Transcript
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Contents Definition
Classification
Impairments & Dysfunctions
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history First recorded in medical literature during 19th
century
Before 19th century
-
William Little indicated that the cause of spasticity andparalysis was due to brain damage during infancy
- CP was also k/a Littles Disease
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Differentiated congenital deformities
Grouped clinical presentations as
- Hemiplegic rigidity
- Paraplegia
- Generalized rigidity
Hammond (1871) athetosis
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Osler (1889) gave the following classification:- Infantile hemiplegia
-
Bilateral Spastic hemiplegia (spastic diplegia)- Spastic paraplegia
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1900 - 2000
Batten (1903) ataxic CP
Phelps ( 1941) grouped all movement disorders
under term dyskinesia that included followingsub categories
- Spasticity- Athetosis
- Overflow/ synkinesia
- Incoordination / ataxia
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Ingram ( 1955) separated hemiplegia, double
hemiplegia and diplegia from diskineticcategories ( dystonia, chorea, athetosis)
Evans et al ( 1987)- Hypertonia
- Hypotonia
- Dyskinesia
- Ataxia
Palisano et al 1
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From 2000
To be classified
- Neurologically ?
- Topographically ?
- Functionally ?
After 150 yrs of discussion.no conclusion
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definition Cerebral Palsy (CP) is defined as a group of disorders
of the development of movement and posture,
causing activity limitation, that are attributed to non-
progressive disturbances that occurred in the
developing fetal or infant brain
Developmental Medicine & Child Neurology 2005
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Classification
Hypertonic
Hypotonic
Dyskinetic
Ataxic
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impairments Neuromuscular
Sensory / Perceptual
Musculoskeletal
Respiratory
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hypertonic
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3. Grading agonist/antagonist
.Abnormal ability to grade between cocontractionand reciprocal inhibition
Can a quadriplegic have a hypotonic trunk???
4. Limited synergies
. Timing and ordering of basic synergies altered
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Sensory / Perceptual systems
1. Vision
o Primary impairments
- Strabismus
- Errors of refraction and accommodation
o Secondary impairments
- Upward gaze
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HIP
Subluxed/dislocated hip
- Retention of shape of acetabulum and femur
- Imbalance of muscle activity
KNEE
Flexion contracture Knee hyperextension
ANKLE & FOOT
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LONG BONES
Decreased bone density
Increased incidence of fractures
Small stature
MUSCLE DEVELOPMENT
Altered distribution of fast and slow twitch motor
units
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Respiratory system
Shallow respiration with an immobile ribcage
Incoordination between breathing, speech &
movement
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dysfunctions
2020
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quadriplegia Head , Neck, Tongue & Eyes
Asymmetric extension of head , neck & trunk
Upward visual gaze, tongue retraction & jaw extension
Loss of ROM in the upper cervical spine flexion
Difficult chin tuck
Graded control of jaw absent
Inability to control C-spine in any other position thanextension
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Thoracic spine, ribcage & UE
Problem in pushing against a surface with UE whilelifting the head up
Lower trunk Easiest synergy
- Lumbar extension with hip flexion
- Sagittal plane flexion ( rectus abdominis) Switch their postures based on position
Unstable trunk
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How are the children with quadriplegia similar tohypotonics wrt trunk???
Lack of activity in postural muscles
Lack thoracic extension control
Lack of abdominal use
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Pelvic girdle & lower extremities
Sustained overactivity of hip flexors, adductorsand IR
- Narrow BOS
- Limited mobility- Tightness & contracture of overactive muscles
- Weakness & inactivity of antagonists
- Early hip dislocation
- Malformation of hip jt
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diplegia
Head , Neck, Tongue & Eyes Able to initiate, maintain and terminate muscle
activity
Coordinate functional movement synergies Effective use of sensory perceptual information
but
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Thoracic spine, ribcage & UE
Able to use UE weight bearing like normals
with a difference???
No lower thoracic extension
- Difficulty in overhead reaching
- Erect sitting
- Lower trunk wt shifting
Ribcage elevation, lower rib flaring
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Upper body substitutes for lower body
- Arms gets stiffer
- Thoracic spine increases in flexion
- Pectorals & RA overwork to pull the COM
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Lower trunk
Common patterns
Upper lumbar extension
Specific wt shifting strategy
No coordination between upper & lower trunk tocontrol COM
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Pelvic girdle & lower extremities
Limited synergies
Poor grading with excessive co contraction
Poor ability to terminate
Abnormal timing, W sitting is common
Gets into sitting and standing earlier than a
quadriplegic
Good or Bad???
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hemiplegia
Head , Neck, Tongue & Eyes
Subtle asymmetrical head position
May have hemianopsia
Difficulty in perception of both tactile and
propriceptive info between two halves
Neck extension and lateral flexion
Affected visual scanning & reduced mobility of
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Thoracic spine, ribcage & UE
Increased muscle contractions
Typical hemiplegic posture
Does the unaffected arm suffer???
Sensory perceptual impairments
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Lower trunk
Asymmetry hemiplegic side shortened, pelvis
elevated & pulled back
Extreme extension in lumbar spine.is it same as
seen in diplegics???
Sitting postures
Scooting
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Pelvic girdle & lower extremities
Asymmetry seen in 2 planes
Functional or true leg length discrepancy may be
present
Different standing postures
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hypotonic
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Decreased segmental moto-neuron pool excitability
Shumway cook, 1985
Other children which may exhibit many of the samecharacteristics :
Downs syndrome
Hydrocephalus
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Neuromuscular System
1. Reflexes / Tone
. May be increased or decreased
2. Muscle contraction
. Phasic burst of movement
. Problem in initiating, sustaining andterminating movement
3 3
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3. Grading agonist/antagonist
. Cannot generate cocontraction
4. Synergies
. limited and predictable
-. Difficulty in using postural muscles to initiate &sustain antigravity work
-. Substitute by using more superficial muscles
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Sensory / Perceptual systems
1. Vision
o. Primary impairments
-. Strabismus
-. Errors of refraction and accommodation
o. Secondary impairments
- Use of eyes for postural control assistance rather
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Do not use information normally from
proprioceptive and tactile systems
Musculoskeletal system
1. Bony changes in spine and rib cage
2. Changes in other bones and joints ( shoulderand hip)
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Tightness in the muscle groups that remain in
shortened position
- Superficial & two joint muscles
-
In response to childs constant, unchangingposition
Uses skeletal stability, closed packed positions tosubstitute for muscular control and strength
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Respiratory system Shallow respiration with an immobile ribcage
Incoordination between breathing, speech &movement
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dysfunctions
Head , Neck, Tongue & Eyes
On attempting head extension, it falls forward or restson the occiput
Both have different implications
Shoulder elevation is a substitute for cervical control
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1. Holding the head up
-. Lack of development of active capital flexion on
an extended C-spine
-. Over lengthening of cervical flexors
-. A shift in the position of laryngeal system
-. Use of upward gaze to help lift the head
-. Passive opening of the jaw with tongue retraction
& overstretching of the facial muscles
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2. Falling of head
- Lack of development of active chin tuck
- Over lengthening of cervical & upper thoracic
extensors
- Partial obstruction of airway
- Little use of vision
- Passive opening of jaw ( drooling)
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Thoracic spine, ribcage & UE
Movement is started with a wide base inextremities & more contact of trunk in both
supine and prone
Unable to develop thoracic extension & graded
shoulder mobility Arms substitute for trunk control, not for
exploration
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Lower trunk
Two common postures :
1. Rounding of thoracic spine into lumbar spine
-. Unstable open packed position
-. Requires much more physical effort for stability
2. Sharp upper lumbar extension
-. Seen in prone or standing
-. Stability at the expense of not moving the lowertrunk
-
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Which child assumes which position???
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Pelvic girdle & lower extremities
Serve function of stability with wide BOS
BOS is so wide that it mechanically blocks
movement from other parts of the body
Poor ability to change positions
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dyskinetic
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athetosis
Constant succesion of slow, writhing, involuntary
movements of
- Flexion / extension
- Pronation / supination
Of fingers and hands and sometimes of toes and feet
Dorland, 1994
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chorea
Irregular, spasmodic, involuntary movements ofthe limbs or facial muscles
A ceaseless occurrence of a wide variety of rapid,highly complex, jerky movements that appear tobe well coordinated but are performed
involuntarily
Dorland, 1994
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dystonia
A state of abnormal tonicity in any of the tissues
Stedman, 1995
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impairments
Neuromuscular System
1. Reflexes / Tone
Likely to show depressed DTRs
2.Muscle contraction Antagonist is overactive
Differing problems in initiating, sustaining and
terminating movement
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3. Grading agonist/antagonist
Alternations between flexion and extension in
movement efforts in posture
4. Limited synergies
Same as seen in subjects with hypotonics
Nashner, 1983
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Sensory / Perceptual systems
1. Vision
o. Primary impairments
-. Nystagmus may be present
o. Secondary impairments
-. Able to control eye movements forcommunication better than other CPs
-
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2. Less impaired kinesthetic and vestibular senses
3. Tactile hyper responsiveness may be present
. Musculoskeletal system
1. Develop fewer contractures
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2. Excessive mobility can result in
Instability of the jaw with TMJ joint deformitypossible
Overlengthening of infrahyoid muscles
Instability of cervical spine Instability of shoulder joint (mostly inferior)
Hyperextension at the elbow
Hyperextension of the IP joints of fingers
Overlengthening of
- Ant hip capsule & ligaments
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Secondary impairments
Hip dislocation Narrowing of the spinal cord
Spondylosis , radiculomyelopathy
Severely increased kyphosis
Scoliosis
Shift of the hyoid bone & laryngeal system
Develop adequate strength in the muscles usedfrequently and repetitively
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Respiratory system
Bursts of phonatory activity
Incoordination between breathing, speech &
movement
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dysfunctions The clinical signs are generally seen after firstyear of life :
- Bursts of movement
- Extraneous movement- Alternations between flexion/ extension
Most of the children stay hypotonic for manymonths past first or second year of life
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Head , Neck, Tongue & Eyes
asymmetric extension of head & neck
Once movement begins, quick bursts of extension
in all positions
(Upward visual gaze, jaw extension & tongue
retraction)
Tongue protrusion ??
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Forceful cervical flexion is sometimes used to
- Holding head to counterbalance strong extension
- Develop for certain postures and movements like To move prone from W-sitting
To stabilise vision
Speaking
To stand
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Thoracic spine, ribcage & UE
(Problem in pushing against a surface with UEwhile lifting the head up)
In sitting & standing, the already flexed thoracicspine becomes a counterbalance for the forcefulextension of the cervical & lumbar extension
Because of UE attitude, wt bearing is seen on thedorsum of hand
Head is used to initiate limb position
Mobility of arm movements comes from mobilityof scapula over ribcage
(restricted movements, poorly aligned scapula)
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On reaching,
Wrist flexion
MP & proximal IP hyperextension
No use of intrinsic muscles
No palmar arches
May use head and trunk flexion and extension to
control finger movements
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Most efficient way of movement scooting in
supine, bunny hopping in sitting
Lower trunk Lumbar & cervical extension Asymmetry of lumbar spine Shortening of lumbar extensors and lengthening
of abdominals Lower trunk cannot hold the COM
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Pelvic girdle & lower extremities
Legs anchor trunk in moving from supine to proneand vice versa by providing a wide, stable BOS or themovement
Consistent, weight bearing position of LE decreaseextraneous, non functional movements
No pattern of hip flexion, adduction and IR seen inthese children
The starting position is hip flexion, abduction & ERwith knees in some degrees of flexion and feet ineversion and dorsiflexion
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Posture in W sitting is different from that of
spastic CP
Gait pattern :
Arms clasped or crossed in front of them toprevent losing balance forward
Wide BOS
Small degrees of hand, eye or jaw movements toshift weight just enough that a foot can move
forward slightly Lack of reciprocity of movement
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ataxic
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Ataxia
failure of muscular coordination, irregularity of
muscle action
Lack of coordination with tremor and dysmetria
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impairments
Neuromuscular System
1. Reflexes / Tone
Depressed or normals DTRs
2.Muscle contraction
Agonist activity is reduced in force
Problems in initiating, sustaining and terminatingmovement
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3. Grading agonist/antagonist
Normal ability to use patterns of cocontraction
and reciprocal inhibition
Abnormal timing & smooth gradation
Hypermetria
4. Synergies
Use a variety of synergies
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Sensory / Perceptual systems
1. Vision
o. Primary impairments
-. Nystagmus may be present
-. Lack smooth visual pursuits
o. Secondary impairments
-. Excessive visual fixation
o. The visual system is their best system in learningof postural control and movement gradation
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Deficits are seen in central sensory feedback
mechanism Alarming behaviour
Auditory processing delays
Musculoskeletal system
Least difficulties
Some limb muscles may become shorten
Adequate strength necessary for functional tasks
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Respiratory system
Incoordination between breathing, speech &movement
Marked delay in the onset of voicing with eachattempt to speak
Dysarthric speech
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dysfunctions
The clinical signs are generally seen after firstyear of life :
- Tremor
-
Dysmetria- Severe sensory perceptual problems
Most of the children stay hypotonic for manymonths past first year of life
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Head , Neck, Tongue & Eyes
Inconsistent responses in terms of grading force
during activity
Usually fixate visually before moving
Excessive drooling, mouthing, biting & tearing
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Thoracic spine, ribcage & UE
Similar to that seen in hypotonic children exceptthat they are active
Tremors and overshooting may be seen whenthey approach any target
Problems using sensory information to guide andcorrect movements
Rib cage elevation, tight intercostals, use ofaccessory muscles, poor speech
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Lower trunk
Similar to the children with hypotonia
Some children keep the trunk in rigid extension
Keep upper body forward to avoid posterior
weight shift
Avoid moving out of midline posture
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Pelvic girdle & lower extremities
Two common postures are seen while standing
1. Hips flexed, abducted, ER, knees flexed, often
pronated feet. Seen in children with more hypotonia
. Two compensations are seen that assures them of
their stability-. A wide BOS
-. Lowered COG
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2. Stiffen lower limbs using voluntary cocontraction
To prevent movement To dampen tremors
Although ambulatory skills are limited but this posture
allows for upright skills
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Thank you !
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