prim haynes & franjoine 2009 child with hemiplegia margo prim haynes, pt, dpt, ma, pcs mary rose...

Prim Haynes & Franjoine 2009

Child with Hemiplegia

Margo Prim Haynes, PT, DPT, MA, PCS

Mary Rose Franjoine, PT, DPT, MS, PCS

2009


• Spastic or Hypertonic CP– Hemiplegia

– Diplegia

– Quadriplegia

Categories of Cerebral Palsy (CP)


General Comments

• Hemiplegia means: Significantly more involvement on one side of the body

• Usually full term pregnancy of single births


Pictures and Video


General Comments

• Diagnosed early …. Why? Asymmetry Hold Bottle

Mom notices hands first

Pick up LE concerns later


Pictures


Dimension Functional Domain

Disability Domain

A. Body structure & functions

Structural & functional integrity

Impairments

A.Primary

B.Secondary

B. Motor functions Effective posture & movement

Ineffective posture & movement

C. Individual functions

Functional activities

Functional activity limitations

D. Social functions Participation Participation restriction

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

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NDT Enablement Classification Model of Health and Disability



Dimension Functional Domain Disability Domain



Impairments

A.Primary

B.Secondary




Functional activities Functional activity limitations


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• Damage (lesion) impacts- – the motor cortex – white matter projections to and from cortical

sensorimotor areas of the brain• Causes:

– Unknown prenatal condition– Asphyxia– Prematurity

• Intracranial bleeds, infection, medical conditions (Campbell S 2000)

Body Structure and Function


CognitionFunction:

• Intelligence Varies:

– Dependent upon many factors:

– Development of seizure activity in later years (7 years)

Impairments:

– Processing

– Attention Deficit Disorders – Right vs Left Involvement (Trauner 2003)


Neuromuscular System

Impaired Muscle Activation

• Excessive co-activation (stiffness increases) during task

– Limits movement – speed

– Limits flexibility of movement responses




• Impaired Muscle Synergies

– Limited repertoire

– Stereotyped patterns of movement

– Performed in limited ranges




• Latency in initiating

• Difficulty sustaining postural muscles

• Often passive termination of muscles



Impaired Motor Execution

• Impaired Modulation & Scaling of Forces

– Inability to slow down as approach target

– Particular difficulties grading grip



• Impaired Timing and Sequencing

• Excessive overflow of Intra-Inter limb contractions

– Decreases the capacity for isolated control during effort



Insufficient Force Generation (muscle strength) : Asymmetrical

• Postural Muscles

• Movement Muscles


Sensory System

• May have:

– Hyposensitive: ↓ sensation one side

– Hypersensitive: ↑ sensitivity

– Total Disregard / Neglect


Sensory System

• May have:

– Sensory Processing Impairment:

– Visually and auditory Impairments


Video


Musculoskeletal SystemSecondary Impairments

• Range of Motion Impairments: UE & LE

• Increased risk: scoliosis

• Increased risk: hip dislocation

• Monitor for limb length discrepancies both UE than LE ( UE < LE)




Disability Domain



ImpairmentsA.PrimaryB.Secondary







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Posture and Movement

General Characteristics: Posture

• Underlying postural tone low

• High tone extremities, low tone trunk

• Asymmetry = poor midline orientation




• One side of the body shows more variability than the other side of body

• Uses “stronger” UE and “stronger LE to support in upright




• Difficulty transferring objects using involved hand

• Limited movement of digits / unable to get stability around wrist.

• Difficulty performing end range supination with flexion for grasp and hold


Pictures




• LE patterns:

– Hip adduction, internal rotation (IR), knee flexion or extension, ankle positioned in plantar-flexion or pronated

– Hip adduction, IR, knee extension, ankle positioned in varus


Pictures



May see: Loss of independent ankle movement on involved LE

• Limited function of ant tibialis and toe extensors

• Splinting options important for this population



General Characteristics: Movement

• Most active movement in sagittal plane

• Moves with asymmetrical phasic bursts

• Initiates movement with asymmetrical extension


Video


Speech and Language

• Speech and Language delays appear to resolve by school age (Trauner 2003)

• Children with LH damage more impaired in expressive language (Thal 2009, Trauner 2003)

• Children with RH damage more impaired in receptive language(Thal 2009, Trauner 2003)

• See facial asymmetry when crying, feeding and smiling- at rest see symmetry


Prone

Postures:

• Positions on one elbow using stronger arm for play

Movement

• Pull with strong arm and push with leg to get toys


Pictures and Video


Supine

Postures:

• Plays in this position until move upright

Movement

• Rolls and transition from this position moving over stronger side


Picture


Sitting

Postures

• Sitting is a functional position

• Independent in a number of positions (“w” position, side sit, modified long sit)

• Asymmetry


Pictures


Sitting

Movement

• Often prefers to move in sitting position

– “Hitch” across floor


Video


Quadruped

Posture: Quadruped

• Select position when UE is strong enough to handle the movement

Movement: May see

• Asymmetrical commando crawl

• Asymmetrical reciprocal creep = pelvis behind knees


Pictures and Video


Kneeling

Posture

• Hips flexed, pelvis in anterior position, ankles planter flexed or dorsi flexed

• Transition to stand from kneel position

Movement

• Stabilize with upper body to move


Pictures


Standing

Postures

• Enjoy being upright

• Asymmetrical stance


Pictures


Walking

Movement

• Ambulation

– 80% ambulate by 2 years of age

– 100% ambulate by 3 years of age


Video




Disability Domain



ImpairmentsA.PrimaryB.Secondary







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Activities & Activities Limitation

Locomotor Skills Often independently ambulatory (3 years of age)

Communicates Communicates with /without articulation issues

Basic ADL’s May be independent with self help skills

Feeding Independent



Dimension Functional Domain Disability Domain



Impairments

A.Primary

B.Secondary




Functional activities Functional activity limitations


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• Function well as member of family: may have difficulty keeping up with siblings

• Mainstreamed or special classroom

• May continue to higher education and full time employment

Participation


Treatment Strategies

1. Provide somatosensory input to assist with building movement repertoire

2. Reinforce with visual and auditory clues.3. Facilitate symmetrical posture and

movement in functional tasks. Midline alignment Symmetrical strength



4. For hand function: choose activities that use individual finger digits (puppet play, finger tip activities)

5. Treat using rhythm and music.



6. Encourage child to explore world thought loading upper extremities

7. Don’t push upright position until ready to go.

8. Introduce variety and speed.


References

• Thal DJ, Marchman, V, Stiles J, Aram D, et al. Early lexical development in children with focal brain injury. Brain Lang 2003; 40: 491-527

• Trauner D. Hemispatial neglect in young children with early unilateral brain damage. Developmental Medicine & Child Neurology 2003; 45: 160-166


Child with Hemiplegia

Margo Prim Haynes, PT, DPT, MA, PCS

Mary Rose Franjoine, PT, DPT, MS, PCS

2009

prim haynes & franjoine 2009 child with hemiplegia margo prim haynes, pt, dpt, ma, pcs mary rose...

Documents

prim haynes franjoine

hemiplegia margo prim

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