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Rehabilitation in Cerebral Palsy through lifespan.pdf
- 1. 1 Physiotherapy perspective of Cerebral Palsy through the lifespan Dr. Kavitha Raja PT, PhD Professor
- 2. Sir William Little • First clinical report of cerebral palsy in 1843 • 19th century the syndrome was widely known as Little’s Disease • Sir William Osler (1849–1919) coined the term ‘cerebral palsy • Freud’s description of spastic diplegia is so complete that it remains as relevant in 2014 as it was at the end of the 19th century
- 3. Definition – summary • Group of disorders that manifest predominantly as motor dysfunction with a static encephalopathy as the etiology • Motor dysfunction may progress and may be accompanied by disorders of sensation, cognitive, behavioural and systemic disorders • The ultimate disorder is that of mobility functions which is interlinked with other manifestations leading to disablement
- 4. ICF and cerebral palsy Core sets developed for cerebral palsy Body Structure Body Function Activity and Participation Structure of lower extremity Structure of upper extremity Additional musculoskeletal structures related to movement Structure of trunk Neuro-musculoskeletal and movement related functions Control of voluntary movement Sensation of pain Gait pattern functions Recreation and leisure Self-care Walking Mobility
- 5. • Management at all stages require knowledge of motor control development • Principles of neural plasticity • Physiology of aging • Physiology of balance 5 6-12 Infancy Child (6-12) Toddler Pre-school Aging with CP Adults
- 6. Neural Plasticity • Synaptic transmission and cellular structures in the brain are arranged in dynamic manner as per the behavioral needs • Changes are usually seen due to repeated training of an activity and continued practice of an activity usually with the sensory experience associated with it • E.g. – piano lessons 6
- 7. From diagnosis to prognosis • Traditional neurological testing – not sensitive or specific enough to enable a reliable diagnosis or prognosis (Ferrari, 2003) • Waiting till a prefect diagnosis – likely to be an obstacle for infant development • No distinct diagnosis of CP, catch all - “Developmental delay” 7
- 8. From diagnosis to prognosis • General movement assessment by Prechtl - endogenously generated motor activity may be a better indicator of the integrity of motor function rather than examination based on reactivity to stimuli (Prechtl, 1989) • Most appropriate tool for guiding PT towards early intervention • Prechtl’s method has shown adequate inter-rater reliability and reliable predictive value for CP 8
- 9. From diagnosis to prognosis • Absence or abnormality of fidgety movements at 47–60 weeks’ post-menstrual age is a reliable predictor for later neurological impairment (Prechtl, 1989) • Absence of complexity and variation in movements such as kicking post-term is found to be highly predictive of CP and an indication of the need for early intervention 9
- 10. Goals • Identification and evaluation 10 Infancy Toddler Pre-school 6-12 Adults Aging with CP
- 11. Evaluation • Observing general movements Young human nervous system endogenously, i.e. without being constantly triggered by specific sensory input, generates a variety of motor patterns Contradicts Sherrington 11 Infancy Toddler Pre-school 6-12 Adults Aging with CP
- 12. Evaluation GMs involve the whole body in a variable sequence of arm, leg, neck and trunk movements They wax and wane in intensity, force and speed, and they have a gradual beginning and end 12 Infancy Toddler Pre-school 6-12 Adults Aging with CP
- 13. Evaluation 13 Infancy • Traditionally, it is accepted that the early ontogenetic process goes from cranial to caudal • However, motor system does not follow this rule Toddler Pre-school 6-12 Adults Aging with CP
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- 16. Implications • Early signs of hemiplegia • Early detection of dyskinetic CP
- 17. Implications • Early signs of hemiplegia • Early detection of dyskinetic CP
- 18. Management • No distinct diagnosis of CP • Catch all - “Developmental delay” • Bleck – 7yrs. • Early intervention – maintenance of soft tissue length for appropriate function • Dynamic interactive systems refutes the idea of hierarchical organization 18 Infancy Toddler Pre-school 6-12 Adults Aging with CP
- 19. Management • Child-initiated movement, task specificity, and environmental modification appear promising interventions Morgan 2016 • Parent education and adequate use of assistive technology is appropriate • Adequate energy intake • Assessment of dysphagia • Movement and exploration 19 Infancy Toddler Pre-school 6-12 Adults Aging with CP
- 20. Management • Infants who have poor balance should sit supported during upper limb training in order to concentrate on reaching and prehension play • During the development of the individual the functional repertoire of the developing neural structure must meet the requirements of the organism and its environment 20 Infancy Toddler Pre-school 6-12 Adults Aging with CP (Shepherd, 2013)
- 21. Management • Child-rearing practices • Motor control and learning should not be considered separate events (Willingham, 1992) • Concrete versus abstract practice • Observational learning: imitation and modelling 21 Infancy Toddler Pre-school 6-12 Adults Aging with CP
- 22. Management • Iatrogenic deformity creation – e.g. incorrect over stretching over forefoot 22 Infancy Toddler Pre-school 6-12 Adults Aging with CP Before serial casting After serial casting (Serial casting requires competency and should not be performed without training)
- 23. 23
- 24. • Iatrogenic deformity creation – e.g. incorrect over stretching over forefoot 24 Infancy Toddler Pre-school 6-12 Adults Aging with CP Before serial casting After serial casting (Serial casting requires competency and should not be performed without training)
- 25. Goals • Mobility • Maintain orthopaedic alignment • Strength • Endurance 25 Toddler Infancy Pre-school 6-12 Adults Aging with CP
- 26. Assessment - Gross motor functional classification (GMFCS) - Manual ability classification system (MACS) - Communication function classification system (CFCS) • GMFM-66 26 Toddler Infancy Pre-school 6-12 Adults Aging with CP
- 29. Management • Work on support, balance, propulsion (treadmill training) • Kicking • Balance in sitting and standing (modulation) • Body image and kinesthetic sensation • Muscle and soft tissue length (Passive stretching does not have lasting benefit ) 29 Toddler Infancy Pre-school 6-12 Adults Aging with CP (Ledebt, 2005), (Damiano, 2009) (Wiart and colleagues, 2008) (Raja and Gupta, 2013)
- 30. • Intensive upper-extremity training on bimanual performance • Hippotherapy on muscle symmetry and activities (Anttila and colleagues, 2008) 30 Toddler Infancy Pre-school 6-12 Adults Aging with CP
- 31. Assessment • Spinal Alignment And Range of Motion Measure (SAROMM) • Selective Motor Control (SMC) • Edinburgh Visual Gait Score (EVGS) 31 Pre-school Infancy Toddler 6-12 Adults Aging with CP
- 35. Management • Postural control - organised control through shifting centre of mass (COM) • Positioning devices in children with poor head control • Optimise body alignment for UE functions • Educate caregiver about barriers and facilitators 35 Pre-school Infancy Toddler 6-12 Adults Aging with CP
- 36. Goals • Mobility on various surfaces • Maintain orthopaedic alignment, • Strength, • Endurance, • Balance, • Sitting • Endurance and stability 36 6-12 Infancy Toddler Pre-school Adults Aging with CP
- 37. Assessment • (SAROMM) • Energy Expenditure Index (EEI) • EVGS • GMFM-66 • Functional Mobility Scale (FMS) • Pediatrics Outcomes Data Collection Instrument (PODCI) 37 6-12 Infancy Toddler Pre-school Adults Aging with CP
- 41. Management • Increase motor variety • Optimise fitness • Teach strategies for safety • Increase participation 41 6-12 Infancy Toddler Pre-school Adults Aging with CP
- 42. Goals • Surgery • Post-op rehabilitation programme (intensive 1 year) 42 6-12 Infancy Toddler Pre-school Adults Aging with CP (Raja, 2011)
- 43. Goals • Identification of aging • Secondary complications • Maintain mobility and function for work 43 Adults Infancy Toddler Pre-school 6-12 Aging with CP
- 44. Evaluation • Muscle length • Strength, • Gait/ mobility based on GMFCS • Fitness, pulmonary function, BMI, FMS, BBS • Pain • AT requirement, • Consider requirement for human assistance/ institution 44 Adults Infancy Toddler Pre-school 6-12 Aging with CP
- 45. Management • Physical fitness- all components, • Pain avoidance, • Avoid joint wear out/ fatigue • Maintain optimum body weight 45 Adults Infancy Toddler Pre-school 6-12 Aging with CP
- 46. • Maintenance of orthopedic alignment • Strengthening • Maintenance of body awareness • Exercise for cardiovascular endurance • Prevent learned non-use • Identify barriers and facilitators in participation 46 Adults Infancy Toddler Pre-school 6-12 Aging with CP (Hagberg, 1989) (Taub, 2006) (Brunton, 2013)
- 47. • Pain and early onset DJD • Decreased function • Decreasing mobility and independence • Falls • Assistive devices • Aerobic and anaerobic training 47 Adults Aging with CP Infancy Toddler Pre-school 6-12 (Verschuren, 2007, 2011) (Ostensjø, 2005), (Harvey, 2008) (Bottos, 2007) (Murphy, 2009)
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