocturnal seizures Reflux and positional discomfort
Causes of hypoxemia
Brainstem dysfunction Upper airway obstruction
(hypertrophy of tonsils & adenoids
Musculoskeletal deformities in different types of cerebral palsy
Imbalances in muscle group Deformities of joints and bones Osteopororosis in children unable
to walk
Hemiplegia
Smaller limbs in affected side Leg shortening Equinus of the foot and ankle Flexion of the elbow, wrist and
fingers Adducted thumb
Diplegia Contractures of the hip flexors &
adductors & hamstrings & calf & internal rotation of the hip and femoral anteversion
Hyperextension of the knee to compensate for tight tendo-achilles
Kyphosis as a sequel to tight hamstrings Hyperlordosis as a compensatory
balance mechanism
Quadriplegia
Dislocation of hips Pelvic obliquity Spinal curvature Limitation in sitting, standing and
walking and hygiene and personal care
Windswept deformity Joint pain
Gross Motor Function Classification System
Level I Walks without restriction:
limitations to more advanced gross motor skills
Level II Walks without assistive devices;
limitations in walking outdoors and in community
Level III:
Walks with assistive devices ; limitations in walking outdoors and in community
Level IV:
Self-mobility with limitations; children are transported or use powered mobility outdoors and in community
Level V
Self –mobility is severely limited , even with the use of assistive technology
Effects of C.P in life periods
Birth to 3 years conservative and non invasive
treatment Preschool increasing complications School age social participation
Effects of C.P in life periods
Maturation sexual maturation social acceptance emphasize on function Adulthood Senior adult
Medications Antiemetrics to control gastric reflux Baclofen orally or intrathecally Dantrolen sodium Tizanidine Neurolytic blocks BTX-A Anticonvulsants
Weakness, liver dysfunction
Surgical and orthopedic management
Release of tendon, muscle or connective tissue for lengthening
Bony surgery Multilevel surgery at the hip,
knee and ankle
Selective Dorsal rhizotomy
Devide the posterior nerve rootlets in the lumbosacral region to reduce lower limb spasticity
Management assistance
Holding, Baby carrying Positioning Daily care Orthosis Adaptive equipments
Management Assessment of Tone, Motor behavior
pattern, posture, sensory status specially vision (cataract, congenital glaucoma, strabismus, visual acuity, blindness, nistagmus, hemianopia
Strengthening, coordination, gait, balance, dexterity
Management
Comprehensive treatment Functional recovery (task-oriented
approach) maintenance of physiologic
conditioning
Management
Training of compensatory mechanisms Adaptive equipments Functional head control W.B Sitting control Serial casting Using crutch, walker, cane, shoe insert
NDT Approach
Handling for abnormal tone and posture and movement pattern
Inhibition of abnormal tone and primitive reflexes
Facilitating normal movements Weight shift & W.B
Vojta approach
Activation of postural reaction & equilibrium reaction
Reaching normal development Proprioceptive inputs
Fay (Patterning)
Breath control Neurological organization by
encouraging prone position & creeping & crawling
Head rotation for flex, ext of limbs Sensory inputs
Rood approach
Sensory and Motor stimulations
SI therapy
Jean Ayers Sensory processing Vestibular, Proprioception, Tactile
9 sensory inputs) Learning disabilities
Other techniques
PNF, Strengthening spasticity?
Electrical stimulation for weakness, spasticity, ROM, voluntary control
Before 2nd Birthday
Level I ( Walking Independently) infants move in & out of sitting and
floor sit with both hands free to manipulate objects. Infants crawl on hands & knees ,pull to stand & take steps holding on to furniture. Infants walk between 18 months and 2 years of age without the need for any assistive mobility device.
Level II (Walking with Assistance)
Infants maintain floor sitting but may need to use their hands for support to maintain balance. Infants creep on their stomach or crawl on hands and knees. Infants may pull to stand and take steps holding on to furniture.
Level III (Roll & Creep)
Infants maintain floor sitting when the low back is supported. Infants roll and creep forward on their stomachs
Level IV ( just Rolling)
Infants have head control but trunk support is required for floor sitting. Infants can roll to supine and may roll to prone.
Level V (No head Control)
Physical impairments limit voluntary control of movement. Infants are unable to maintain antigravity head and trunk postures in prone and sitting. Infants require adult assistance to roll.
Between 2nd and 4th Birthdays
Level IChildren floor sit with both hands free
to manipulate objects. Movements in and out of floor sitting & standing are performed without adult assistance. Children walk as the preferred method of mobility without the need for any assistive mobility device.
Level II
Children floor sit but may have difficulty with balance when both hands are free to manipulate objects. Movements in & out of sitting are performed without adult assistance. Children pull to stand on a stable surface. Children crawl on hands & knees with a reciprocal pattern, cruise Holding onto furniture and walk using an assistive mobility device as preferred Methods of mobility.
Level III Children maintain floor sitting often by “W- sitting” (sitting between flexed &
internally rotated hips & knees) and may require adult assistance to assume sitting. Children creep on their stomach or crawl on hands and knees (often without reciprocal leg movements) as their primacy method of self- mobility. Children may pull to stand on a stable surface and cruise short distances. Children may walk short distances indoors using an assistive mobility device an adult assistance for steering and turning.
Level IV Children sit on a chair but need adaptive
seating for trunk control and to maximize hand function . Children move in and out of chair sitting with assistance from an adult or a stable surface to push or pull up on with their arms. Children may best walk short distances with a walker and adult supervision but have difficulty turning & maintaining balance on uneven surfaces. Children are transported in the community. Children may achieve self- mobility using a power wheelchair.
Power wheelchair
Level V Physical impairments resist voluntary control
of movement and the ability to maintain antigravity head &trunk postures. All areas of motor function are limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment & assistive technology. Children have no means of independent mobility and are transported. Some children achieve self-mobility using a power wheelchair with extensive adaptations.
Between 4th and 6th Birthdays
Level I: Children get into & out of, and sit in, a chair without the need for hand support. Children move from the floor & from chair sitting to standing without the need for support. Children walk indoors & outdoors, and climb stairs. Emerging ability to run & jump.
Level II Children sit in a chair with both hands
free to manipulate objects. Children move from the floor to standing and from chair sitting to standing but often a stable surface to push up with their arms. Children walk without the need for any assistive mobility device indoors and for short distances on level surfaces outdoors. Children climb stairs holding onto a railing but are unable to run or jump.
Level III Children sit on a regular chair but may
require pelvic or trunk support to maximize hand function .Children move in & out of chair sitting using a stable surface to push on or pull up with their arms. Children walk with an assistive mobility device on level surfaces and climb stairs with assistance from an adult. Children frequently are transported when traveling for long distances or outdoors on uneven terrain.
Level IV
Children sit on a chair but need adaptive seating for trunk control & to maximize hand function. Children move in & out of chair sitting with assistive an adult or a stable surface to push or pull up on with their arms. Children may at best walk short distances with a walker and adult supervision but have difficulty turning and maintaining balance on uneven surfaces. Children are transported in the community. Children may achieve self-mobility using a power wheelchair.
Level V Physical impairments restrict voluntary control
of movement and the ability to maintain antigravity head and trunk postures. All areas of motor function are limited. Functional limitations in sitting and standing are not fully compensated for through the use of adaptive equipment and assistive technology. Children have no means of independent mobility & are transported. Some children achieve self- mobility using a power with extensive adaptations.
Manual Ability Classification System for Children with
Cerebral Palsy4-18 yearsMarch 2005
MACS
1. Handles objects easily and successfully.
At most, limitation in the ease of performing manual tasks requiring speed and accuracy. However , any limitation in manual abilities do not restrict independence in daily activities.
MACS
2. Handles most objects but with somewhat reduced quality and/or speed of achievement.
Certain activities may be avoided or be achieved with some difficulty; alternative ways of performance might be used but manual abilities do not usually restrict independence in daily activities.
MACS
3. Handles objects with difficulty; needs help to prepare and/or modify activities.
The performance is slow and achieved with limited success regarding quality and quantity. Activities are performed independently if they have been set up or adapted.
MACS
4. Handles a limited selection of easily managed objects in adapted situations.
Performs parts of activities with effort and with limited success. Requires continuous support and assistance and/or adapted equipment, for even partial achievement of the activity.
MACS
5. Does not handle objects and has severely limited ability to perform even simple actions.
Requires total assistance
Morbidity
Those children with severe spastic quadriplegia and poor nutritional status have been shown to have a high risk of dying
The most common cause of death for those at high risk was respiratory problems(59%),with epilepsy as the second most common cause of death.
Mortality risk increased with increasing intellectual impairment, motor impairment & number of severe impairment.
With the exception of those children with profound learning difficulty, most children with c.p can expect survive into adulthood.
Risks for severe types
Osteopenia & osteoporosis Fractures may be caused by: Joint contracrure poor nutrition hip dislocation immobilisation
Learning disabilities Behavioural difficulties Epilepsy Sensory difficulties Hydrocephalus Eating & swallowing problems gastroesophageal reflux Speech & language difficulties Problem with manual dexterity
Impairments, Functional limitation, and focus of treatment in children with spasticity
Impairments
Increased muscle stiffness, slow , labored movement
Functional limitationsStereotypical movement patterns, poor static & dynamic balance; postural insecurity,
Treatment focusDecrease stiffness, head & trunk righting & equilibrum & protective reactions,
continueimpairments Functional
limitationstreatment focus
Decreased trunk Rotation
poor movement transitions
Practice mvt transitions like, trunk rot, rolling, come to sit & walking
Decreased ROM
Reaching, walking
Mvt in all ranges, variation
continue
Impairment Functional limitations
Treatment focus
Skeletal malalignmentMuscle weaknessInaccurate muscle recruitment
Scoliosis, musculoskeletal deformities. Movements against gravity, Inefficient movement ; high energy cost
Position properly for function; use orthoses, Strengthen through mvt experiences, use novel environment
Influence of Tonic Reflexes on Functional movement
Tonic Reflex Impairment Functional Movement Limitation
TLR in supine ContracturesAbnormal Vestibular inputLimited visual field
Rolling from supine to prone, Reaching in supine, coming to sit, sitting
Tonic Reflex Impairment Impairment
Functional Movement Limitation
TLR in prone Contractures, Abnormal vestibular input, Limited visual field
Rolling from prone to supine, Coming to sit, sitting
ATNR ContracturesHip dislocationTrunk asymmetry, scoliosis
Segmental rolling, reaching, Bringing hand to mouth,sitting
Tonic Reflex Tonic Reflex Functional Movement Limitation
STNR Contractures,lack of upper & lower extremity dissociation, lack of trunk rotation
Creeping,kneeling,Walking
Impairments
Functional limitation
Treatment focus in children with Athetosis
Low or fluctuating muscle tone- Wide , incoordinated movements
Potural instability ; poor balance & safety, poor mvt transitions;Unsafe mvt
Hold postures, cocontraction in midline, control & direct mvt with resistance;resist reciprocal mvts
Impairment Functional limitation
Treatment focus
Lack of midrange control
Reaching, walking
Hold in midrange; work in small increment of range
Lack of use of hands for support
Poor movement transitions; unsafe movement
Weight bearing through arm;use upper extremity weight bearing for safe movement transitions
Impairment Functional limitation
Treatment focus
Lack of graded movement
Difficulty grasping; changing positions
Facilitating shoulder position; stabilize trunk or opposite extremity
Emotional Lability
Poor judgement of balance risk
Modify behavior
Predictors of ambulation for cerebral palsy
Predictor
By diagnosis: MonoplegiaHemiplegiaAtaxiaDiplegia
Spastic quadriplegia
Ambulation Potential100%
100%100%
85-90%0-70%
PredictorBy motor function
Ambulation Potential
Sit independently by 2 years
100%
Sit independently by 3-4 years
50% community ambulation
Presence of primitive reactions beyond 2 years
poor
Absence of postural reactions beyond 2 yearsIndependently crawled symmetrically or reciprocally by 2 & half- 3 years
poor
100%