internship paediatric physical therapy unit presentation october 2011 rushed finishing

8/3/2019 Internship Paediatric Physical Therapy Unit Presentation October 2011 Rushed Finishing

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BENEFITS OF EARLY INTERVENTION

PHYSICAL THERAPY IN CEREBRAL PALSY

TWO CASES REPORT

Presented By

IROGUE. EGHOSA . KENNEDYIntern Physical Therapist

Department of Physical Therapy

Pediatrics Physical Therapy UnitUniversity of Port Harcourt Teaching Hospital

Port Harcourt, South-South Region, Nigeria


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PRESENTATION OBJECTIVES

To inform our knowledge of evidence basedPhysical therapy in cerebral palsy.

To enumerate physiotherapeutic interventions inchildren with cerebral palsy.

To inform the design of larger studies thatexamines the efficacy of early intervention in

children with CP.


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OUTLINE History

Definition and pathological findings Brief Anatomy

Classification

Etiology, Risk factors

Epidemiology

Physical examination, early signs and Diagnosis, Differentials

Clinical findings and Associated problems

prognosis

Outcome measures

Treatment Team

Physical Therapy Interventions

Cases Report


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HISTORY OF CEREBRAL PALSY

In 1861 William Little

described a paralytic

condition of children that

is recognizable as spastic

diplegia.

Sigmund Freud challenged

Littles opinion on the

association between CP and

birth trauma

In his paper, Dr. Little

showed a child with

adductor spasm ,crouch

gait and in toeing.


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DEFINITION OF CEREBRAL PALSY

Cerebral palsy (CP) describes a group of permanentdisorders of the development of movement and posture,causing activity limitation, that are attributed to non-progressive disturbances that occurred in the immature or

developing fetal or infant brain. problems.Rosenbaum etal, 2007

The International Classification of Functioning, Disabilityand Health (ICF) defines activit y asthe executionof a task

or action by an individual and activity limitations asdifficulties an individual may experience in executingactivities. For the child with CP, this can include taskssuch as rolling, , running, and climbing stairs. (WHO,2001)


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PATHOLOGICAL FINDINGS IN CP

Specific brain lesions related to CP can be identified inmost of the cases.

These lesions occur in regions that are particularly

sensitive to disturbances in blood supply and are groupedunder the term hypoxic ischemic encephalopathy.(HIE)

Five types of hypoxic ischemic encephalopathy exists.They are


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FIVE TYPES OF H.I.E


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PATHOLOGICAL FINDINGS IN CP

The lesion in the brain may occur during the prenatal,perinatal, or postnatal periods.

CP is not a single disease but a name given to a wide

variety of static neuromotor impairment syndromesoccurring secondary to a lesion in the developing brain.

Any non progressive central nervous system (CNS) injuryoccurring during the first 2 years of life is considered to beCP.


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DEFINITION OF CEREBRAL PALSY

Time of brain injury

Prenatal period : Conception to the onset of labor Perinatal period : 28 weeks intrauterine to 7 days postnatal

Postnatal period : First two years of life

The motor disorders of cerebral palsy are oftenaccompanied by disturbances of sensation, perception,cognition, communication, and behaviour, by epilepsy, and

by secondary musculoskeletal problems.Rosenbaum et al,2007

Although CP is non- progressive But the clinicalmanifestation is said to change over time.


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BRIEF ANATOMY


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BRIEF ANATOMY


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BRIEF ANATOMY


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BRIEF ANATOMY


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CLASSIFICATION OF CEREBRAL PALSY

CP can be broadly classified into two: Clinical and Anatomical

These are based on Muscle tone, Anatomical

distribution and severity of the problem(s).Clinical classification

Tonus Lesion site

Spastic Cortex Dyskinetic Basal ganglia - extra pyramidal system

Hypotonic / Ataxic Cerebellum

Mixed Diffuse


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CLASSIFICATION OF CEREBRAL PALSYAnatomical classification

Location Description

Hemiplegia: Upper and lower extremity on one side of body

Diplegia: Four extremities, legs more affected than the arms

Quadriplegia: Four extremities plus the trunk, neck and face

Triplegia: Both lower extremities and one upper extremity

Monoplegia: One extremity (rare)

Double hemiplegia: Four extremities, arms more affected than the legs

Clinicians classify patients to describe the specific problem, to predictprognosis and to guide treatment. Classification provides a clearerunderstanding of the specific patient and directs management. Eventhough some of these types are clinically imprecise and may lack

reliability among observers ,these terms are conceptually useful.


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Spastic CP

Spasticity is defined as an increase in thephysiological resistance of muscle to passivemotion. It is part of the upper motor neuron

syndrome characterized by hyperreflexia, clonus,extensor plantar responses and primitive reflexes.Spastic CP is the most common form of CP.

Approximately 70% to 80%of children with CP arespastic. Spastic CP is predominantly anatomicallydistributed into three types namely


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CLASSIFICATION OF CEREBRAL PALSYSpastic hemiplegia

Seizure disorders, visual field deficits, astereognosis, andproprioceptive loss are likely. Twenty percent of children with spastic CP have hemiplegia. A focal traumatic,vascular, or infectious lesion is the cause in many cases. A

unilateral brain infarct with post hemorrhagic porencephalycan be seen on magnetic resonance imaging (MRI). Allhemiplegic children become independent walkers by theage of 3. Sensory deficit and learning disability add to the

movement problem in hemiplegia. Prognosis forindependent living is good.


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Spastic diplegia

Intelligence usually is normal, and epilepsy is less common. Fiftypercent of children with spastic CP have diplegia. A history ofprematurity is usual. Diplegia is becoming more common as morelow- birth-weight babies survive. MRI reveals mild periventricular

leukomalacia(PVL).Most diplegic children need various treatments to be able to walkindependently. Problems in maintaining balance and spasticityinterfere with walking. Children who can sit by the age of 2 can

usually walk by the age of 4 to 7. Hand dexterity is impaired.Children have difficulty writing or other tasks that need fine motorcontrol. Almost all diplegic children need surgery for contractures

and deformities Especially when physical therapy is not early.

Many use walking aids.


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Spastic Quadriplegia (Total body involvementtetraplegia)

The trunk and muscles that control the mouth,

tongue, and pharynx are also involved .When one

upper extremity is less involved, the term Triplegiais used. Thirty percent of children with spastic CPhave quadriplegia. More serious involvement of

lower extremities is common in premature babies.Some have perinatal hypoxic ischemicencephalopathy. MRI reveals PVL.


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CLASSIFICATION OF CEREBRAL PALSY Dyskinetic CP

Abnormal movements that occur when the patient initiatesmovement are termed dyskinesias (Dyskinetic syndromes).Dysarthria, dysphagia, and drooling accompany the movementproblem. Mental status is generally normal, however severe

dysarthria makes communication difficult and leads the clinician tothink that the child has intellectual impairment. Sensorineuralhearing dysfunction also impairs communication. Dyskinetic CPaccounts for approximately 10% to 15 % of all cases of CP.Hyperbilirubinemia or severe anoxia causes basal gangliadysfunction and results in dyskinetic CP. It is divided into Athetiodand Dystonia

Dystonia is the term used for sustained muscle contractions thatfrequently cause twisting or repetitive movements, or abnormal

postures


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CLASSIFICATION OF CEREBRAL PALSY Dyskinetic CP

Abnormal movements that occur when the patient initiatesmovement are termed dyskinesias (Dyskinetic syndromes).Dysarthria, dysphagia, and drooling accompany the movementproblem. Mental status is generally normal, however severe

dysarthria makes communication difficult and leads the clinician tothink that the child has intellectual impairment. Sensorineuralhearing dysfunction also impairs communication. Dyskinetic CPaccounts for approximately 10% to 15 % of all cases of CP.Hyperbilirubinemia or severe anoxia causes basal gangliadysfunction and results in dyskinetic CP. It is divided into Athetiodand Dystonia

Dystonia is the term used for sustained muscle contractions thatfrequently cause twisting or repetitive movements, or abnormal

postures


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Athetosis are uncontrolled extra movements that occur particularly

in the arms, hands and feet, and around the mouth. The lack ofcontrol is often most noticeable when the child starts to move forexample, when the child attempts to grasp toy or a spoon. Inaddition, children with athetoid cerebral palsy often feel floppy

when carried. Types of athetoid dyskinesia arei. Non tension athetoid: Involuntary movements without

increased tone

ii. Dystonic athetoid: Abnormal positioning of limbs, head and

trunk, with unpredictable increased toneiii. Choreoathetoid :Involuntary, unpredictable, small movements of

the distal parts of the extremities

iv. Tension athetoid: Increased muscle tone that usually blocks

involuntary movement


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Ataxic CP

Ataxia is loss of balance, coordination, and finemotor control. Ataxic children cannot coordinatetheir movements. They are hypotonic during the

first 2 years of life. Muscle tone becomes normaland ataxia becomes apparent toward the age of 2to 3 years. Children who can walk have a wide-

based gait and a mild intention tremor (dysmetria).Dexterity and fine motor control is poor. Ataxia isassociated with cerebellar lesions.


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Mixed CP

Children with a mixed type of CP commonly havemild spasticity, dystonia, and/or athetoid

movements. Ataxic may be a component of themotor dysfunction in patients in this group. Ataxia

and spasticity often occur together. Spastic ataxic

diplegia is a common mixed type that often isassociated with hydrocephalus.


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ETIOLOGY

The etiology can be identified only in 50% ofthe cases. Certain factors in the history of the

child increase the risk of CP. The incidence of

CP among babies who have one or more ofthese risk factors is higher than among the

normal population. We should therefore be

alerted to the possibility of the presence ofCP in a patient with these factors. Risk factorsassociated with CP are grouped into prenatal,

perinatal, and postnatal factors.


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PRENATAL RISK FACTORS

Prematurity (gestational age less than 36 weeks)

Low birth weight (less than 2500 g)

Maternal epilepsy

Hyperthyroidism

Infections (TORCH)

Bleeding in the third trimester

Incompetent cervix

Severe toxemia, eclampsia

HyperthyroidismDrug abuse

Trauma

Multiple pregnancies

Placental insufficiency


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PERINATAL RISK FACTORS

Prolonged and difficult labor

Premature rupture of membranes

Presentation anomalies

Vaginal bleeding at the time of admission for laborBradycardia

Hypoxia


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POSTNATAL RISK FACTORS(0-2YEARS)

CNS infection (encephalitis, meningitis)

Hypoxia

Seizures

CoagulopathiesNeonatal hyperbilirubinemia

Head trauma


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EPIDEMIOLOGY

CP is the most common congenital neurologic disorder

(Gandhi, 2007) and also most common cause of childhooddisability in Western societies. The incidence is 2-2.5/1000live births. The incidence is higher in males than infemales; the Surveillance of Cerebral Palsy in Europe

(SCPE) reports a M:F ratio of 1.33:1(Johnson andAnn,2002).

Data emanating from Nigeria shows that the spastic CP isthe most common type with birth asphyxia being thecommonest etiology.


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EPIDEMIOLOGY

In a research conducted in physiotherapy

department by the paediatric team in UPTH; CPincidence was 35% next to Erbs palsy producing a

higher Male to female incidence rate M:F ratio of

I.82:1( UPTH physiotherapy medical records andarchive 2006-2010).

Some CP children do not survive hence the

prevalence varies between 1-5/1000 babies indifferent countries. In the past it was thought tooccur as a result of acute intrapartum hypoxicevents.


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EPIDEMIOLOGY

Recent epidemiological studies suggest that in only

10% of cases this is true, and 90% of cases are due tochronic events or congenital factors (Blair and

Stanley,1988; Nelson, 1986; Yadkin et al.,1994)

It was also previously thought that improvements inperinatal and obstetric care would decrease theincidence of CP. However, the incidence has not

declined and the overall prevalence increased duringthe 1980s and 1990s. This is explained by increasedsurvival of premature and very-low birth-weightinfants and by a rise in the number of multiple births


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EPIDEMIOLOGY

Approximately 11% of premature babies who survive inneonatal intensive care units develop CP.


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EPIDEMIOLOGY

In vitro fertilization results in multiple pregnanciesand increases the risk of CP.


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EPIDEMIOLOGY

Multiple births have a substantially higher risk ofdeveloping CP. The reported prevalence rate perpregnancy for singles is 0.2%, for twins 1.5%, for

triplets 8.0%, and for quadruplets 43%.(Yokoyama

et al.,1995). Even at centers where optimal conditions exist for

perinatal care and birth asphyxia is relatively

uncommon, the incidence of CP in term babies hasremained the same. This has led researchers toconsider unknown prenatal causative factors.


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PHYSICAL EXAMINATIONS AND MAKING DIAGNOSIS

Physical examination of a child with movementproblem has two basic purposes.

First, physical examination accompanying a

detailed history enables an accurate diagnosis. Second, it allows the physical therapist to define

the impairments and disabilities, determine the

functional prognosis and set treatment goals inchildren with CP.


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Goals of physical examination in a child with

movement disorder

Establish an accurate diagnosis

Differentiate CP from progressive causes of childhood neuromotordisability

Classify the type and severity of involvement

Define the musculoskeletal impairment (spasticity, balance,

weakness, contractures and deformities) and decide on ways oftreatment

Evaluate associated impairments and get appropriate treatment

Determine functional prognosis

Set treatment goals

Devise a treatment plan

Evaluate the outcome of previous treatment procedures

Assess the changes that occur with treatment as well as with growth& develo ment


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HISTORY TAKING

History is a key component in evaluating the child.It provides valuable information for diagnosis. Inchildren with a definite diagnosis, the timing of

achievement of developmental milestones and the

presence of associated impairments help to decide afunctional prognosis.

A detailed history provides knowledge about

Risk factors

Timing of achievement of developmental milestones

The presence of associated impairments

Progression of childs capabilities


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KEY POINTS OF HISTORY

Health of parents

Hereditary factors

Siblings

Pregnancy

Labor and delivery Rh factor

Birth weight

Condition at birth

Neonatal history

Age disability recognized and symptoms noted

Development and present status of Head balance & control


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KEY POINTS OF HISTORY

Sitting Crawling

Walking

Feeding

Dressing

Toilet care

Speech

Mental status

Hearing


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KEY POINTS IN HISTORY

Vision

Handedness

Drooling

Convulsions

Emotional development

Social and recreational activities

School placement

Parental attitude

Braces Medication

Previous treatment

Reason for referral


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CLINICAL EXAMINATION

Examination begins with observation. Do not touchthe child before you watch her move.


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Examine the young and frightened child in his mothers lap.

Evaluate tonus abnormalities when the child is comfortable.


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Guide the parents to help you during the clinical examination


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Start the examination by giving the child something to playwith. A ball or a balloon will help to test upper extremity

function.


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Examination outlineNeurological examination

Skull, head circumference

Spine

Mental status

Cranial nerves

Vision - hearing - speech

Motor system

Muscle tone


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Muscle power

Muscle bulk

Degree of voluntary control

Reflexes Involuntary movements

Sensory examination

Sphincters Developmental milestones


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Musculoskeletal examination

Range of motion

Deformities, contractures

PostureFunctional examination

Sitting

Balance Gait

Hand function


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NEUROLOGICAL EXAMINATION

Neurological evaluation of the infant and the child

requires adequate knowledge of neurological

developmental stages.

Also the evaluation of persistent primitive reflexes

and the absence of advanced postural reactions

Evaluate muscle tone and involuntary movements

Muscle strength and selective motor control

.


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This 8 month old baby has difficulty maintaining head control ontraction response indicating developmental delay.


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This spastic quadriplegic child still has not developedprotective extension and is severely delayed.

PRIMITIVE REFLEXES


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PRIMITIVE REFLEXES

SOME EXAMPLES OF PRIMITIVE REFLEXES


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SOME EXAMPLES OF PRIMITIVE REFLEXES

Asymmetrical tonic neck reflex (ASTNR): The child lies supine.Turn the head to one side and then the other. The extremities onthe face side extend and the ones on the occiput side flex. This iscalled the fencing position. The reflex is present at birth and

disappears at 6 months.

FOOT PLACEMENT REACTION


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FOOT PLACEMENT REACTION

Foot placement reaction: Hold the child by the axilla and bring thedorsum of the foot against the edge of the table. The child willautomatically place his foot on the table top. This is a normal responsein all children and is inhibited b a e 3 to 4.


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Tone labyrinthine reflex

Tonic labyrinthine reflex: Put the baby in the prone position, bring the neckto 45o flexion. The response is flexion of the arms, trunk and legs. Put thebaby in the supine position and bring the neck to 45o extension. Extensor

tone will increase. This reflex is present at birth and disappears at 4 months

Landau Reflex


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Landau Reflex

Landau reflex: Suspend the baby horizontally. The neck, trunk and armsextend, legs partially flex. This is an advanced postural reaction which

appears at 6 months.

PARACHUTE RESPONSE


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PARACHUTE RESPONSE

Parachute response: The child lies prone on the table. Lift the childvertically and suddenly tilt forward towards the table. The arms and thelegs extend as a protective reaction. This is an advanced postural reactionthat a ears at 8 months.

SIGNS SUGGESTIVE OF CP IN AN INFANTS


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SIGNS SUGGESTIVE OF CP IN AN INFANTS

Absent Landau reflex at 11months is a

sign of developmental delay.

Si n ti f CP in n Inf nt


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Signs suggestive of CP in an Infants

Absent traction responseindicating poor head control in a10month old baby.

Increased tone in the limbs andtruncal hypotonia is common inspastic quadriplegia.

ABNORMAL MUSCLE TONE AND INVOLUNTORY


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ABNORMAL MUSCLE TONE AND INVOLUNTORY

MOVEMENT

SELECTIVE MOTOR CONTROL


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SELECTIVE MOTOR CONTROL

Children who do not have selective motor control are unable todorsiflex the ankle without moving the hip or knee; but they canproduce this response in a gross flexion movement of the lowerextremity. This is called pattern response. When the child flexes the

hip against resistance, ankle dorsiflexion becomes apparent.

EXAMINE THE MUSCULOSKELETAL


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EXAMINE THE MUSCULOSKELETAL

FUNCTIONAL EXAMINATION


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Hands-free sitter Hand-dependent sitter

Propped sitters needs external support to sit.

EARLY SIGNS SUGGESTIVE OF CP


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EARLY SIGNS SUGGESTIVE OF CP

DIFFERENTIAL DIAGNOSIS


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CLINICAL FINDINGS


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CLINICAL FINDINGS CONTS


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CLINICAL FINDINGS CONTS

GROUP OF MUSCLES OFTEN AFFECTED


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GROUP OF MUSCLES OFTEN AFFECTED

ASSOCIATED PROBLEMS


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ASSOCIATED PROBLEMS

ASSOCIATED PROBLEMS


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ASSOCIATED PROBLEMS

ASSOCIATED PROBLEMS CONTS


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ASSOCIATED PROBLEMS CONT S

ASSOCIATED PROBLEMS CONTS


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ASSOCIATED PROBLEMS CONT S

PREDICTING FUNCTIONAL PROGNOSIS IN CP


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Clinical findings established over time helpdetermine prognosis.

Potential ambulators usually begin to walk between

2 to 7years of age. Approximately 85% of partiallyinvolved children have the potential to becomeindependent ambulators compared to only 15% of

severely involved.

He must be able to hold his head before he can sit, and hemust be able to sit independently before he can walk onhis own. In children between 5 to 7 years of age



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FUNCTIONAL PROGNOSIS


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FUNCTIONAL PROGNOSIS

OUTCOME MEASURES IN CP


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OUTCOME MEASURES IN CP


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MANUAL ABILITY CLASSIFICATION SYSTEM (MACS)

MODIFIED ASHWORTH SCALE FOR SPASTICITY (MAS)

TARDIEU SCALE FOR SPASTICITY

CANADIAN OCCUPATIONAL PERFORMANCE MEASURE(COPM)

DENVER DEVELOPMENT SCREEN TEST

BAYLEY SCALE OF INFANT DEVELOPMENT

OUTCOME MEASURES


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Many outcome measure tools are available for use

in children with CP. Some of these assess activity

or activity limitations; some quantify activity levelsin conjunction with participation which is definedby the ICF as involvement in a life situation

(WHO, 2001).

This study is focused on evaluative measures usedto quantify the magnitude of change over time in

an individual or groups (kirschner and Guyatt,1985).

OUTCOME MEASURES


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To be robust, an outcome measures need to be

reliable (consistent and free from error) and Valid(measures what it is intended to) (Streiner andNorman, 2003).

The evaluative outcome tools is also required to showresponsiveness to change, which means that theydetect minimal clinically important differences(MCID).

The MCID is the smallest change on an objectivemeasurement tool in which the patient detects asignificant change in their health (Jaeschke, Singer,

and Gu att, 1989 .

OUTCOME MEASURES


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In a detailed systematic review by Harvey et al

(2008) they critically appraise literatures on

psychometric properties and clinical utility ofevaluative activity limitation of eight evaluativeoutcome measures ASK, CHQ, FAQ, FMS,

GMFM, PEDI, PODCI, and WeeFIM used inchildren with CP.

They reported that ASK and GMFM showed the

most robust psychometric properties with othertools requiring further confirmation of validity and

responsiveness.

OUTCOME MEASURES


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They advised clinicians to select tools based on

established psychometric properties and thepurpose of measurement. Since no single measureadequately addresses all aspects of the ICF

The GMFCS is now the preferred means ofclassifying motor impairment in children with CP.For this reason, discriminative validity of toolsshould be examined using GMFCS level rather

than mild, moderate, or severe, and topographicaldistribution. This has been addressed more recently(Ottenbacher et al., 1997).

OUTCOME MEASURES


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The GMFM is a valid and reliable tool for

measuring changes in motor function of children with CP consisting of 88 items across fivedimensions:(A) lying and rolling; (B) sitting; (C)

crawling and kneeling; (D) standing; and (E)

walking, running, and jumping (Palisano et al, 2000;Vos-Vromans, Ketelaar, and Gorter, 2005).

For each item, the child is asked to perform a gross

motor task. The test administrator observes thechild and assigns a score of 0 to 3 based on thechilds performance of this task.

OUTCOME MEASURES


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A score of 0 indicates that the child is unable to

initiate the task; 1 indicates that the child initiates

but performs less than 10% of the task; 2 indicatesthat the child can perform more than 10% of thetask but does not fully complete the task; and 3

indicates that the child is able to complete the task.

Each dimension is scored as a percentage of the

maximum score for that section and eachdimension contributes equally to the total GMFM

score.

TREATMENT TEAM


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PHYSICAL THERAPY INTERVENTIONS


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Importance of proper positioning the neonate,

Lyingsupine and prone positions and theirimplications,

Rolling

Head controlTrunk control

Sitting

CrawlingWalking

Upper extremity function



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Respiration and Speech

Feeding

Visual perception

Social development

Cognitive development

Parents involvement in early intervention

programmes.



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Proper positioning is important as numerous

benefits have been found from systematicreview which include

a greater awareness of external stimuli, enhanced

development, a calming effect, and quicker

acquisition of developmental skills such as headand ocular control, upper and lower extremityfunction and decreased extensor patterns of the

neonate (Brown 1985,Anderson & Anderson

1986, Monterosso et al 2003, Schoger 2005)



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Correct positioning of the neonate is very

important in the control of posture of thosewho are at risk of developing fixed deformities,therefore is of importance to physical therapists

in early intervention (Monterosso et al 2003,

Brown 1985).



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Lying Supine Versus Prone Positions and

Its Implications An infants primary sleeping position has been

suggested to affect the age range in which

developmental milestones occur (Jantz et al1997).

Early Intervention should include prone play for theinfant at 2-4 months as it has been reported to

maximize the development of the childs upper bodystrength; shoulder girdle strength and extensionmovements in infants (Davis et al 1998, Bridgewater&Sullivan 1999, Liao et al 2005).



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It is suggested that instead of emphasizing a

single position during awake and sleep time, i.e.prone and supine respectively, the use ofchanging positions (Back-to-side) during

sleeping in early infancy may be beneficial for

the child to attain the whole range of skills in theaverage normal development (Vaivre-Douret et

al 2004, Vaivre-Douret et al 2005).



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Early Intervention should include prone play for the

infant at 2-4 months as it has been reported tomaximize the development of the childs upper bodystrength; shoulder girdle strength and extension

movements in infants (Davis et al 1998, Bridgewater&

Sullivan 1999, Liao et al 2005). The physicaltherapists role should include educating parents of

the importance of prone positioning in playtime as many parents

may misinterpret the intent of Sudden Infant Death Syndrome(SIDS) prevention programmes and avoid placing their child inprone whilst awake and/or asleep (Salls et al 2002, Monson et al2003, Liao et al 2005, Vaivre-Douret et al 2005)



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Rolling

Early Intervention however one study bySmither (1991) reports that facilitationtechniques used by the therapist are shown to

increase quantity and quality of a childs rollingability. A beneficial outcome is reported as aresult of facilitation techniques; diminishment ofrocking from side to side and rolling over of the

pelvis followed by the shoulder girdle, howeverthis study has limited creditability, as thetechniques used are not detailed.



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Head control is considered as constituting the

beginning of body equilibrium development andsubsequent locomotor development (Assaiante1998)

The importance of head control can be drawnfrom the published literature.

Head control is found to improve reaching andhead eye stabilizations in order to relate to a stable

frame of reference for reaching in infants (Thelen

1984, Bertenthal&Von Hofsten 1998).



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This is supported by Thelen & Spencer (1998)

study which found head control to be importantin the onset of successful reaching, with eachinfant showing good head control several weeks

prior to reaching.

Stabilization of the head appears to be moresensitive to the dynamic characteristics of theactivity being performed than the pelvis e.g. in

walking there is a higher degree of stability ofthe head in space (Ledebt& Wiener-Vacher1996, Assaiante 1998).



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Development of head control is very importantas the head position of a child significantlyimpacts their ability to access and function

within the environment and in meeting their

educational needs (Doherty 1998).

Therefore Early Intervention is required in orderto facilitate maximum functioning of the child

within their environment and increased

opportunities from an early onset of typicalnormal development.



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Head control may be promoted by the physicaltherapist by placing a wedge with a shallow,bevelled surface attached on to a tray, and

placed at a comfortable height in positioning the

head in an upright position relieving stress on

the spinal structure(Pope et al 1994).

Numerous studies have found sensory feedback

used by physical therapists very successful in

improving head control (Wooldridge& Russell1976, Bishop 1977,Walmsley et al 1981,Catanese& Sanford 1984, Hallum



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Support in prone facilitates visual orientation, headcontrol, development of postural extension and activecontrol of weight shift



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Trunk Control

Trunk extension is reported to be a componentof overall trunk control and is important to theattainment of independent sitting, trunk mobility

and functional activity therefore it is animportant area considered in Early Intervention(Miedaner 1990, Barks 2004, McDonald et al2004).

Like head control, trunk control is important asa foundation to executive function anddevelopment of a child (Kangas,2002)



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Vision is thought to influence trunk control inconjunction with sitting experience(Hempel1993, Bertenthal & Von Hofsten 1998)

Although reaching is dependent on eye and head

co-ordination, reaching requires a nestedhierarchy of stabilized systems in which the eyesand head are supported by the trunk in either asitting or standing posture (Bertenthal & Von

Hofsten 1998).



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Adaptive seating is identified within EarlyIntervention as an important treatmentapproach to facilitate sitting of a child who does

not have the adequate head, trunk or pelvic

control to maintain this position independently

(McDonald et al 2004, Washington et al 2002). Prescription of adaptive seating is found within this

review as early as six months due to a childs lack of

ability to initiate sitting upright and presentation ofdeficits at this stage of development (Pain et al 2000).Green et al (1995) reported that when adaptive seating

was provided to children with cerebral palsy, immediate

improvements in sitting ability was observed.



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Conductive education

Vojta therapy Bobath therapy

Vibration therapy

Suit therapy Hippotherapy

Patterning

Body weight support treadmill training

Constraint induced therapy

Hyperbaric therapy



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Sensory integration

Electrical Stimulation- functional or ThresholdConventional exercises



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EARLY INTERVENTION

Early Intervention is defined by Stephens &


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Early Intervention is defined by Stephens &

Tauber (2001) in two parts,

earlyrefers to the most critical period of a childsdevelopment between birth and three years of age.

Interventionrefers to programme implementationdesigned to maintain or enhance the childs

development in natural environments and as a

member of a family

Numerous studies have identified the importanceof early intervention and many benefits have beenreported (Ayres 1979, Gulnerick 1998, Farel et al

2003 These are identified in the table below



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GOAL OF EARLY INTERVENTIONS


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Goals of Early Intervention include -

Strengthen childs skills Provide parents with information, social and

emotional support

Strengthen parents coping abilities and childrearing skills

Instructing parents in providing their children

emotional support and intellectual stimulation(Benasich et al 1992, Guralnick 1997, Meisels& Shonkoff 1990).

EARLY INTERVENTIONS


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Early intervention programmes that combine a

child and parent focus are reported to have agreater impact on the developmental outcomes of

the child (Lekskulchai &Cole 2001).

Children are deemed eligible for early interventionservices if they are delayed in one or more of thefollowing areas: physical, cognitive, language and

speech, psychosocial and self-help, or if they havea diagnosis of a physical or mental condition which

will result in developmental del(Hanft1988,Pelchat et al 2004).

SUMMARY OF PHYSICAL THERAPY INTERVENTION


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BENEFIT OF IMPROVING THE TRUNK CONTROL


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BENEFIT OF ADAPTIVE SEATING


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CASE REPORTS


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CONCLUSION AND RECOMMENDATION


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Cerebral palsy treatment has to be tailored

according to the patients age, clinical form, severityof the diseases and it involves a multitasking teamincluding the patients family. At this moment there

are available a large number of treatments optionsto chose from. Identifying the right approach needs

an evidence based evaluation to prove theusefulness and superiority of a method over the

other and a skilled physical therapist,

CONLUSION AND RECOMMENDATION


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There is currently very little clinical evidence with

regards to the physical therapy Early Interventionin CP, and in relation to the efficacy and

effectiveness of Early Intervention. It would appear

that Early Intervention programmes are based uponindividual physical therapists knowledge, skills andclinical opinion.

THANKS FOR LISTENING


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HELP US DEVELOP MOTOR SKILLS

internship paediatric physical therapy unit presentation october 2011 rushed finishing

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