UPPER LIMB AND HAND PATTERNS CLASSIFICATIONS IN …

6/19/2019

1

Rachel Bard-Pondarré, OT

Emmanuelle Chaléat-Valayer, MD PhD

UPPER LIMB AND HAND PATTERNS CLASSIFICATIONS IN CEREBRAL PALSY:

DO THEY MAKE SENSE ONLY FOR RESEARCHOR CAN THEY PROMOTE COMMUNICATION WITH

PATIENTS ALSO IN CLINICAL PRACTICE?

1

REHABILITATION MEDICINE

Is not only taking care of …

2

3

4

6/19/2019

2

LINK BETWEEN DEFICIENCES AND CAPACITIES ?• Not well-known !

• Desloovere K, Molenaers G. Gait and posture Nov 2005. Do dynamic and staticclinical measurements correlate with gait analysis parameters in children with CP ?

• Feys H. et al. EJPN 2010. Relation between neuroradiological findings and upper limb function in hemiplegic cerebral palsy.

• Systematic review 2019. Correlations between lower limb bone morphology and function, activities and participation in individuals with ambulant Cerebral Palsy.

• there was low to moderate level of evidence of low to moderate correlationbetween bone morphology and specific gait parameters…

• More research is needed !

5

IMPROVING PARTICIPATION IN CP ?• NICE guidelines 2019 about Cerebral Palsy in adults

• Interventions that improve physical function and participation :

• Low or very low quality of evidence for most results !

• Strengthening/training programs for gross motor function

• Task oriented upper limb training programmes

• Orthopaedic surgery

• Suggestions of the NICE committee

• Physical activities would help in maintaining general fitness, ROM, healthy weight, muscle strenghtand flexibility of joints

• Access to mobility aids, including wheelchais, is fundamental to participation in work, social and leisure activities

• Managing muskuloskeletal pain or joint problems is important and patients should be referred to a specialist surgeon

6

SO WHY FOCUSING ON STRUCTURAL AND ANATOMICAL ASPECTS…?

7

IN CHILDREN WITH CP Growth Prevention of neuro-orthopaedic complications …that may lead to pain in adulthood and potentially impact participation and quality of adult life

8

6/19/2019

3

BODY FUNCTION AND STRUCTUREIS SOMETIMES AT THE HEART OF FAMILIES’ CONCERN

• Parents may identify body function goals for treatment if they clearly know that the treatment offered will act on these aspects.

• Nguyen et al (BMC Pediatrics 2018) : Development of an inventory of goals using the ICF in a population of non-ambulatory children and adolescents with CP treated with botulinum toxin A.

• >75% of parents wanted BoNT-A treatment to help manage body structure and function, specifically reduce muscle tone

• But it may also be that the objectives expressed by the parents are directly related to the pathological pattern

• Aesthetic aspects, hygienic problems …

9

IF WE WORK CLIENT-CENTERED…

With goal-oriented therapies :

Identifying uncomfortable postures and pathological motor patterns

10

RODDA AND GRAHAM CLASSIFICATION

11

CLASSIFICATIONS• Manual Ability Classification System

• Eliasson A.C et al. Dev Med Child Neur 2006

12

6/19/2019

4

CLASSIFICATIONS• Zancolli classification for wrist anf fingers flexors and extensors

• Zancolli E.A et al. Surg. Clin. North Am, 1981

• Matev classification for thumb positions and muscles involvement

13

OBJECTIVE• To describe Upper Limb patterns and Hand types in Cerebral Palsy

• Including potential muscles’ involvement to orient treatment

• Useful in clinical practice• to identify predominant patterns of deformity for example in patients with dyskinesia• to facilitate communication between clinicians • to follow-up patients.

• Useful in research • to identify homogenous subgroups of patients with CP for investigations • to evaluate the effects of treatments such as botulinum toxin injection or surgery.

14

DEVELOPMENT OF CLASSIFICATIONS• Initial development :

• based on the description of UL and hand patterns from 100 films of patients with cerebral palsy (Bard 2010).

• separate classifications were developed as we found no correlations between upper limb and hand patterns

• Preliminary study of validity• 45 short films of patients with CP• Classified by 8 examiners

Refining the wordings and the distinctions between the different UL and Hand patterns Important to state the conditions of examination (rest, activity…)

15

UPPER LIMB PATTERNSThree main patterns

different subtypes

16

6/19/2019

5

ELBOW FLEXION ELBOW EXTENSION (+/- 20°)

TYPE I : no external rotation TYPE II : external rotation TYPE III

Elbow flexor pattern Candelabra pattern Elbow extension patternType I aNeutral shoulder rotation

Withoutextension

Type I bInternal shoulder rotationWithout

extension

Type I cShoulder

extension and internal rotation

Type II a ForearmPronation

Type II b Forearm Neutral

Type II cForearm

Supination

Type III aShoulderflexion

Type III bShoulderextension

ABDuction very common ABD / ADD variable

Type I aHypertonia Brachialis

Biceps brachii Brachioradialis, Pronator teres± Deltoidus

Type I bHypertonia

Pectoralis majorSubscapularisTeres majorBrachialis

Biceps brachiiBrachioradialis± Pronator teres

Type I c Hypertonia

Deltoidus posteriorTeres major

Latissimus dorsiBiceps brachiiTriceps brachiiPronator teres

Type II a HypertoniaDeltoidus

± Pectoralis major

Teres minorInfraspinatus

Biceps brachiiBrachialis

Pronator teres

Type II b HypertoniaDeltoidus

± Pectoralis major


Biceps brachiiBrachioradialis

Type II cHypertoniaDeltoidus

± Pectoralis major


Biceps brachii

Type III aHypertonia

Deltoidus anterior± Deltoidus medialis

Pectoralis majorTriceps brachiiPronator teres

Type III bHypertonia

Deltoidus posterior±- Deltoidus medialis± Latissimus Dorsi

Triceps brachiiPronator teres

17

ELBOW FLEXION ELBOW EXTENSION (+/- 20°)

TYPE I : no external rotation TYPE II : external rotation TYPE III

Elbow flexor pattern Candelabra pattern Elbow extension patternType I aNeutral shoulder rotation

Withoutextension

Type I bInternal shoulder rotationWithout

extension

Type I cShoulder

extension and internal rotation

Type II a ForearmPronation

Type II b Forearm Neutral

Type II cForearm

Supination



ABDuction very common ABD / ADD variable

Type I aHypertonia Brachialis

Biceps brachii Brachioradialis, Pronator teres± Deltoidus

Type I bHypertonia

Pectoralis majorSubscapularisTeres majorBrachialis

Biceps brachiiBrachioradialis± Pronator teres

Type I c Hypertonia

Deltoidus posteriorTeres major

Latissimus dorsiBiceps brachiiTriceps brachiiPronator teres

Type II a HypertoniaDeltoidus

± Pectoralis major


Biceps brachiiBrachialis

Pronator teres

Type II b HypertoniaDeltoidus

± Pectoralis major


Biceps brachiiBrachioradialis

Type II cHypertoniaDeltoidus

± Pectoralis major


Biceps brachii

Type III aHypertonia

Deltoidus anterior± Deltoidus medialis

Pectoralis majorTriceps brachiiPronator teres

Type III bHypertonia

Deltoidus posterior±- Deltoidus medialis± Latissimus Dorsi

Triceps brachiiPronator teres

Hands ?

18

Type I a• Very frequent in hemiplegia (90%)

• Little proximal hypertonia but enough to disrupt the balance of

the upper limb when walking Fixed shoulder Little range of motion in the elbow

Stays flexed

Neutral rotation Or little passive internal rotation if

the shoulder is abducted

19

Type I b• Mainly in severe deficiencies

• 75% quadriplegia• 25% hemiplegia

• Important proximal hypertonia Associated most often with a

pronated forearm Or supinated to some extent in

dyskinesia

20

6/19/2019

6

Type I c• The “bowls player” pattern

• Shoulder extension and internal rotation

• Typical dyskinetic pattern• Muscular hypertrophia

• Often associated with extreme hand positions

21

UL PATTERNS AND BIMANUAL FUNCTION• Type Ia and type Ib

• The two hands are close to each other• Not too pejorative for bimanual function

• Type Ic• It's the back of the hand that faces the other hand

• Difficult interactions between the two hands

• Types II• Keep hands away from each other

• Difficult interactions between the two hands

22

Type II• Typical pattern in quadriplegia• Mainly with poor volunteer motor activity• Severe hypertonia in external rotators and

elbow flexors• Specific role of the biceps whose long

head is stretched by external rotation

Type II aPronation

Type II bNeutralposition

Type II cSupination

23

Type III• Dyskinetic pattern

• with clear elbow extension• Often associated with internal rotation and

pronation



24

6/19/2019

7

TYPE III « INDICATING » UPPER LIMB

• Sometimes with some abduction

• And more rarely with adduction

• In dyskinesia, can be alternately observed with type II

25

HAND PATTERNSTwo main patterns characterized by the wrist position

different subtypes

26

WRIST ?

WRIST FLEXED… FINGERS ?

FINGER EXTENDED

SIMPLE FLEX SIMPLE FLEX PLUS

FINGER FLEXED

TOTAL FLEX TOTAL FLEX PLUS

WIRST EXTENDED… FINGERS ?

MCP FLEXED

INTRINSIC PUNCHING

MCP AND PIP FLEXED

SUPERFICIALIS PUNCHING

MCP, PIP and DIP FLEXED

PROFUNDUS PUNCHING

27

SIMPLE FLEX HAND• The « wrist collapse » may by only passive

• For example when associated with TYPE I Upper limbs

• Or may be caused by hypertonia in wrist flexors(+/- fingers flexors)

• Compensatory hyperextension of MCP joints may be observed while approaching objects

• Generally associated with thumb adduction

28

6/19/2019

8

TOTAL FLEX HAND• Flexion of wrist, fingers and thumb….

• Hypertonia +/- contractures of all flexors• Often associated with ulnar deviation

• FCU / FDS / +/- ECU

• When spastic, this kinf of hand often has no function

• But it may be functional in dyskinetic context• Where active extension of MCP joints may be seen

when trying to use the hand and open it• « spider hand »

29

SIMPLE FLEX + AND TOTAL FLEX + HANDS• These hands are complex

• Primary deficiencies, Secondary contractures and lesions, Tertiary phenomenons

• The + indicates that the Simple Flex or the Total Flex hand are associated withcomplications as :

• Swan neck fingers

• Dinosaur hand

30

PUNCHING HANDS

Intrinsic

Mind the thumb hypertonia, as this may be the only capacity for holding objects

Superficialis Profundus

31

SUPERFICIALIS OR PROFUNDUS ?• Is the Flexor Digitorum Profundus implied …?

• Have a look on the last phalanges… !

• These Punching patterns may lead to complications as :

• hyperpressure (white phalanges)

• skin lesions,

• ingrown nails,

• ...

32

6/19/2019

9

These classifications should be used to describe one pattern at one time

UPPER LIMB AND HAND PATTERNS MAY BE HIGHLY VARIABLE…

DEPENDING ON THE CONDITIONS OF OBSERVATION

While walkingAt rest

While moving the wheelchair

During controlateral

activity

While trying to catch an

object…

While running

33

34

LET US TRAIN !

35



UPPER LIMB AND HAND PATTERNS CLASSIFICATION IN CEREBRAL PALSY:

TRAINING TIME

36

6/19/2019

10

Right UL Pattern ?

37

Left UL Pattern ?Left Hand type ?

38

Left UL Pattern ? Left Hand type ?

39

Right UL Pattern ?

40

6/19/2019

11

Left UL Pattern ?

41

Left UL Pattern ?

42

Left UL Pattern ?

43

Both UL Pattern ?

44

6/19/2019

12

Left UL Pattern ?

45

Left Hand type ?

46

Right UL Pattern ?

47

Left UL Pattern ?

48

6/19/2019

13

Right UL Pattern ?

49

Left UL Pattern ?

50

Right UL Pattern ? Hand type ?

51

Left Hand type ?

52

6/19/2019

14

Left UL Pattern ? Hand type ?

53


54


55

Left UL Pattern ?

56

6/19/2019

15

Left Hand type ?

57

Right UL Pattern ?

58

Right UL Pattern ?

59

Right UL Pattern ?

60

6/19/2019

16

Left UL Pattern ?

61


62

Left Hand type ?

63


64

6/19/2019

17

Right UL Pattern ?

65


66


67


68

6/19/2019

18

Left Hand type ?

69



UPPER LIMB AND HAND PATTERNS CLASSIFICATION IN CEREBRAL PALSY:

HOW ARE THEY USED IN CLINICAL PRACTICE ?

70

1. Identification of patterns

71

2. Assistance in the emergence of objectives

…from a “menu” depending on the type of pattern

72

6/19/2019

19

3. Communication

…simplified language during consultations between therapists and doctors

73

4. Treatment decision

…from the identification of muscles involved in the pathological pattern

74

Some patterns are directly associated withpotential functional problems …

HOW CAN IT HELP TO DETERMINE OBJECTIVES ?

75

Type I• Is the person embarrassed by an aesthetic problem?• Is the pattern hindering balance while walking or other moving activities (skiing…)?

Type II• Is dressing difficult (especially for putting on sleeves)?• Is the positioning of the person difficult (wheelchair…)?• Does the person feel pain or discomfort in shoulders ?• Is there any problems of interaction between both hands for bimanual activities ?• Is the person embarrassed because of touching people involuntary ?• Is moving difficult (especially to get through the doors) ?

Type III• Is the person embarrassed by an aesthetic problem?• Is the person embarrassed because of touching people involuntary ?• Is dressing difficult (especially for putting on the 2nd sleeve or for putting of a shirt)?• Is moving difficult (especially to get through the doors) ?• Is it difficult to reach for objects just in front on the person ?

76

6/19/2019

20

Simple Flex• Is the person embarrassed by an aesthetic problem?• Is the grasping stable enough ?• Is it difficult to push the hand in the sleeve while dressing ?

Total Flex• Are there hygiene problems (maceration, nail clipping, skin lesions ...)?• Is it difficult to push the hand in the sleeve while dressing ?• Is is difficult to introduce an object in the hand ? • Is it difficult to release ?

Punching Hand• Are there hygiene problems (maceration, nail clipping, skin lesions ...)?• Is is difficult to introduce an object in the hand ? • Is it difficult to release ?

77

THANK YOU FOR YOUR ATTENTION

78

UPPER LIMB AND HAND PATTERNS CLASSIFICATIONS IN …

Documents