AlWasl Hospital - Rehabilitation Section Rehabilitation Approach of Children with Cerebral Palsy Presented by Amal AlShamlan Head of Rehabilitation Section AlWasl Hospital Dubai Health Authority
Transcript
Slide 1
AlWasl Hospital - Rehabilitation Section Rehabilitation
Approach of Children with Cerebral Palsy Presented by Amal
AlShamlan Head of Rehabilitation Section AlWasl Hospital Dubai
Health Authority
Slide 2
outline Definitions Model of care Classification Outcome
measures Intervention strategies & philosophies AlWasl Hospital
- Rehabilitation Section
Slide 3
What is Cerebral Palsy? It is a group of conditions results in
permanent disorders of movement & posture due to damage in
fetal or infant brain Features: 1.epilepsy. 2. involuntary movement
3. abnormal sensation & cognition 4- abnormal vision, hearing
& speech. 5- mental retardation. 6. abnormal movement /
behaviour. AlWasl Hospital - Rehabilitation Section
Slide 4
What is Rehabilitation ? Rehabilitation is combined and
coordinated use of medical, therapeutic, social, educational and
vocational measures for training or retraining the individual to
highest possible level of function Holistic Approach QOL AlWasl
Hospital - Rehabilitation Section
Slide 5
Aims Improve functional status Prevent secondary impairments
& functional limitations Efficiently use resources when there
is reasonable prognosis for improvement Facilitate integration into
the community AlWasl Hospital - Rehabilitation Section
Slide 6
Model of care Functional & social vs disease-based Growth
& development Child-focused & family centered. AlWasl
Hospital - Rehabilitation Section
Slide 7
International Classification of Functioning, disability and
Health (ICF) condition Body Function & structure
ActivitiesParticipation Environmental FactorsPersonal Factors World
Health Organization, 2001
Slide 8
AlWasl Hospital - Rehabilitation Section International
Classification of Functioning, disability and Health (ICF) C.P.
Impairments Muscle weakness Muscle hypoextensibility Poor balance
Poor endurance Activity Limitation Walking on slopes Walking in
crowds Climbing on equipment Participation Walking to class room
Play during recess P.E class Environmental Factors Teachers concern
Distance to play ground Children crowded in equipment Personal
Factors Childs attitude toward: being transported Adult
assistance
Slide 9
Multidisciplinary Team AlWasl Hospital - Rehabilitation Section
client Social workerpsychologistPhysicianOrthotists Speech
/language therapists Occupational Therapists Physiotherapists
Slide 10
referralscreeningInitiate therapy Cross referral - therapy
Interdisciplinary clinic Discharge / long term follow up Care
Pathway AlWasl Hospital - Rehabilitation Section
Slide 11
Interdisciplinary Approach Working for common goals Pooling of
expertise Opportunity for personal growth & development Forum
for problem solving AlWasl Hospital - Rehabilitation Section
Slide 12
Classification of CP Etiology Body involvement Movement
disorder AlWasl Hospital - Rehabilitation Section impairment
Slide 13
GMFCS for children with CP GMFCSDescription Level IWalks
without restrictions; limitation in more advanced gross motor
skills Level IIWalks without assistive devices; limitations are
walking outdoors and in the community Level IIIWalks with assistive
mobility devices; limitations are walking outdoors and in the
community Level IVSelf-mobility with limitations; children are
transported or use powered mobility outdoors or in the community
Level VSelf-mobility is severely limited even with the use of
assistive technology AlWasl Hospital - Rehabilitation Section
Slide 14
Outcome measures Validate progress Provides accountability to
child/family/third-party payers for intervention used Aides in plan
of care Provides normative data to obtain developmental levels e.g.
age equivalent, standard score AlWasl Hospital - Rehabilitation
Section
Assess postural control & alignment needed for age
appropriate functional activities in early infancy 34 wks
gestational age to 4 mths post full term delivery date Assess
postural control & alignment needed for age appropriate
functional activities in early infancy 34 wks gestational age to 4
mths post full term delivery date Assess gross motor function
including maturation of skills and postural alignment of of infants
from birth to 18 mths of age Specifically designed for CP,
developed to measure change over time. Consists of activities in 5
dimensions: lying & rolling, sitting, creeping & kneeling,
standing & walking, running & jumping. Assessment of motor
tone & oromotor function for preterm babies More than 33 wks
corrected age 1 mths post term Assessment of motor tone &
oromotor function for preterm babies More than 33 wks corrected age
1 mths post term Used to evaluate quality of UE functions in 4
domains: dissociated movement, grasping, protective extension &
weight bearing Assesses normative performance of gross/fine motor
function for children from birth to 72 months of age
Slide 17
communication rating scale skill% Pointing0 10 Gestures11- 20
Gestures with speech sounds 21- 30 Speech sounds31- 40 Single
words41 50 Phrases51 60 Short sentences61 70 Complete sentences71
80 Complex sentences81 90 paragraphes91 - 100 AlWasl Hospital -
Rehabilitation Section
Slide 18
Spasticity Spasticity is one of the most common UMN lesion
problem seen in children with CP resulting in postural control
& movement disorder thereby limitting, delaying or arresting
the sensory motor development.(also other areas like communication,
cognition, social, perception etc). AlWasl Hospital -
Rehabilitation Section
Slide 19
What is spasticity? Spasticity is a motor disorder
characterized by a velocity dependent increase in stretch
reflexes(muscle tone) with exaggerated tendon jerks resulting from
hyper excitability of the stretch reflex as one component of the
UMN syndrome (Lance, 1980). Spasticity is a movement disorder
affecting both the neural & non-neural characteristics of
postural tone and can be described by the positive & negative
UMN symptoms (D. Burke, 1988).
Slide 20
Neural components of UMN symptoms Positive symptoms Spasticity.
Spasms (flexor & extensor). Exaggerated tendon reflexes.
Clonus. Babinski response. Negative symptoms Weakness. Loss of
dexterity. Fatigability. AlWasl Hospital - Rehabilitation
Section
Slide 21
Non-neural component of UMN symptoms Altered muscle length
(elasticity): muscle fibres shorten (hypoextensible). Altered
muscle structure (viscosity): filaments become sticky affecting
muscle glide(stiffness). Abnormal co- contraction (reciprocal
innervation) : due to bio- mechanical effects of abnormal position.
(too much stability & not enough mobility). Changes in
visco-elastic properties leads to stiffness, tightness &
contracture. AlWasl Hospital - Rehabilitation Section
Slide 22
Normal postural tone Normal patterns of movement Success in
normal patterns of movement repetitions Normal functional Skills
achievements
Slide 23
AlWasl Hospital - Rehabilitation Section CP? Abnormal postural
tone Abnormal patterns of movement Success in abnormal patterns of
movement/ stereotyped repetition Deformity/ less functional skills
acheivments
Slide 24
AlWasl Hospital - Rehabilitation Section Intervention
Philosophies & strategies Evidence based? There is no evidence
that any one treatment method is superior to another. Therapists
select from the variety of treatments available those that best
meet the childs and familys need.
Slide 25
Analyzing Analysing the postural tone & patterns of
movement. What the child can do? How? /cant do ? why? Choosing
appropriate intervention/frequency depends on: Age ( infant,
toddlers, preschool, adolescent etc ) Distribution of postural tone
( diplegic, hemiplegic, quadriplegic etc) Quality of postural tone
( mild, moderate or severe ). Associated problems.( vision,
hearing, cognitive, seizure, SPD etc) AlWasl Hospital -
Rehabilitation Section
Slide 26
Early intervention Studies focused on child and family reported
favorable outcomes. The analysis also suggested that parent
participation might have a greater impact on childs outcomes for
children younger than 3 yrs.
Slide 27
AlWasl Hospital - Rehabilitation Section Neonatal physiotherapy
is an advanced practice subspecialty area of paediatric
physiotherapy and involves a highly complex set of skills in
observation, examination and intervention procedures for the
extremely fragile NICU population. Main objective to identify
developmental delay in 1 st year of life Early intervention can
change abnormal movement pattern in mild to moderate cerebral palsy
Those whom deemed to be delay remain delay if no intervention
started. Neonatal Developmental screening
Slide 28
AlWasl Hospital - Rehabilitation Section All high risk preterm
infants with meeting criteria: 1. Gestation 32 weeks and below 2.
Birth weight < 1.5 kg 3. IVH GR.3&4, PVL 4. Chronic lung
disease or O2 dependency 5. Ventilated for RSD
Relative comparison of sensitivity and specificity of unit
assessment and BUSS in this audit AlWasl Hospital - Rehabilitation
Section
Slide 31
Relative comparison of sensitivity and specificity of unit
assessment and BUSS in this audit AlWasl Hospital - Rehabilitation
Section
Slide 32
Intervention Philosophies & strategies Neurodevelopmental
Therapy ( NDT) Moving through normal movement patterns to
experience normal movement Major components : reflex-inhibiting
posture, inhibition of abnormal reflexes, normalization of muscle
tone, and adherence to normal developmental sequence of motor
progression AlWasl Hospital - Rehabilitation Section
Slide 33
NDT Inhibiting abnormal movement patterns. Facilitating normal
movement patterns. No strong evidence that supports the
effectiveness of NDT for children with CP with respect to
normalizing muscle tone, increasing rate of attaining motor skills,
and improving functional motor skills Butler C, Darrah J: Effects
of Neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM
evidence report. Dev Med Child Neurol 2001 ; 43: 778 - 790 AlWasl
Hospital - Rehabilitation Section
Slide 34
Slide 35
Intervention Philosophies & strategies Sensory Integration
Therapy Principle: a neurobiological process organizes sensation
from ones own body and from environment and makes it possible to
use the body effectively within environment Emphasis on importance
of three body centered sensory systems : tactile, proprioceptive
& vestibular AlWasl Hospital - Rehabilitation Section
Slide 36
SI Therapy AlWasl Hospital - Rehabilitation Section
Slide 37
Intervention Philosophies & strategies Constrained -
Induced Movement Therapy Constraining non-affected arm to encourage
performance of therapeutic task with the affected arm, which
children normally tend to disregard. Systematic review has found
the effectiveness of CIMT for children with hemiplegic CP. AlWasl
Hospital - Rehabilitation Section
Slide 38
Serial casting Serial casting may serve to reduce spasticity in
muscles by decreasing the strength of abnormally strong tonic foot
reflexes.(Bertoli 1996). Serial casting in the CP population has
been shown to improve ROM.( Brouwer 2000) Casting provides
stability and prolonged stretch of a muscle which is immobilized in
a lengthened position(Mosley 1997). At least 6 hrs of prolonged
stretch is needed for effectiveness(Tardieu 1987).
Slide 39
AlWasl Hospital - Rehabilitation Section Botox + serial casting
Botox reduces spasticity and improves ambulatory status.(Flett
1999) When used in combination with serial casting it has shown to
help maintain and improve muscle length and passive ROM.(Kay 2004)
Without conservative interventions such as serial casting, (with
& without botox injection) more expensive procedures may be
necessary. (Flett 1999)
Slide 40
Intervention Philosophies & strategies Body Weight
Supported Treadmill Training AlWasl Hospital - Rehabilitation
Section Uses theories of motor learning & importance of early
task specific training Theory : activate spinal & supraspinal
pattern generators for gait
Slide 41
Intervention Philosophies & strategies Strengthening
Progressive resisted exercise improves muscle performance &
functional outcomes in CP children Research had supported
effectiveness on increasing force production in CP Dodd et.al.
systematic review of strengthening for individuals with cerebral
palsy. Arch Phys Med Reh,83:1157-1164, 2002 AlWasl Hospital -
Rehabilitation Section
Slide 42
Intervention Philosophies & strategies NMES Multiple
studies have demonstrated the effectiveness of NMES, Reduce
spasticity. Increase ROM & strength. Increase force production.
Promote initial learning of selective motor control. AlWasl
Hospital - Rehabilitation Section
Slide 43
Intervention Philosophies & strategies Orthotic devices,
splints, cast Goals : Maintenance or increase ROM Protection or
stabilization of a joint Promotion of joint alignment Promotion of
function AlWasl Hospital - Rehabilitation Section
Slide 44
Slide 45
Ankle Foot Orthosis Compared with barefoot gait, AFOs enhanced
gait function in diplegic subjects. Benefits resulted from
elimination of premature PF and improved progression of foot
contact during stance. AlWasl Hospital - Rehabilitation
Section
Intervention Philosophies & strategies Speech &
Language Therapy Oralmotor function using strengthening / Intraoral
stimulation verbal ( PROMPT) & non-verbal communication skills
( AAC & PECS, macatone) auditory training for HI audiometry
screening swallowing function AlWasl Hospital - Rehabilitation
Section
Slide 49
Intervention Philosophies & strategies Psychological
Assessment & Management Social support AlWasl Hospital -
Rehabilitation Section
Slide 50
Out of 32 patients received botox 69% attended PT & 31% did
not attend AlWasl Hospital - Rehabilitation Section
Slide 51
Out of 22 patients, 91% fully attended PT Mx. AlWasl Hospital -
Rehabilitation Section
Slide 52
% of patients who improved in ROM post botox 3-6 weeks &
3-6 months. AlWasl Hospital - Rehabilitation Section
Slide 53
Benefits of communication Case selection. Goal setting.
Educating parents/caregiver in active participation Compliance
AlWasl Hospital - Rehabilitation Section
Slide 54
Thank you AlWasl Hospital - Rehabilitation Section