Strategies to treat Athetoid children

1. Athetoid CP: Therapy Strategies

2. Athetosis: Therapy Strategies
• General Principles
1. Goal-Directed Therapy
2. Facilitate symmetrical positioning (prevent asymmetry)- to enhance motor
control,
3. Optimize seating and positioning with good stability/support,
4. Orthosis and splints- to increase stability and coordination,
5. Consider needs for communication supports.

3. Athetoid CP: Therapy Strategies
• Therapy Aims
1. Minimize development of secondary problems (contractures and deformities)
2. Reduce/normalize tone, facilitate optimal stretch to muscles, and increase active
ROM;
3. Strengthen weak muscles;
4. Improve mobility and acquire functional motor skills;
5. Promote functional independence- at house, school and in community.

4. Athetoid CP:
THE KEY for Physical Therapy Interventions
• Must Manage BOTH
a. Excessive Co-contraction and THEN,
b. No Contraction at ALL for few
Seconds.
Due to these,
treatment TECHNIQUES and STRATEGIES
CHANGES FREQUENTLY.

5. Understanding Movement Impairments in
Athetoid CP
is
IMPORTANT to Structure Therapy Sequences

6. Impairments in ATHETOID CP
1. Difficulty with Muscle contractions:
• Problems in control of starting and stopping muscle contractions,
• Poor ability to initiate movements (due to overactive antagonist) and terminate activity (due to
excessive contraction that tends to increase with effort, and initiation of antagonist rather than
intended agonist),
• During functional tasks, some children sustain too much muscle activity and few can not sustain
enough to complete the task, some sustain too much in some areas of the body and not enough in
others, or at different times child sustain sufficiently- too much or too little.
Due to Basal Ganglia involvement, TIMING and INITIATION of movements are ABNORMAL.

7. Impairments in ATHETOID CP
2. Grading Agonist/Antagonist activity:
• Extreme variability during movements that require interaction of antagonists,
• Recurrence of unpredictable force and initiation of movements with opposite muscle groups
during INTENDED/SPONTANEOUS movements,
• EMG activity of elbow movements showed RAPID, BALLISTIC MOVEMENTS (Triphasic burst of
activity, 1st from AGONIST- 2nd from ANTAGONIST and then - AGONIST again [RECIPROCAL
INTERACTION OF FLEXORS AND EXTENSORS]),
• Some children use more co-contraction with effort that makes the movements less functional,
hence they NEED TO QUIT THE OVERACTIVITY OF THE ANTAGONIST, before beginning to move.

8. Impairments in ATHETOID CP
3. Limited synergies used to produce posture and movement:
• In Athetoid CP- Proximal muscles of lower body fire first, and additionally
contraction time variability present between synergists,
But in children without disability
Distal muscles fire prior to proximal in lower body, and precisely time the
muscle contraction of synergists
to stabilize the body when balance is required.

9. Athetoid CP: Sensory and Perceptual Changes
• Imbalance of Eye Muscle,
• Controlled Eye Movement for
communication,
• Uses extreme Asymmetrical posture with
Upward Visual Gaze,
• Controls Head and Eye to move,
• Uses Gaze Aversion during reaching or
motor skills- Looking away while reaching
(Part of an Strategy to gain Postural Stability),
• Absent or Abnormal Ocular reflex.

10. Athetoid CP: Kinesthetic Sensation
Athetoid CP
Reduced Kinesthetic Sensation (compared to Hypertonic).
Responds well to Kinesthetic information (provided
actively through therapy) and
with repetition, helps to remember joint position and
movement gradation (after being shown how a movement should
be performed), paired with suitable verbal and visual cues
TEACHING FUNCTIONAL SKILLS EASY (because Athetoid
have intact perceptual skills than motor execution skills).

11. Athetoid CP: Tactile Sensation
• Very Strong and Repetitive responses- to Tactile Inputs
• Not Tactile Defensive, but Tactile Over-responsive (means any tactile input causes
prolonged and repetitive response of exaggerated movement [increased movement
frequency or both]).
• Often opposed to bracing, splinting and wheelchair designs that provide
intermittent skin contact (because they move inside or against it).
(Tend to pull away after contact with the equipment and often refuse to use it - due to tactile sensitivity)

12. Athetoid CP: Tactile Sensation
• Responds positively to Lycra®splinting, because it gives firm contact with skin and its design
allow movements while supporting the joints. Blair E, Balluntyne J, Housman S, chauvel, p. (2008). A study of a dynamic proximal stability
splint in the management of children with cerebral palsy. developmental medicine & child neurology, 3:544–554.
• Lycra®splinting: Reduces Involuntary movements, gives stable head and trunk with less
asymmetry- by reducing tactile hyper-responsiveness through deep pressure in to the
proprioceptive system.

13. Athetoid CP: Musculoskeletal System
• Athetoid develop fewer tightness/contracture (because they move more frequently and
through larger ranges ) compare to hypertonia.
Tightness/contracture develop, where muscles are not able to move the joints due to
fixed posture (may cause bones or joint deformities).
• Common muscles develop tightness/contractures are:
UE: Pectorals, Upper Cervical Extensors, Latissimus Dorsi, Scapular Elevators, Rectus Abdominus,
Intercostals, Forearm Pronators, Wrist and Finger Flexors, Thumb Extensors and abductors;
LE: Hamstrings, Ankle Dorsiflexors, Ankle Evertors and Toe Flexors.

14. Athetoid CP: Secondary Impairments in Musculoskeletal System
• Instability of TMJ
• Overlengthening of Infrahyoid Muscles
• Instability of Cervical Spine
• Instability or Dislocation (mainly Inferior)
of Shoulder Joint
• Hyperextension of Elbow
• Hyperextension of IP joints of Fingers and
Thumb
• Overlengthening of Anterior Hip Capsule and
Ligaments
• Overlengthening of Plantar Flexors and
Invertors

15. Athetoid CP: Secondary Impairments in Musculoskeletal System
Hip Dislocation
• Anterior Hip Dislocation- due to pushing of Lumbar spine
and hips in to EXTENSION IN SUPINE OR SITTING-
(anteriorly hip Ligaments and joint capsule are strong so
it takes time to dislocate)- Hip flexion becomes difficult
causing difficulty in sitting (if not impossible).
• Posterior Hip Dislocation- Extension and Abduction of
hip is severely limited in standing and leg become
functionally shorter.
• Children with Spastic Athetosis may dislocate one hip
anteriorly and other posteriorly.
Anterior
Posterior

16. Athetoid CP: Secondary Impairments in Musculoskeletal System
Cervical Spine Instability
• Excessive or Abnormal Head Movement in Athetoid over years (adulthood age) may cause:
a. Malalignment
b. Spinal Canal Narrowing
c. Spondylosis
d. Radiculomyelopathy
Note: May develop Spinal Cord type clinical symptoms!

17. Athetoid CP: Secondary Impairments in Musculoskeletal System
Thoracic Kyphosis and Scoliosis
Increased Kyphosis as compensatory posture due to child’s strong cervical and
Lumbar/Hip Extension.
to bring the COM back over the BOS in sitting and standing to counterbalance extension
in cervical and lumbar spine that tend to knock the child over backward.
Child uses strong (tight) pectorals and Latissimus Dorsi to internally rotate the elevated
shoulder girdle and to bring the thoracic spine in flexion.
• Scoliosis in Athetoid CP may be due to Open-Packed, unstable position of thoracic
spine and severe asymmetry of posture and movements.

18. Athetoid CP: Secondary Impairments in Musculoskeletal System
Shift of Hyoid Bone and Laryngeal System
Due to pushing of CERVICAL SPINE INTO STRONG EXTENSION
with asymmetry,
Anterior surface of Neck Overlengthen
causes
Overlengthening of Masseter muscle and Elevation +
Forward tipping (anteriorly) of Hyoid and Laryngeal system
(affecting posterior stability of Tongue and Laryngeal system)
causes child to push
tongue against the Palate to gain stability,
that compromises the
PHONATION AND SWALLOWING.
Normal Position of Hyoid
bone, Suprahyoid muscles and
Larynx in 8M old Child.
Elevation of Tongue
Posteriorly to the Palate
for Stability
Normal Position
Note: Correcting the alignment- from CERVICAL EXTENSION TO
FLEXION, may interfere with ability to BREATHE.

19. Athetoid CP: Secondary Impairments in Musculoskeletal System
Poor muscle strength throughout the ranges in all the joints due to:
a. Lack of use,
b. Lack of ability to sustain muscle activity,
c. Poor alignment of body segments for the development of muscle tension,
d. Poor nutrition- energy expenditure due to uncontrolled, extraneous
movements causing average increase in resting metabolic rate of 534Kcal/day;
difficulty in GRADING JAW MOVEMENTS for feeding and POOR ABILITY OF THE
TONGUE SURFACE TO PROVIDE PRECISION FOR EATING – adds difficulty in calories
intake for muscle building.

20. Athetoid CP: Secondary Impairments in Musculoskeletal System
Why Athetosis children develop Tightness and Strength in Selected Muscles?
• Muscles commonly working in shortened ranges-
1. PECTORALS
assist Tx- spine in Flexion to balance the
strong cervical and lumbar/Hip extension
used frequently and repetitively by
Athetoid children (and develop adequate
strength).
2. Medial Hamstrings (MH)
used frequently to flex knees in STANDING and
TO HOLD IN SITTING
to counterbalance the powerful extension (Quadriceps) and
help to prevent from falling backward
MH sustain muscle activity in shortened ranges
for these activities and become quite strong,
CAUSING;
MH to become very tight and very strong in shortened
ranges.

21. Athetoid CP: Secondary Impairments
Respiratory System
• Arrhythmical respiration, difficulty in controlling exhalation with voicing,- may attempt to
voice at the end of exhalation,
• Difficulty in Coordinating breathing with onset of voicing and swallowing,
• Shows burst of Phonatory activity (if making sound), similar to the burst of muscular activity
[unable to produce sound- need augmentative communication system],
• Preserved eye movement, uses eye pointing to access system for communication.
• Note: Mid-line orientation of Head- most important for communication, while Speaking.

22. Athetoid CP: Typical Posture and Movement Strategies
• Appearance of typical bursts of movements, Extraneous movements, and alteration
between Flexion-Extension- Not seen until 1st year of life.
• Some children who develop ATHETODIS- stay clinically Hypotonic for many months
even after 1-2 years and do not show any burst extension movement from an
asymmetrical position- may be due to severe involvement, where all movement is
impossible to generate.

23. Athetoid CP: Typical Posture and Movement Strategies
Newborn with No Disability: Lie
Prone with Hips Flexed and
Head and spine
asymmetrically positioned,
and weight is on Cheek of
the Face.

24. Athetoid CP: Typical Posture and Movement Strategies
• Child with Athetosis- Learns to lift and hold Head up (if he can do) from an
asymmetrical base,
• Child with Hypertonia and Mild to Moderate Hypotonia- Lift and hold Head up
(if he can do), but with reduced asymmetry,

25. Athetoid CP: Typical Posture and Movement Strategies
But a child with Severe Hypotonia, who may later
develop Athetosis, rest weight on the EARS (large
and heavy occiput is pulled into gravity with no muscular
resistance).
Starting point for child with Athetosis to
attempt to learn,
TO LIFT AND HOLD HEAD UP.
Severe Hypotonic Child- Little or no activity in
POSTURAL TRUNK MUSCLES- limb rests against
support surface and are very inactive- child may
pull little with HIP FLEXORS-
Arms taking no weight or push against the surface and
legs remain extremely ABDUCTED- Head rotated to one
side and will INITIATE EXTENSION FROM ASYMMETRICAL
HEAD POSITION- SETTING UP STRONG ASYMMETRY IN
ATHETOSIS.

26. Athetoid CP: Typical Posture and Movement Strategies
The EXTENSION may be so forceful, that CERVICAL AND LUMBAR SPINE
will extend simultaneously, causing STRONG ARCHING OF SPINE.
Child may stay in this position for months, if placed
in PRONE or lie with similar asymmetry in SUPINE.
Since, EXTENSION is usually used first in all babies, Athetosis children
Learn to use QUICK BURST OF EXTENSION IN ALL POSITIONS.

27. Athetoid CP: Typical Posture and Movement Strategies
CERVICAL FLEXORS are quickly and forcefully over-lengthened with
strong, asymmetrical cervical extension, mainly Infrahyoid, that
initiates the MALALIGNMENT OF HYOID AND LARYNGEAL SYSTEM.
This over-lengthening may be ASYMMETRICAL, since Children with
Athetosis, may LIFT HEAD WHILE ROTATED TO ONE SIDE.
Eyes follow or lead the movement (used in peripheries)- because of asymmetrical head position
Upward Gaze (Eye Extension)- used often to lead and assist head movement- hold head up longer.
Uses eye extension to lead any body movement
Eyes are not available for seeking and scanning or social contact and to help in controlling posture and movements.
therefore

28. Athetoid CP: Typical Posture and Movement Strategies
Jaw Extension
• Jaw Extension (Mouth opening)- [forceful through full ranges]
Often, part of the Head Extension
Assist to sustain open Jaw position and cannot release until the head
drops
Since, jaw extension is done with asymmetrical
head position, so jaw opens asymmetrically
Abnormal lateral movements to begin at TMJs.
FACIAL GRIMACING – that is associated with
FORCEFUL ASYMMETRICAL JAW OPENING.
Causing
Causing

29. Athetoid CP: Typical Posture and Movement Strategies
Tongue Retraction
Initiates Strong Tongue Retraction in attempt to assist head
extension and to hold head against gravity
In Infant Suprahyoid muscles are tight at birth, causing babies to use tongue
retraction during CRY and with efforts to move antigravity.
Child with Athetosis does the same thing, but more forcefully and with increased
frequency.
Clinically tongue protrusion in children with Athetosis is, A WAY TO CLEAR THE TONGUE FOR
SWALLOWING AND BREATHING, but this protrusion is forceful and extreme in range.
Hence, tongue protrusion is not the original problem, but a solution to moving the
strongly retracted tongue.
So, therapeutically we must deal with the problem of tongue retraction TO TREAT THE
PROBLEM OF TONGUE PROTRACTION.
Tongue retraction with Head
asymmetrically positioned)

30. Athetoid CP: Typical Posture and Movement Strategies
Tongue Retraction- Therapy
This child forcefully protrudes her tongue.
She has only sagittal plane movements available for
tongue movements, just as she has sagittal plane
movements available for the rest of her body.
To facilitate more mid-range movements of the tongue, we must
help her initially position her tongue out of retraction and then
assist active movements.

31. Athetoid CP: Typical Posture and Movement Strategies
Some children with Athetosis uses FORCEFUL CERVICAL FLEXION to hold head up
or to counterbalance the tendency for strong extension.
This cervical flexion is done by the LARGE CERVICAL FLEXORS, causing mass flexion without
mid-range control of the head on the neck.
CERVICAL FLEXION is primary way for a child with Athetosis to hold head, or some children
develop it as compensatory strategy for certain posture or movements i.e. attempt to
move prone or W-sitting- to stabilize vision, to speak and to stand.
Lumbar
Extension
FUNCTIONAL LIMITATIONS: arise from Severe Head Asymmetry, Forceful Extension to Control
Head, and the accompanying Tongue, Jaw and Eye Movements to assist that extension.

32. Athetoid CP: Thoracic Spine, Ribcage and Upper Extremities
• Children with Athetosis completely and often
bypass any weight bearing into the surface
with their UE. This could be due to multiple
reasons;
• Strong cervical and lumbar extension may lift
children in prone, or push them into the
surface in supine, that substitutes for pushing
with arms.
• Additionally arms are often placed in extremes
of shoulder extension and internal rotation
where the joint is biomechanically stable.
• Since Athetosis causes unpredictable force
generation at unpredictable times, the child
does not learn to rely on the arms for
supporting antigravity postures.
• The shoulder complex may assist head control
with strong elevation and shoulder IR.

33. Athetoid CP: Changes in BMD
Bone 71 (2015) 89–93

34. Total Hip Joint BMD:- Non-
Ambulatory & Ambulatory: Spastic
CP Vs Dyskinetic CP
Findings: Hyperkinetic and Dynamic
movement patterns coupled with sufficient
joint ROM have ANABOLIC EFFECT ON
BONE BY REPETITIVE LOADING, hence
higher BMD than Spastic CP.

35. Athetosis: Therapy Strategies
Understand the Key Problems Differences between
SPASTICITY
Poverty of Movements and Richness in Muscle Tightness
ATHETOSIS
Richness of Movement and Limitations in Joint Stability
PHASIC & TONIC MUSCLES functions as TONIC
Causing Generalized Stiffness/Tightness/Contractures in Muscles/
Joints
TONIC MUSCLES functions as PHASIC and Phasic Muscles
Functions as TONIC
Giving Outer Range of Movements at Proximal Joints
without Joint Stability and Distal joint muscles reacts by
Fisting or Mass Extension.
Don’t Develop Tightness in Muscles

36. Should we do Passive Movements in Dystonia?
Whenever the limb is passively moved in Dyskinetic disorders, the limb shows,
1. involuntary resistance,
2. increased EMG responses of the antagonist muscles, and
3. delayed muscle relaxation.
These responses reduces ROM when movements are voluntary.

37. Athetoid CP: Intervention Strategies
• 30 to 45 minute therapy sessions/ 2 times per day/ 5 sessions a week.
• Closed Chain/ postural stabilization activities (Weight-Bearing Exercises): allows limbs to
be fixed and stabilized, and provide way to strengthen specific muscle groups. Initially
focused more on proximal stabilizing muscle groups and then more distal
musculature (with improvements).
1. In Supine: Bridging to wall squats for strengthening of hip musculature.
2. In Prone: Maintaining weight-bearing position initially on elbows to quadruped
(Extended Elbow with Open Palm position).
Pediatr Phys Ther 2014;26:85–93

38. Athetoid CP: Intervention Strategies
Closed Chain/ postural stabilization activities (Weight-Bearing Exercises)
3. Quadruped position: support and maximize weight bearing and facilitate weight
shifting through lower extremities, trunk, and weighted upper extremity.
4. Maintain each position until complained of fatigue or fatigue is evident (requiring
increased assistance or unable to balance further).
5. Repeat position 2 to 3 times/ session, based on the time to tolerate the position.
Pediatr Phys Ther 2014;26:85–93

39. Athetoid CP: Intervention Strategies
Open Chain Exercises and activities
1. Open chain exercise and activities: increased the amount of non-purposeful
movement and made it difficult to focus on specific muscle groups effectively.
2. With improvements in selective motor control, therapy progressed to more
open chain exercises and movement activities, e.g. Crawling and eventually
ambulating.
Note: Verbal and tactile cues- to perform movement at a decreased speed with small ROM-
– facilitated by environmental adaptation i.e. small pieces of carpet placed close together
on floor- to step only on carpet square, forcing child to take small, controlled steps.
Pediatr Phys Ther 2014;26:85–93

40. Athetoid CP: Progression with Therapy Strategy
• Use Barriers during functional tasks, i.e. crawling through small tunnel to limit space
and therefore the ROM.
• During reaching tasks: keep objects initially close to the child, and with
progression place it further away- gradually increasing the ROM needed to
accomplish the task.
• With progression, apply manual resistance during functional activities to limit
speed of movement and ROM.
• Use COUNTING: as verbal cue for desired speed/duration to perform a tasks.
Pediatr Phys Ther 2014;26:85–93

41. Athetoid CP: Important Points for effective Therapy Strategy
• Doing task at slower speed and within smaller movement amplitude – facilitates to
completed functional tasks successfully, increases motivation and provides strategy
to decrease Athetoid effect during movement.
• As SELECTIVE MOVEMENTS improves, progressed to activities requiring greater ROM
at increased speed.
• ALWAYS control non-purposeful movement by weighting the extremities during open chain
activities. E.g. Use ankle cuff weights during initial ambulation trials, and weighted pencil
for writing activities (to reduce intensity, velocity, and degree of non-purposeful
movements).
Pediatr Phys Ther 2014;26:85–93
Note: Weighting limbs during fine and gross motor tasks- not effective in diminishing excessive
movements and not considered as an appropriate intervention strategy for Athetoid children.

42. Athetoid CP: Important Points for effective Therapy Strategy
• Minimal assistance- child performing 75% of the task,
• Moderate assistance- child performing 25% to 75% of the task, and
• maximal assistance- child performing 25% of the task
Pediatr Phys Ther 2014;26:85–93

43. Athetoid CP:
Variations in resulting impairments after successful Physical Therapy Interventions
Many ATHETOID children initially presents with HYPERTONICITY
After TREATMENT of HYPERTONICITY, we see more SUBTLE IMPAIRMENTS (that was
masked by the strong influence of HYPERTONICITY)
called EMERGING components of ATHETOID CP [Alternating FLEXION & EXTENSION of FINGERS,
Asymmetrical Posturing, Large-range Sagittal Plane Movements of TOUNGUE (Protrusion/Retraction) and
Postures with more END-RANGE Positions].

44. Athetoid CP:
Variations in resulting impairments after successful Physical Therapy Interventions
Few ATHETOID CP (severely involved ones), were initially HYPOTONIC for many
Years (with Postures associated with HYPOTONICITY)
Begins to show impairments once they achieve any degree of movement against GRAVITY
Thus, during treatment we need to be wise to continually OBSERVE and ASSESS.
NOTE: Due to this, SPASTICITY Mx by SURGERY or Medications needs careful rethink.

45. Athetoid CP: Hydrotherapy use
Hydrotherapy
gives resistance to movements, facilitates slower and
smaller movements, minimizes involuntary movement,
and provide strengthening opportunities for muscles.
helps to control speed and amplitude of movements during
ambulation.
Buoyancy give support to body weight, useful for focused
gait training compared to the land.
Pediatr Phys Ther 2014;26:85–93