Gait training in children with cp

presented by:
Mohammad Khayatzadeh Mahani
Assistant professor in OT
Ahvaz Jundishapur University of medical sciences
Feb 2018
Tehran
‫در‬ ‫شده‬ ‫ارائه‬
‫فلج‬ ‫به‬‫مبتال‬‫کودکان‬‫در‬‫رفتن‬‫اه‬‫ر‬ ‫مشکالت‬‫توانبخشی‬‫و‬‫ارزیابی‬ ‫تخصصی‬‫کارگاه‬‫مغزی‬

Gait Abnormalities in CP
System Approach to Gait Training
2

Focusing on Individual
 Strength Training
 Deformity Control
 Spasticity Management
 Balance and Postural Control
Training
 Motor Learning
 Sensory Regulation
 Treadmill Training
 Robot-Assisted Gait
Training/ Virtual gait training
 Hippotherapy
 Aquatic Therapy
 Space Suit Therapy
3

Strength Training Program
 To participate in a strength training program, the
child must be able to comprehend and to consistently
produce a maximal or near-maximal effort.
 Children as young as 3 years of age may be capable of
this, but waiting to augment the program until the
child is age 4 or 5 years is more realistic.
4

 Even highly functional children with spastic CP are likely to
have considerable weakness in their involved extremities .
 If a child has at least some voluntary control in a muscle
group, the capacity for strengthening exists.
 In the absence of voluntary control, strength training is more
problematic, but may be facilitated by the use of electrical
stimulation or by strengthening within synergistic movement
patterns.
 Most ambulatory children with CP have the capacity to
strengthen their muscles.
 Nonambulatory children may also experience improvements
in their ability to use their upper extremities, transfer more
effectively, or engage more actively in recreational and fitness
activities.
5

 Invasive procedures such as muscle–tendon
lengthening, selective dorsal rhizotomy, intrathecal
baclofen pump implantation, or botulinum toxin
injections may improve muscle length and/or control
so that muscles can then be strengthened more
effectively.
 In turn, strength training may serve to augment or
prolong the outcomes of these procedures.
6

Strength Training Effectiveness
 Improve motor activity in people
with CP without adverse effects.
Spasticity remained unchanged
 Improve LE muscle strength
 To develop cardiovascular and
muscular endurance
7

Strength Training Effectiveness
 Task-specific strengthening exercise, run
as a group circuit class, resulted in
improved strength and functional
performance that was maintained over
time.
 Exercise training improves physical
fitness, participation level, and quality of
life in children with CP
8

Strength Training
Progressive resisted exercise improves
muscle performance & functional
outcomes in CP children.
 Closed chain V open chain
 use of theraband, theratube, Springs,
weight cuff, Bike, stationary bike,
treadmill
 Aerobic
 Plyometric
 Core stability: Ball, TRX
 Circuit Training: treadmill walking,
step-ups, sit-to-stands and leg presses.
9

Strength and Endurance Training
 In practical terms, a person should be able to lift a
specified load two to three times before experiencing
fatigue.
 An optimal strength training program would be to use high
loads with a low number of repetitions (3 to 8) arranged in
multiple sets with a rest between each set.
 To improve muscle endurance, the load does not need to
be high, but repetitions should be greater (8 to 20) before
resting.
 As the patient improves, the load and/or the number of
repetitions can be increased depending again on the
therapist’s goal.
 If the goal is to try to increase strength, the recommended
frequency of sessions is three times a week.
10

Deformity Control
 Manual Stretch
 Casting
 BTX-A
 Orthosis
 Surgery (SEMLS)
11

Manual Stretching
 No conclusive evidence to definitely state that passive
stretching can increase the range of movement in a joints
 It was difficult to judge if the decrease in spasticity was
clinically significant after stretching.
 Duration and period of stretching differs from:
 40–60s, 3 times for each movement, 1 or 2 times per week
 60s, 5 repetitions for each joint, 3 times a day and 5 days a
week
 20–60s, 5 repetitions for each joint, 5 days a week
12

Passive Stretching by Tilt-table
 Standing in tilt-table for 30 min each time, 3 times per
week for 42 days reported a significant reduction in
resistance during passive plantar flexion of the ankles
after stretching and the effect lasted up to 35 minutes
poststretching.
 They did not find any significant changes in gait
patterns as measured by video recording after 30
minutes of stretching on a tilt-table.
13

Deformity Control
(Orthotic Management)
 6 hours a day for muscle enlargement
 As a general rule the use of KAFOs is not indicated for
children with CP and fixed knee are poorly tolerated.
 Anterior Floor Reaction AFOs that prevent dorsiflexion
at the ankle can prevent knee flexion during stance by
realigning the GRF in front of the knee.
 Twister orthoses incorporating a flexible torque cable
extending from a waistband to an AFO create active
rotational forces and can alter the foot-progression
angle.
 Different kinds of AFO such as Solid, hinged, PLS ,
supramalleolar , and FR AFO are prescribed
14

AFO Effectiveness
Wingstrand et al(2014): 2200 cases
 The use of AFO is most frequent at 4–6 years of age in
children with lower levels of gross motor function.
 Three quarters of the children treated with AFO attained
the treatment goals.
15

FR AFO and Solid AFO
16

PL AFO and Hinged AFO
17

Adjustable Splint-assisted AFO
18

Gait Abnormalities in CP 19
Casting
 Serial casting in the CP
population has been shown to
improve ROM.( Brouwer 2000)
 Novak proposed that Casting is a
good method of contracture
management in UE and LE (2013)

Orthopedic Surgery Goals
 Correct anatomical abnormalities (hip dislocation,
Uneven leg length, Femoral Osteotomy)
 Decrease spasticity (Fasciectomy, SDR)
 Lengthen muscles and tendons( Iliopsoas, Adductors,
Hamstrings, Achill)
 Release contractures (Knee flex)
 Restore muscle balance ( Rectus transfer)
 Stabilize joints (Subtalar Fusion)
20

Most Frequent Surgery in CP
21

Knee Flex Contracture
 Spasticity in hamestrings
 Semitendinosus (shorter fiber lengths) the
most contracted muscle
 Then semimembranosus and biceps
 Relative decreased growth rate of the
length of the muscle fibers
 Tend to be worse in children who do no
stand and spend all day sitting in a
wheelchair (GMFCS 4 & 5)
 Fixed flexion contracture develop (
contracture of the posterior knee capsule)
 Severe contractures , secondary changes
can develop in the knee joint with
flattening of the femoral condyles.
22

(Non surgical)
 PT/OT: Manual stretching, prolonged stretching
using a tilt table, prolonged stretching using a
sandbag/weight over the distal femur, mechanical
traction, passive range of motion exercises and joint
mobilization
 Casting
 Spasticity management (Botulinum toxin, SDR)
23

(Orthotic Management)
 Turnbuckle
 Adjustable Knee Cage
24

Knee Flex Contracture Surgery
 Distal hamstring lengthening
 Posterior capsulotomy
 Quadriceps mechanism shortening
 Supracondylar Extension Osteotomy
25

Spasticity Management
26

BTX-A
27

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)
28

Balance and Postural
Control Training
 Normal balance development
involves three systems: the
vestibular, visual, and
somatosensory.
 The apparent integration of the
visual, vestibular, and
somatosensory inputs appears to
occur by 4 to 6 years of age, with
the responses of the 7- to 10-year-
old group being similar to adults.
29

Balance Training
 Environments must be structured
and tasks created in both open and
closed situations to allow the
greatest carryover to functional life
skills.
 Closed tasks are those whose
characteristics do not change from
one trial to the next; these require
less information processing with
practice.
 Open environments require more
attention and information
processing.
30

Balance Training
 Lateral sway is helped by training standing on one foot
(counterpoising), and is also developed in cruising
sideways and other activities which promote lateral
weight shift from leg to leg.
 Recent studies of treatment to improve balance in
children with spastic and ataxic CP are promising and
include the application of cerebellar transcranial direct
current stimulation (TDCS), in combination with
treadmill training.

Role of AFO in Improvement of
Balance
 Three side support AFO
 Gait Plate
32

Treatment Program
for all Hemiplegic Gait Patterns
 Equal distribution of weight on each foot.
 Teach weight shift on to the affected side.
 Standing on two weighing scales and help him correct this
as you read the equal weight borne on each scale.
 Use a mirror for both you and the child to see that he is in
correct alignment with his weight on both feet.
 Use a wide base and then bring both feet together for
standing, then stand with one foot in front of the other.
 Correct any deformities, especially of the feet, such as
equinus
 Stand on different surfaces, e.g. carpet, sponge rubber,
rough ground
 Using video games
33
GaitAbnormalitiesinCP

Treadmill Based Gait Vs Ground
Gait
 Spatiotemporal gait variables: increased cadence and
decreased stride length
 Change in Joint kinematics
 Change in kinetic gait parameters
 Narrow treadmill belt
 Consistent speed in treadmill
34

Treadmill Gait Training Benefits
 Controlling environmental constraints
 Reducing physical demand of service providers
 Providing a consistent training setup
 It can be ideal for a task-oriented training and target-
specific training, such as improvement on cadence, ankle
dorsiflexion, or hip flexion.
 The treadmill can be one of the best tools for gait
endurance training.
35

The combination of a
Treadmill and technology
 Partial Body Weight Support (
Less fear of falling, non
ambulatory chidren)
 Underwater Treadmill
 Antigravity Treadmill
 Robotic Gait Training
36

Robot-Assisted Gait Training
 Intensive, repetitive and task-oriented therapies, such
as robotic-assisted gait training (RAGT), improve
walking function in children with CP.
 This therapy is believed to promote motor learning
and influence neuroplasticity.
 RAGT has the potential to improve walking speed,
walking endurance, balance and gross motor function
in children with CP.
 With the addition of virtual reality (VR) scenarios,
especially game-based VR, this type of training further
offers the patients diversification, fun and challenge
37

Robot-Assisted Gait Training
 RAGT was performed using the commercially available
Lokomat.
 The legs of the Lokomat are connected to the frame of a
bodyweight support system
38

Hippotherapy
 “The use of the movement of a horse as a tool by PT/OT /SLP
to address impairments, functional limitations and disabilities
in patients with neuromusculoskeletal dysfunction.
 Hippotherapy is not to be confused with therapeutic riding.
Therapeutic riding is not a formal treatment and focuses on
recreation or riding skills for disabled riders.
39

Hippotherapy Benefits
40

Hippotherapy
 A typical hippotherapy session lasts from 45 minutes to
an hour, two times per week, for at least 10 weeks.
41

Aquatic Therapy
 The relief of hypertonus
in the spastic type of CP is
one of the major
advantages of aquatic
therapy.
 Buoyancy, viscosity,
turbulence, and
hydrostatic pressure are
properties of water that
can provide assistance or
resistance to a body.
42

Aquatic Therapy
 For a gradual increase in
weightbearing activities, the
individual can be
progressively moved to
shallower water, starting in
deep water using flotation
devices.
 In addition to providing
weight relief from
gravitational forces, buoyancy
can support movements
43

Aquatic Therapy
 Due to its hydrostatic pressure, water is a natural brace to
the trunk and a compression garment for lower extremities.
 The viscosity of water acts as resistance to movement,
meaning the faster the motion, the greater the resistance.
 Sensory and vestibular issues can also be addressed in an
aquatics environment. Underwater swimming, splashing,
water play, and pouring are examples of sensory exercises.
 The vestibular system can be challenged through activities
such as spinning in an innertube, flips underwater, and
diving for rings
44

www.farvardin-group.com
@farvardin_group_channel
@neuroscience4family
@farvardin_group96
‫تخصصی‬‫کارگاه‬
‫مغزی‬‫فلج‬‫به‬‫مبتال‬ ‫کودکان‬‫در‬‫رفتن‬‫اه‬‫ر‬ ‫مشکالت‬ ‫انبخشی‬‫و‬‫ت‬‫و‬ ‫ارزیابی‬
‫اریم‬‫ز‬‫سپاسگ‬

Gait training in children with cp

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