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DYNAMIC CORE STABILITY IN CHILDREN WITH CEREBRAL PALSY Shelley Mannell PT, Julie Wiebe PT
Conflict of Interest Statement
Both Shelley Mannell PT and Julie Wiebe PT provide continuing education courses, live and online, for various academic institutions, organizations, clinics and conferences.
Objectives: Upon completion of this course, you will be able to: 1. Explain how the core functions in typical development and the development of children with CP, based on the current literature. 2. Identify the important role of alignment for activation of the inner core. 3. Identify the connection between breathing pattern, inner core muscle activation, and outer core muscle activation. 4. Demonstrate a basic understanding of the principles underlying an alternative clinical model for core stability used in children with CP.
2015 Shelley Mannell, PT and Julie Wiebe, PT. All rights reserved. DuplicaCon, transfer and/or transmission of these materials is prohibited.
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Tug O’ War
=
Integration: TAP
Stability that is responsive to the demands of function (non-uniform response) § § §
Teamwork Alignment Preparation
Integration: TAP
Stability that is responsive to the demands of function (non-uniform response) §
Teamwork
2015 Shelley Mannell, PT and Julie Wiebe, PT. All rights reserved. DuplicaCon, transfer and/or transmission of these materials is prohibited.
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Gears in the Core Machine Diaphragm
Transversus Abdominis
Pelvic Floor
Multifidus
Teamwork The Core Machine •
•
•
Machine is optimized when all gears work together. Gears must move or the machine will fail Coordinated interaction will produce central stability
Teamwork Postural and Respiratory Functions of the PFM Hodges, Sapsford, Pengel (2007) • PFM followed respiratory cycle •
•
(ant, not post) PFM expiratory activity more associated with abs (low-level tonic activity w/bursts at mov’t frequency) PISTON
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Teamwork
Changes in IAP during Postural and Respiratory Activation of the Human Diaphragm Hodges et al (2000):
Teamwork
Teamwork
¨
¨
¨ ¨ ¨
Balanced interplay between the diaphragm, pelvic floor and abdominals preserves relative IAP throughout the respiratory cycle. A dynamic and coordinated model of core function 5TH member of our team Intersection of multiple systems Breath gives us a new gateway
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Teamwork The Piston, driven by the action of the diaphragm, is a dynamic model for core function. q Accessing the deep core system through breath provides a gateway for our pediatric clients. q
Graphic courtesy of Lee 2001, www.dianelee.ca
Integration: TAP
Stability that is responsive to the demands of function (non-uniform response) § § §
Teamwork Alignment Preparation
Alignment The Core Machine Machine works best if all the gears line up
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Alignment Muscles are strongest at the midpoint of available ROM • Muscles are weakest when long or short • Neutral Pelvis and Ribcage alignment (ribcage over pelvis) puts the Core in midrange positioning. •
Alignment
•
•
•
Different Ways to Balance the Spine Claus et al (2009): Flat, Long Lordosis, Short Lordosis, Slump Short Lordosis best activity for TA and Multifidus Flat-Least***
Alignment: Claus et al
Long Lordosis
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Alignment: Claus et al Short Lordosis
Alignment
•
•
•
Different Ways to Balance the Spine Claus et al (2009): Flat, Long Lordosis, Short Lordosis, Slump Short Lordosis best activity for TA and Multifidus Flat-Least***
Alignment Sitting Postures Affects PFM Activity in Parous Women Sapsford et al (2006) Slump, Upright Unsupported, and Very Tall Unsupported (thoracic) • Increased resting activation of PFM as alignment improved •
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Alignment: Sapsford et al Slump
Upright unsupported
Very Tall Unsupported
Alignment Sitting Postures Affects PFM Activity in Parous Women Sapsford et al (2006) Slump, Upright Unsupported, and Very Tall Unsupported (thoracic) • Increased resting activation of PFM as alignment improved •
Alignment Neutral Rib Cage and Pelvis §
§ §
Position of optimum Core recruitment (range) Move toward neutral “Sweet Spot” : optimized for your patient
2015 Shelley Mannell, PT and Julie Wiebe, PT. All rights reserved. DuplicaCon, transfer and/or transmission of these materials is prohibited.
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Integration: TAP
Stability that is responsive to the demands of function (non-uniform response) § § §
Teamwork Alignment Preparation
Preparation Neuromuscular Strategy: Preprogrammed motor control system, engaged through nervous system. The sensory system feeds information to create a graded response. Anticipatory + Reactive = Fxn Prepares for task + engaged based on demands of task = Function/ movement
Preparation Transverse Abdominis is not Influenced by the Direction of Arm Movement Hodges et al (1997)
TA EMG increased prior to deltoid regardless of UE direction • EMG of superficial abdominals varied with movement direction •
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Preparation Contraction of the Human Diaphragm During Rapid Postural Adjustments Hodges et al (1997): • Same result for the Diaphragm • Anticipatory contraction occurred regardless of phase of respiration • Same result for elbow motions, not hand or digits
Preparation Hodges et al (2007) •
Same result for the pelvic floor
•
Pelvic floor preceded the abdominals
Sjodhal et al (2009) •
PF precedes supine LE movement
Luginbuehl et al (2013) •
PF precedes heel strike in running
Integration Build a clinical model that: • • •
Teamwork: All gears moving Alignment: Optimized Preparation: Strategy
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Core Redefined CORE EXERCISE:
CORE STRATEGY: NEUROMUSCULAR
MUSCULOSKELETAL
Core Strategy: Defined Core Strategy is a system that harnesses the neuromuscular relationship that exists between the Anticipatory Core, Reactive Core, IAP Stability Cycle, Sensory System and the Brain. A cascade of force from the inside-out that provides both the stability and flexibility required to respond to the task at hand. #balance
Questions?
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Pediatric Core Research In contrast to the adult literature, very little pediatric research has specifically investigated the inner core musculature
Pediatric Research
What do we know about postural control in children with CP?
Pediatric Research Altered Trunk Movements During Gait in Children with Diplegia: Compensatory or Underlying Trunk Control Deficit? Heyrman L et al. 2014 • Looked at correlation between trunk movement and LE movement • Provided support for a primary trunk control deficit NOT just as a result of LE impairment
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Pediatric Core Research Differences in Respiratory and Pulmonary Function Among Children with Spastic Diplegia and Hemiplegia Cerebral Palsy in Comparison with Normal Controls. Kwon YH, Lee HY 2015 • Children with spastic diplegic and hemiplegia generate decreased respiratory pressure
Pediatric Research Development of Postural Responses During Standing in Healthy Children and Children with Spastic Diplegia Woollacott et al. 1998 • Group of typical children standing in alignment of child with spastic diplegia, showed similar disordered recruitment pattern during postural adjustments
Pediatric Core Research
• •
•
Anticipatory and Compensatory Postural Adjustments in Sitting in Children with Cerebral Palsy Bigongiari et al 2011 Tested in sitting Main postural control strategy is compensatory Increased levels of co-activation in outer core muscles (& others)
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Pediatric Core Research
• •
Anticipatory Postural Adjustments in Children with Hemiplegia and Diplegia Girolami G et al 2011 Tested in standing Higher levels of coactivation reported in outer core muscles (& others)
Pediatric Research
•
•
Effect of Seat Surface Inclination on Postural Stability and Forward Reaching Efficiency in Children with Spastic CP Cherng et al. 2009 Studied effects of seat angle on postural stability and forward reach Forward incline (=anterior inclination) more beneficial for both stability and reach for typical children and those with CP
Pediatric Research
• •
Seat Surface Inclination May Affect Postural Stability During Bocci Ball Throwing in Children with CP Tsai et al 2014 GMFCS levels I, II and III Anterior inclination associated with better postural stability and improved amplitude of elbow movement
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Pediatric Research Effects of Seat Surface Inclination on Respiration and Speech Production in Children with Spastic Cerebral Palsy Shin et al 2015 • FVC was significantly improved with anterior inclination
The Role of Core Function in Typical Development
Typical Development Examining details of typical development allows us to infer more about the development of the Core musculature
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Typical Development •
At birth, there is relatively low tone in the Core musculature (Hulme J, 2005)
Implications for Core Activity • Resting tone of Core gradually increases during the first 2 – 3 years (Hulme J, 2005)
Implications for Core Activity •
This occurs as motor tracts form increased number and strength of connections with neurons in spinal cord during early movement (Kasumacic N 2010, Martin JH 2005, Petersen TH 2012, Shumway Cook A, 2007)
•
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Typical Development: Newborn •
•
Physiological Flexion High, triangular-shaped rib cage Ribs close together
Implications for Anticipatory Core Activity •
•
Alignment of rib cage allows for inferior excursion of diaphragm only Little activity of the PF or TA
Typical Development: Newborn Milestones Motor Function: • Belly breathing • Feeding • Sleeping • Uncontrolled elimination
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Typical Development: 0-3 Months •
•
Asymmetry Expansion of anterior chest with activity of UEs in supine and prone Decreased hip flexion with LE activity
Implications for Anticipatory Core Activity Some increased excursion of diaphragm contributes to increased activity in PF Increased excursion of diaphragm, activity of PF and LEs contributes to activation of TA; the team is developing
•
•
Implications for Reactive Core Activity •
Pushing against surface in prone begins to activate reactive core Posterior oblique synergist (POS = contralateral latissiumus dorsi and glute max) (Lee D, 1999)
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Implications for Reactive Core Activity •
•
Activation of reactive core Anterior oblique synergist (AOS = abdominal oblique and contralateral adductor) follows (Lee D, 1999) Creates balance of extension and flexion activity
Typical Development: 0-3 Milestones Motor Function: • Prone: head lifting • Supported sitting: head bobbing • Begins to swipe at objects • Voiced sounds with movement
Typical Development: 4-6 Months •
Symmetry With increased muscle activation and independent movement, general increase in space between ribs occurs
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Implications for Anticipatory Core Activity Increased space between ribs supports change in rib cage shape allowing: ü Deeper excursion of diaphragm ü Improved activity of intercostals ü Increased activity of PF and TA
Implications for Anticipatory Core Activity •
Increased rotation activity around hip joints contributes to activation of PF
Implications for Reactive Core Activity •
As hip flexion decreases, the POS becomes increasingly active, gains strength within the available range and contributes to anti-gravity function
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Typical Development: 4-6 Milestones Motor Function: • Supine: bridges, rolling • Prone: propping on extended arms, superman, rolling • Sitting with hands propped • Beginning to reach forward (humeral flexion) • Transfers hand to hand • Deeper breaths, longer sounds
Typical Development: 7-9 Months •
•
Rotation Shape of rib cage is elongating, changing alignment of shoulder girdle Transitional movement creates functional linkage between the shoulder girdle and pelvic girdle
Implications for Anticipatory Core Activity •
•
Increased hip ROM and capacity to maintain midline hip rotation ramps up activation of PF Increased differentiation of control of diaphragm for postural stability, air flow and sound for speech (Alexander R, 1991)
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Implications for Reactive Core Activity POS contributes hip extension for active base of support (anti-gravity extension) AOS contributes to increased active rotation (protective reactions and transitional movement)
•
•
Implications for Reactive Core Activity •
•
Crawling and ½ kneeling positions reflect activity in reactive core Lateral synergist (LS = Contralateral Glute Med/Min and Adductors) Lee D, 1999 and Rotational Synergist (Ipsilateral Hip Lateral Rotators and Adductors) Wiebe J 2013
Typical Development: 7-9 Milestones Motor Function: • Pushing up into sitting, creeping/crawling, kneeling, pulling to stand, cruising • UEs for play, maturing grasp pattern • Produces sound independent of movement
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Typical Development: 10-12 Months •
•
Gross Motor Independence Rib cage becoming more rectangular in shape Movement begins in all planes against gravity
Implications for Anticipatory Core Activity •
•
Trunk movement in all planes increases activation of diaphragm Increased demand on midrange hip control in standing contributes to activation of PF
Implications for Anticipatory Core Activity •
Diaphragm, pelvic floor and TA partnership provides increased stabilization of lumbar spine and pelvis allowing initiation of movement from pelvis rather than upper trunk
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Implications for Reactive Core Activity Increased activity in all postural synergists in tandem with anticipatory core team
•
Typical Development: 10-12 Milestones Motor Function: • Climbing stairs, taking first steps • Manipulates and combine fine motor in play, dressing and feeding • Increased air intake, decreased respiratory rate • Abdominal-thoracic breathing pattern begins
Typical Development: 12-24 Months
•
I Can Do It Myself effective Core muscle activation now in place for maintenance of stable trunk with simultaneous movement of the body in all planes
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Typical Development: 12-24 Milestones Motor Function: • continued refinement in all areas of development
Effective Core Strategy Core Strategy =
stable head mobile trunk stable pelvis = dynamic postural control within function
Q and A
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What Happens to Core Function When Development is Atypical?
Atypical Development •
Motor development can be impacted by difficulties in either the motor or the sensory systems
Atypical Development •
•
Ultimately, lack of physiological flexion at birth fundamentally impacts alignment This negatively impacts the development of Core Strategy
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Atypical Development Movement patterns develop to compensate for this inefficient postural control: ü Breath holding ü Head/neck extension ü Stabilization by using end ranges
Atypical Development: Breath holding Task: Stabilize body against gravity Compensation: Breath holding
Implications for Anticipatory Core Activity •
•
Rib cage remains high and compact Decreased activation of respiratory diaphragm
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Atypical Development: Breath holding Functional Consequences: • Poor midline head control • Dislikes prone, unable to push off surface with UEs • Compromised movement – moving for as long as breath holding • Decreased sounds • Monocular fixation retained
Atypical Development: Neck Hyperextension Task: Stabilize head to provide stable base for eyes Compensation: Neck hyperextension possibly combined with active tongue retraction
Implications for Anticipatory Core Activity
•
•
Rib cage remains high and compact secondary to shoulder elevation Decreased activation of respiratory diaphragm
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Atypical Development: Neck Hyperextension Functional Consequences: • Poor midline head control • Dislikes prone • Decreased ability to pair UE function or movement with vision • Belly breathing • ?voiced sounds with movement • Monocular fixation retained
Atypical Development: Dynamic Holding Task: Stabilizing the trunk against gravity Compensation: Active holding with rectus abdominus, iliopsoas and diaphragm
Implications for Anticipatory Core Activity •
•
•
Muscles used isometrically for stabilizing during movement and against gravity Substituting phasic muscle activity for postural muscle activity Anticipatory core offline
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Atypical Development: Dynamic Holding Functional Consequences: • Supine preferred • Sitting with posterior pelvic tilt • Humerus remains internally rotated w/elbow, wrist and hand flexed • Breath holding with movement • Difficulty with development of binocular vision
Atypical Development: Dynamic Holding Mechanical (stiffness) Neurological
Dynamic Holding
(spasticity or hypotonia)
Muscle Tone
Atypical Development: Dynamic Holding Mechanical (stiffness) Neurological (spasticity, hypotonia)
Dynamic Holding
• Changing alignment and muscle activation alters dynamic holding • can improve postural control
Muscle Tone
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An Evidence-Based Pediatric Model for Dynamic Core Stability
Pop Quiz
Name that alignment?
K Pre-Botox
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K 8 Weeks Post-Botox
Alignment: Function follows Form
Ribcage position dictates: Excursion and contribution of the diaphragm to physiologic priorities, postural control and movement support ¨ Impacts the capacity of the diaphragm to set up the IAP pressure system ¨
Alignment How Do Anterior/Posterior Translations of the Thoracic Cage Affect Lumbar Spine, Pelvic Tilt, and Thoracic Kyphosis Harrison et al (2002): Posterior Thoracic Cage Translation • Decrease lumbar lordosis (7.4) • S-curve L-S (T-12-L2 flex) *apex* • Increase pelvic posterior tilt (15.9) • Sacral base posterior tilt (13.1), closer to horizontal
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Posterior Ribcage Translation
Position of the ribcage relative to the pelvis q
Part 1: Military
Posterior Ribcage Translation
Position of the ribcage relative to the pelvis q
Part 2: Slouch
Rib Cage Tip Lower Ribcage: Anterior/Superior (Top of the RibCage behind pelvis)
Lower Ribcage: Post/Inf (Bottom of the Ribcage behind pelvis)
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Dixie Cup on a Stick Lower Ribcage: Anterior/Superior
Named by lower rib cage
Dixie Cup on a Stick Lower Ribcage: Posterior/Inferior
Named by lower rib cage
Seated Lab Let’s play
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Seated Lab Make your rib cage tip Ant/Sup
Named by lower ribcage
Seated Lab Make your rib cage tip Post/Inf
Named by lower rib cage
Defining Neutral Alignment Neutral Ribcage/Pelvis • Position of optimum recruitment of the Diaphragm/Pelvic Floor Piston • Balance of flexors and extensors • “Sweet Spot” within neutral range; balancing their structure, muscular forces, and pressure
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Breathing and Rib Cage Position
Diaphragm: Dysfunction Breath Holding: • •
•
Valsalva: large loads Substitution for the Core in postural control, movement strategies, transitions and prepping for small exertions Repeated high intra-thoracic (ITP) and IAP can contribute to incontinence and constipation
Diaphragm: Dysfunction Chest and Belly Breathers: •
•
•
•
Lateral component dysfunction (lower 6 ribs) Keeps ribs high and flared or fixed Core disconnected/IAP potential is reduced Both use breath holding as a stability strategy
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Diaphragm: Intervention Umbrella Inhale
Close the Umbrella Around the Handle
Umbrella Breathing
Shelley’s Cues for Umbrella Breathing • • •
Alignment is the key! Teach using an actual umbrella Use visual of diaphragm action
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Shelley’s Cues for Umbrella Breathing •
•
• •
•
Place your hands around ribs 8-10 and provide gentle resistance throughout breath: “Breathe into my hands” “Make my hands move out” Use Theraband around ribs 8-10 and provide resistance (home program) Emphasize gentle breath in Breathe out “through a straw”; some children may need a straw to work with Some children may have increased difficulty with lip pursing (orbicularis oris = flexion activity)
Alignment is the key!
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Standing Lab Let’s Play
Pelvic Floor Anatomy 101: Action • Anticipatory contraction to stabilize lumbo-sacral, SI, pelvic-hip, and PS joints • Force couple with multifidus to control the sacrum • Synergist with TA (1˚ Anterior) • Ebbs and flows with the Diaphragm (1-7 mm) • Supports pelvic viscera • Pelvic floor (slow twitch) and urogenital diaphragm (fast twitch) • S2,3 nerve roots for PF and foot intrinsics Graphic courtesy of Lee 2001, www.discoverphysio.ca
Pelvic Floor: Function Function: •
•
Needs to be integrated into Core recruitment, and functional patterns Anticipatory, balanced contraction between: • •
•
• •
anterior/posterior Right (R)/Left (L)
Spine length remains the same; No pelvic movement Concentric/Eccentric Creating a motor program, strategy, and resting tone Graphic courtesy of Lee 2001, www.discoverphysio.ca
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Pelvic Floor: Dysfunction Dysfunction: • •
•
Bum gripping No link to the rest of Core o No TA o Breath holding Movement
o
Hollowing Pelvic rocking Ribcage elevation/depression
o
Teeth gritting
o o
Graphic courtesy of Lee 2001, www.discoverphysio.ca
Pelvic Floor: Tricks
Tricks: •
Ski Jump
•
Pursed lips/open mouth
• •
Turn feet in/out Lift your arches
Pelvic Floor and Kids Primarily look at PF in function - pelvic stability in: • Crawling • Standing • Moving from bilateral to unilateral stance • Unilateral stance
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Palpation •
•
Generally don’t palpate for motor function – observation! Dealing with continence, always palpate
Permission •
• •
•
Ask permission of child and/or adult Explain why “I need to put my hand here (demonstrate on yourself) to feel what your PF is doing. Is that OK with you?” Document, have another person present, use TA
Pelvic Floor Cues Alignment is key! Gently “stop a toot” Break sequence down: • Practice PF • Inhale, extend the exhale • Blow before you go • Then practice movement • “Beans” for teens • •
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Clinical Practice Case Presentation
Client Scenario: CP Hemiplegia •
•
MD born at 25 weeks, 971 grams Dx R hemiplegia CP
Client Scenario: CP Hemiplegia At 12 years old: • Decreased range and strength • Difficulties with visual scanning, attention • Altered sitting and standing posture • Altered gait pattern
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Client Scenario: CP Hemiplegia Functional limitations: • Sit to stand transition with UE support • Decreased sitting tolerance • Decreased standing balance
Client Scenario: CP Hemiplegia Anticipatory Core Deficit: • Breath holding for transitional movement or challenging tasks • Indicated poor diaphragm function
Client Scenario: CP Hemiplegia Anticipatory Core Deficit: • Inability to hold midrange posture in any position, stabilizing in end range • Indicated deficit in all four anticipatory core elements
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Client Scenario: CP Hemiplegia Anticipatory Core Deficit: • Pelvic retraction and poor hip control in midstance gait • Indicated poor pelvic floor integration to stabilize pelvis and anchor hip during gait
Client Scenario: CP Hemiplegia Anticipatory and Reactive Core Integration: • Poor anticipatory postural control in sitting, standing and gait • Indicated poor timing of recruitment of both anticipatory and reactive core components
Client Scenario: CP Hemiplegia
Pre-Treatment Sitting
Pre-Treatment Standing
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Client Scenario: CP Hemiplegia First Intervention Block: • Ability to maintain bench sitting for 20 minutes to meet demands of classroom organization and transitions. • Increase dynamic postural control as demonstrated by transitioning from sit-stand without the use of arms in order to carry school materials while moving and no loss of balance when stance is achieved.
Client Scenario: CP Hemiplegia First Intervention Block: 1 hr/week x 8 weeks • Taught neutral alignment of rib cage and pelvis in supine • Taught full utilization of diaphragm in supine “umbrella breathing” • Progressed to sitting with postural supports (wedge) and standing
Client Scenario: CP Hemiplegia •
•
Taught proper diaphragm engagement before transitional movement ”Blow before you go”
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Client Scenario: CP Hemiplegia In supine and sitting: • Paired optimized alignment with breathing with movement exercises for inside-out recruitment pattern • Variety of exercises and movement patterns targeted prioritized postural synergists
Client Scenario: CP Hemiplegia
Pre-Treatment
Post-Treatment (first block)
Post-Treatment w/ wedge
Client Scenario: CP Hemiplegia Second Intervention Block: • Increase trunk muscle coordination, strength and stability in a more demanding position against gravity as demonstrated by standing in a more neutral alignment with ribs over pelvis and reduced reliance on extreme anterior tilt. • Increase standing balance as demonstrated by maintaining standing in the same place for 30 seconds to facilitate safety in standing and social interaction.
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Client Scenario: CP Hemiplegia Second intervention block: In sitting and standing: • Paired optimized alignment with breathing with movement exercises for inside-out recruitment pattern • Increased awareness of alignment in standing • Variety of exercises and movement patterns targeted prioritized postural synergists
Client Scenario: CP Hemiplegia
Pre-Treatment 2009
Post-Treatment 2010
2013
Client Scenario: CP Hemiplegia
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Client Scenario: CP Hemiplegia
Treatment in Different Populations • • • • • • • • •
Cerebral Palsy Developmental Coordination Disorder Autism Spectrum Disorder Down Syndrome Varied Chromosomal Anomalies Organ Transplant Sensory Processing Disorder Anxiety Disorder Pediatric and Adolescent Stroke
Q and A
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Connect Shelley Mannell BSc, BHScPT www.heartspacept.com Twi8er @heartspacept Facebook.com/HeartSpacePT
[email protected] Julie Wiebe BSC, MPT www.juliewiebept.com Twi8er @JulieWiebePT Facebook.com/JulieWiebePT
[email protected]
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Bigongiari A, de Andrade e Souza F, Franciulli PM, El Razi Neto S et al. Anticipatory and compensatory postural adjustments in sitting in children with cerebral palsy. Hum Mov Sci. 2011;30:648-657. Bordoni B, Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidisciplinary Healthcare. 2013;6:281-291. Brogren E, Hadders-Algra M, Forssberg H. Postural control in children with spastic diplegia: muscle activation during perturbations in sitting. Dev Med Child Neurol. 1996;38:379-388. Cherng RJ, Lin HC, Ju YH, Ho CS. Effect of seat surface inclination on postural stability and forward reaching efficiency in children with spastic cerebral palsy. Res Dev Disabil. 2009;30:1420-1427. Claus AP, Hides JA, Moseley GL, Hodges PW. Different ways to balance the spine: subtle changes in sagittal spinal curves affect regional muscle activity. Spine. 2009;34(6):E208-214. Dodd ME, Langham, H. Urinary incontinence in cystic fibrosis. J Soc Med. 2005:98 (suppl 45):28-36 Girolami, G, Shiratori T, Aruin AS. Anticipatory postural adjustments in children with hemiplegia and diplegia. J Electromyogr Kinesiol. 2011;21:988-997.
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Heyrman L, Feys H, Molenaers G, Jaspers E et al. Altered trunk movements during gait in children with diplegia: Compensatory or underlying trunk control deficit? Res Devel Disabil. 2014; 35: 2044-52. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997;505 (2):539–548. Hodges PW, Richardson CA. Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res. 1997;114(2):362-370. Hodges PW, Gandevia SC. Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. J Applied Physiol. 2000;89:967-976. Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurouro Urodyn. 2007;26(3):362-371. Holmes J. Bladder and Bowel Issues for Kids. Missoula, MT: Phoenix Publishing; 2003. Kasumacic N, Glover JC, Perreault MC. Segmental patterns of vestibular- mediated synaptic inputs to axial and limb motorneurons in the neontatal mouse assessed by optical recording. J Physiol. 2010; 588(Pt 24): 4905-25.
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Kolar P, Sulc J, Kyncl M, Sanda J, Ondrej C, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without low back pain. J Orthop Sports Phys Ther. 2012;42(4):352-362 Kwon YH, Lee HY. Differences in respiratory and pulmonary function among children with spastic diplegia and hemiplegia cerebral palsy in comparison with normal controls. J Phys Ther Sci. 2015; 27: 401-03. Lee, D. The Pelvic Girdle: An Approach to the Examination and Treatment of the Lumbo-Pelvic-Hip Region. Edinburgh: Churchill Livingstone; 1999. Luginbuehl H, Greter C, Gruenenfelder D, Baeyens JP, Kuhn A, Radlinger L. Intra-session testretest reliability of pelvic floor muscle electromyography during running. Int Urogynecol J. 2013; 24: 1515-1522. Martin JH. The corticopinal system: from development to motor control. Neuroscientist. 2005; 11(2): 161–73. doi: 10.1177/1073858404270843 Massery M, Hagins M. Stafford R, Moerchen V , Hodges PW. Effect of airway control by glottal structures on postural stability. J Appl Physiol. 2013;115:483-490 Petersen TH, Farmer SF, Kliim-Due M, Nielson JB. Failure of normal development of central drive to ankle dorsiflexion relates to gait deficits in children with Cerebral Palsy. J Neurophysiol 2012; 109: 623-39.
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Sjodhal J, Kvist J, Gutke A, Oberg B. The Postural Response of the Pelvic Floor Muscles During Limb Movements: A Methodological Electromyography Study in Parous Women Without Lumbopelvic Pain. Clinical Biomechanics. 2009; (24): 183-189. Sapsford RR, Richardson CA, Stanton WR. 2006. Sitting posture affects pelvic floor muscle activity in parous women: an observational study. Aust J Physiotherapy. 2006;52(3):219-222. Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 2008;89(9): 1741-1747 van der Heide JC, Fock JM, Otten E, Stremmelaar E, van Eykern LA, Hadders-Aldra M. Postural control in during reaching in preterm children with cerebral palsy. Dev Med Child Neurol. 2004;46:253-266. Shin HK, Byeon EJ, Kim SH. Effects of seat surface inclination on respiration and speech production in children with spastic cerebral palsy. J Physiol Anthropol. 2015; 34: 17. doi 10.1186%2Fs40101-015-0057-3. Shumway-Cook A, Woollacott MH. Motor Control: Translating Research into Clinical Practice. Philadelphia, PA: Lippincott, Williams and Wilkins; 2007.
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