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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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