این پاورپوینت در کارگاه فلج مغزی دکتر خیاط زاده که توسط گروه آموزشی عصب شناختی فروردین برگزار شد ارائه شده است.

1. Bottom Up
Approaches
Tehran CP Workshop, May 20171
 ‫تخصصی‬ ‫کارگاه‬
‫در‬ ‫دان‬ ‫تاپ‬ ‫و‬ ‫آپ‬ ‫باتم‬ ‫رویکردهای‬ ‫ای‬ ‫مقایسه‬ ‫بررسی‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬ ‫کاردرمانی‬ ‫مداخالت‬
 ‫تنظیم‬ ‫و‬ ‫تهیه‬:‫زاده‬ ‫خیاط‬ ‫محمد‬ ‫دکتر‬
 ‫بهار‬1396

2. Electrical Stimulation
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3. Electrical Stimulation
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• Some uncontrolled trials of TES
show subjective improvements;
controlled trials, however, are
inconclusive.
• Multiple studies have demonstrated the
effectiveness of NMES, especially the
FES in Reduce spasticity, Increase ROM
& strength, Increase force production, and
Promote initial learning of selective
motor control.
• However, studies are limited by many
confounding variables including
concomitant use of other therapies, wide
variation in methods of application, and
lack of control subjects

4. Tehran CP Workshop, May 20174
Casting
 Serial casting may serve to reduce
spasticity in muscles by decreasing
the strength of abnormally strong
tonic foot reflexes.(Bertoli 1996).
 Serial casting in the CP population
has been shown to improve ROM.(
Brouwer 2000)
 Casting provides stability and
prolonged stretch of a muscle which
is immobilized in a lengthened
position(Mosley 1997).
 Novak proposed that Casting is a
good method of contracture
management in UE and LE (2013)

5. BTX-A
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6. Spasticity management
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7. Tehran CP Workshop, May 20177
BTX-A
 Target muscles in LE
 In more severe cases: medial hamstrings and adductors
 in less severe cases: hamstrings or calf, or occasionally
adductors and calf
 In hemiplegia: 1. calf 2. hamstring
 In diplegia: 1. hamstrings 2. calf
 In quadriplegia: 1. adductors 2. calf and hamstrings
 Repeated exposure to BTX-A can lead to
immunoresistance
 Novak proposed that BTX-A is a good method of
spasticity management in children with CP(2013)
 BTX-A reduces spasticity and improves ambulatory
status.(Flett 1999)

8. BTX-A + casting/orthosis
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 When used in combination with casting it has
shown to help maintain and improve muscle
length and passive ROM.(Kay 2004)
 If the contracture is early, soft and mild, then WB
together with orthoses and stretching may be
sufficient for management of calf and hamstring
following BTX-A.
 If contracture is more fixed but some dynamic
range of motion is available, consider BTX-A
supplemented after 3 weeks by a short period of
casting to alleviate the residual contracture

9. BTX-A plus therapy/Orthosis
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 Fehlings et al showed that
upper extremity injections of
BTX-A plus OT were superior
to OT alone on the QUEST.
 Orthoses are used in
conjunction with PT/OT to
facilitate carry-over of
improved motor control
following BTX-A injection,
particularly in the LE.

10. Orthotic Management
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11. Orthotic Management
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Goals :
Maintenance or
increase ROM
Protection or
stabilization of a joint
Promotion of
function
 Spasticity
management

12. AFO effectiveness
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Wingstrand et al(2014): 2200 cases
 The use of AFO is most frequent at 4–6 years of age
and in children with lower levels of gross motor
function.
 Three quarters of the children treated with AFO
attained the treatment goals.
 A higher proportion of the children with a lower ROM at
baseline improved their ankle dorsiflexion using AFOs
compared to children with a higher initial ROM.

13. Hand splint effectiveness
 Functional splints are prescribed for use during
activities to directly improve task performance, such
as a wrist cock-up splint designed to stabilize the
wrist during tasks such as handwriting
 Preliminary evidence suggests that functional hand
splints may have an immediate positive effect on
hand function
 Whilst splints may provide a very small clinical effect,
it is unclear whether this leads to any improvement in
function
 There is no reliable evidence to support the use of
hand splints as a therapeutic modality in isolation of
other intervention approaches
13 Tehran CP Workshop, May 2017

14. Strength Training
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 Progressive resisted exercise improves
muscle performance & functional
outcomes in CP children.
 Closed chain V open chain
 use of theraband, theratube, weight cuff,
stationary bike, treadmill, medicine ball, …
 Aerobic
 Plyometric
 Aquatic
 Whole Body Vibration (WBV)
 Core stability: Ball, TRX
 Circuit Training: treadmill walking, step-
ups, sit-to-stands and leg presses.

15. Strength Training effectiveness
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15
 Blundell et al (2002): task-specific
strengthening exercise, run as a
group circuit class, resulted in
improved strength and functional
performance that was maintained
over time.
 Verschuren et al (2007): An
exercise training improves physical
fitness, participation level, and
quality of life in children with CP
 It could be used as a target
treatment specifically anticipating
temporary muscle weakness, such

16. Strength Training effectiveness
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 Unger et al (2006)[RCT]: The
experimental group differed
significantly from the control group in
crouch gait. Walking velocity,
cadence and stride length did not
change
 Mockford et al (2008)[sys review]:
Isotonic strength training was
associated with moderate to large
strength and function gains which
were maintained after detraining, and
small-to-moderate gait improvements
that partially deteriorated during
detraining. Subjects experienced no

17. Strength Training effectiveness
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17
 Johnson et al (2014): Plyometric
training improves gross motor
ability, agility, and UE power in
boys with unilateral cerebral
palsy.
 Ruck et al (2010): WBV protocol
appears to be safe in children
with CP and improve mobility
function but we did not detect a
positive effect on bone.
 Dodd et al (2002)[sys review]:
training can increase strength
and may improve motor activity in

18. Strength Training Effectiveness
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18
 Verschuren et al(2008) [sys
review]: Children with CP may
benefit from improved exercise
programs that focus on LE muscle
strength, cardiovascular fitness, or
a combination.
 Despite being able to increase
muscle strength and aerobic
capacity, more evidence is needed
to determine whether training can
make substantial or sustained
improvements in ADLs , the

19. Complementary and Alternative
Methods
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 HBOT
 Stem cell Therapy
 Acupuncture
 Hippo therapy
 Space suit Therapy
 Craniosacral
Therapy
 Massage
 Aquatic therapy
 Dolphin Therapy
 Yoga
 Traditional medicine
 Homeopathy
 Energy therapy

20. Complementary and Alternative Methods
Tehran CP Workshop, May 201720

21. Complementary and Alternative Methods
Tehran CP Workshop, May 201721
 Hurvitz et al (2003): 56%, used one or more
CAM. Massage therapy (25%) and Aquatherapy
(25%) were the most common.
 Children of families that used CAM were
significantly younger . Children with spastic
quadriplegic and those who could not walk were
more commonly exposed to CAM.
 Studies of Acupuncture are promising, but more
studies are required before specific
recommendations can be made
 HBOT: More evidence is required before
recommendations can be made.

22. Complementary and Alternative Methods
Tehran CP Workshop, May 201722
 Craniosacral Therapy: No studies showing efficacy in
CP; some question the basis of the intervention.
 Hippotherapy: Zandikar et al (2011)[Meta-analysis]:
The results show that children with spastic CP
demonstrated significant improvement in postural
control and balance
 Stem cell Therapy: Chahine et al (2016):A Report of 17
Cases; Patients treated having a good response using
the GMFCS. Bartley et al (2005)[sys review]: Use of
stem cell therapy is promising, there are no controlled
trials in humans with CP.

23. Space Suit Therapy
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24. The Adeli Methods have been
working from 1994 at Russian
rehabilitation centers.
A total of 250 rehabilitation centers
in the territory of the Russian
Federation have successfully
mastered Adeli Methodology.
 In addition, training courses in
term of the application of Adeli Suits
have been launched in the Ayurveda
Teaching Center at the Skobykino in
the city of Yaroslavl.
Tehran CP Workshop, May 201724

25. All these pieces are interlocked by
bungee type chords. These chords assist
with proper alignment of the body and
essentially frame the body from the outside
(external skeleton).
The Adeli loading suit is essentially a
system of supporting elements, namely:
special vest, shorts, knee-caps and
footwear.
Characteristics and Elements
A loading suit creates a breathable, soft
dynamic orthotic that acts as an elastic shell
to make the patient move without restricting
the amplitudes of movements.
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25

26. The Adeli Suit may also be fitted with
some extras to meet a patient’s
biomechanical requirements for
example, a cap linked to the special
vest by adjustable elastic bungees to
keep the patient’s head in its natural
position.
Adeli Suit Characteristics
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26

27. Adeli Suit
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In the mid 90’s Euromed clinic in
Poland developed an Intensive
suit therapy utilizing the Adeli
suit.

28. Spider
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Spider is an space
therapy , was first
invented by the firma
Norman in 1993.

29. Thera Suit
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30. Bungy Suit
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31. Suit Therapy Effectiveness
Tehran CP Workshop, May 201731
 In some studies showed its effectiveness
in improvement of mechanical efficiency or
motor function compared to regular NDT
(Bar-Haim 2006, khayatzadeh 2009).
 Sys reviews showed no significant
difference between ST and other
interventions such as NDT ( Novak 2013,
Liptak 2005).

32. Tehran CP Workshop, May 201732
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