2016. Classifications of Cerebral Palsy. Tone Patterns. Negative Signs. Definition

8/21/2016 Classifications of Cerebral Palsy • Anatomic – – – – Diplegia Quadriplegia Hemiplegia Other: • Asymmetric Diplegia • Monoplegia • Double H...
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8/21/2016

Classifications of Cerebral Palsy • Anatomic – – – –

Diplegia Quadriplegia Hemiplegia Other: • Asymmetric Diplegia • Monoplegia • Double Hemiplegia

• Physiologic Mark J. Romness, MD Associate Professor of Orthopaedic Surgery uvaortho.com

– Spastic - velocity induced resistance to movement – Extrapyramidal - dystonia, athetosis, ballismus/chorea, ataxia – Mixed Tone University of Virginia

Tone Patterns

Orthopaedic Surgery

Negative Signs

• Hypertonia

• Hyperkinetic

– Spasticity – Dystonia – Rigidity

• Negative Motor Signs – Weakness – Poor control

– Dystonia – Chorea – Athetosis – Monoclonus – Tremor – Tics – Stereotypies

– Inability to generate normal voluntary force

• Poor Control – Reduced selective motor control – Ataxia: Incorrect patterns for movement – Apraxia: Impaired patterns for a task – Dyspraxia: Lack of age-appropriate motor actions Sanger TD, et al. Pediatrics 2006 Nov;118(5) Definition and Classification of Negative Motor Signs in Childhood. Taskforce on Childhood Motor Disorders

Sanger TD, et al. Mov Disord. 2010 Aug 15;25(11):1538-49 Taskforce on Childhood Motor Disorders University of Virginia

• Weakness

Orthopaedic Surgery

University of Virginia

Orthopaedic Surgery

University of Virginia

Orthopaedic Surgery

Definition • Hypotonia not well defined • Was not included in the Sanger Task Force • Difficult to distinguish from – Weakness – Diffuse laxity • Personally, I would say “inappropriately low resistance to passive stretch, manifested by reduced reflex response to unexpected perturbations” Sanger TD – Personal Communication University of Virginia

Orthopaedic Surgery

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Characteristics of Hypotonia • • • • • •

Decreased strength Decreased activity tolerance Delayed motor skills development Rounded shoulder posture, with leaning onto supports Hypermobile joints/increased flexibility Poor attention and motivation

Diagnosis • Hypotonia v. Laxity • Central v. Peripheral • History & Exam • Tests

• Martin K, et al Pediatr Phys Ther. 2005 Winter;17(4):275-82. University of Virginia

Orthopaedic Surgery

Laxity

University of Virginia

Orthopaedic Surgery

Hypotonia Etiology

• Beighton score:

• Central nervous system • Peripheral nervous system • Neuromuscular junction • Muscle diseases * in order of prevalence

hypermobility.org

Harris SR. Dev Med Child Neurol. 2008 Dec;50(12):889-92. University of Virginia

Orthopaedic Surgery

University of Virginia

Orthopaedic Surgery

Central v. Peripheral • Central disorders

• Transient Hypotonia

– Neonatal seizures – Hypoxic-ischemic events – Neonatal encephalopathy

– Preterm infants – Perinatal drug exposure – Acute infectious state

• Peripheral disorders – Diminished reflexes – Decreased anti-gravity limb movements

University of Virginia

Orthopaedic Surgery

University of Virginia

Orthopaedic Surgery

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History

Examination

• Family History • Prenatal History

• Head circumference • Reflexes

– Prenatal fetal movement – Poly or Oligohydramnios – Maternal health during pregnancy

• Primitive • DTRs

• Muscle tone • Standardized Tests

• Drugs/alcohol, infections, illness

• Perinatal – Apgar scores – Respiratory problems – Feeding difficulties

• Neurological Assessment of the Preterm and Full-term Newborn Infant • Test of Infant Motor Performance –TIMP – 34 weeks postconceptional age to 4 months post-term

• Infants

• Harris Infant Neuromotor Test – HINT

– Motor milestones

– 2.5 to 12.5 months http://thetimp.com/ University of Virginia

Orthopaedic Surgery

Interventional Assessment

University of Virginia

Orthopaedic Surgery

University of Virginia

Orthopaedic Surgery

Hypotonia

• Muscle/nerve biopsy • EMG – denervation in the muscle – muscle irritability

• CT/MRI • Ultrasound sheer wave elastography? Joline E. Brandenburg, MD

– Quantifies the elasticity of tissue – Used to show increased passive muscle stiffness in children with CP – Hypotonia pending

University of Virginia

Orthopaedic Surgery

 I measure hypotonia using a scale of 6 items

Ginny Paleg, PT, DScPT [email protected]

suggested by Dr. Andrew Morgan from Peoria, Illinois (Morgan-Paleg Hypotonia Scale) 1. Head Control 2. Vertical Suspension 3. Sitting 4. Hip Abduction 5. Ankle Dorsiflexion 6. Standing

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Score each item 0, 1 or 2 points Recommend services 2x/mo

1 = normal 2 = eh 3 = oy vey Add score, divide by 6 That’s the total score

Seating Device Stander

Hip Helper compression shorts $15

Theo at 9 months

Supported Stepping and/or

treadmill training

Compression Garment

(Neoprene thigh wrap, Benik, SPIO, Theratogs. DMO, etc.) Orthotics

Gericke, 2006 Paleg, 2013

Systematic Review of over 70 articles

(Paleg, Romness and Livingstone, in progress) age 0-6 years It’s not done yet Treadmill will be green light “GO!” Orthotics “might” be Green Light

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Exercise and Physical Therapy came

out well (but no one type) Whole Body Vibration came out well, but fell out when we went to younger children. Video taken at Dr. Rainer Blank’s clinic in Germany

Compression

Garments/Lycra Suits

Bicycle Massage Kinesiotaping Power Toy Car and

Power Chair

Vestibular/Sensory

Training including Wii

Already adapted Comes with wireless

remote Lil Rover $70 from toysrus.com

Treadmills will be strongest

recommendation at 8 min 5x/wk for pre-walkers to 2030 min 2-5x/wk for older children Damiano said this intervention should be standard of care for children with Down syndrome Hi intensity is better than low intensity

If you don’t have access to a

treadmill and/or prefer natural environment, try a gait trainer Start at 9-12 months adjusted age. R82/Convaid (formally known as Snug Seat), Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam

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Start at 9 months if child is not

yet sitting independently to play Start at 12-15 months if child is not yet pulling to stand and cruising Consider abduction to protect hips is you suspect child will be at GMFCS Levels III, IV or V (Martinsson 2011, Macias 2015 a&b)

No evidence Martin showed that most

PTs thought that children with hypotonia “lean into supports” Children without head control may benefit supportive seating at 3-6 months of age Try dynamic setaing

Get orthotics when child is pulling up to stand and

cruising (very weak evidence for Sure Steps over Cascase Dafo #4) Wear 50% of waking time No orthotics = handplay, w/ orthotics = postural play (Martin and Looper CSM 2015)

We need a definition Is it CP? We need a valid reliable measurement tool We need outcome measures Once we have these, we can better evaluate

interventions

Email Ginny for handouts:

[email protected]

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