Child with Hemiplegia
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Child with Hemiplegia Margo Prim Haynes, PT, DPT, MA, PCS Mary Rose Franjoine, PT, DPT, MS, PCS 2009 Prim Haynes & Franjoine 2009 Categories of Cerebral Palsy (CP) • Spastic or Hypertonic CP – Hemiplegia – Diplegia – Quadriplegia Prim Haynes & Franjoine 2009 General Comments • Hemiplegia means: Significantly more involvement on one side of the body • Usually full term pregnancy of single births Prim Haynes & Franjoine 2009 Pictures and Video Prim Haynes & Franjoine 2009 General Comments • Diagnosed early …. Why? Asymmetry Hold Bottle Mom notices hands first Pick up LE concerns later Prim Haynes & Franjoine 2009 Pictures Prim Haynes & Franjoine 2009 Dimensions NDT Enablement Classification Model of Health and Disability + Domains - Dimension Functional Domain Disability Domain A. Body structure & functions Structural & functional integrity Impairments A.Primary B.Secondary B. Motor functions Effective posture & Ineffective posture & movement 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 Prim Haynes & Franjoine 2009 NDT Enablement Classification Model of Health and Disability Dimensions + Domains - 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 2009 Prim Haynes & Franjoine 2009 Body Structure and Function • 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) Prim Haynes & Franjoine 2009 Cognition Function: • 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) Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Muscle Activation • Excessive co-activation (stiffness increases) during task – Limits movement – speed – Limits flexibility of movement responses Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Muscle Activation • Impaired Muscle Synergies – Limited repertoire – Stereotyped patterns of movement – Performed in limited ranges Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Muscle Activation • Latency in initiating • Difficulty sustaining postural muscles • Often passive termination of muscles Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Motor Execution • Impaired Modulation & Scaling of Forces – Inability to slow down as approach target – Particular difficulties grading grip Prim Haynes & Franjoine 2009 Neuromuscular System • Impaired Timing and Sequencing • Excessive overflow of Intra-Inter limb contractions – Decreases the capacity for isolated control during effort Prim Haynes & Franjoine 2009 Neuromuscular System Insufficient Force Generation (muscle strength) : Asymmetrical • Postural Muscles • Movement Muscles Prim Haynes & Franjoine 2009 Sensory System • May have: – Hyposensitive: ↓ sensation one side – Hypersensitive: ↑ sensitivity – Total Disregard / Neglect Prim Haynes & Franjoine 2009 Sensory System • May have: – Sensory Processing Impairment: – Visually and auditory Impairments Prim Haynes & Franjoine 2009 Video Prim Haynes & Franjoine 2009 Musculoskeletal System Secondary 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) Prim Haynes & Franjoine 2009 Dimensions NDT Enablement Classification Model of Health and Disability + Domains 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 Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture • Underlying postural tone low • High tone extremities, low tone trunk • Asymmetry = poor midline orientation Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture • One side of the body shows more variability than the other side of body • Uses “stronger” UE and “stronger LE to support in upright Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture • 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 Prim Haynes & Franjoine 2009 Pictures Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture • 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 Prim Haynes & Franjoine 2009 Pictures Prim Haynes & Franjoine 2009 Posture and Movement May see: Loss of independent ankle movement on involved LE • Limited function of ant tibialis and toe extensors • Splinting options important for this population Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Movement • Most active movement in sagittal plane • Moves with asymmetrical phasic bursts • Initiates movement with asymmetrical extension Prim Haynes & Franjoine 2009 Video Prim Haynes & Franjoine 2009 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 Prim Haynes & Franjoine 2009 Prone Postures: • Positions on one elbow using stronger arm for play Movement • Pull with strong arm and push with leg to get toys Prim Haynes & Franjoine 2009 Pictures and Video Prim Haynes & Franjoine 2009 Supine Postures: • Plays in this position until move upright Movement • Rolls and transition from this position moving over stronger side Prim Haynes & Franjoine 2009 Picture Prim Haynes & Franjoine 2009 Sitting Postures • Sitting is a functional position • Independent in a number of positions (“w” position, side sit, modified long sit) • Asymmetry Prim Haynes & Franjoine 2009 Pictures Prim Haynes & Franjoine 2009 Sitting Movement • Often prefers to move in sitting position – “Hitch” across floor Prim Haynes & Franjoine 2009 Video Prim Haynes & Franjoine 2009 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 Prim Haynes & Franjoine 2009 Pictures and Video Prim Haynes & Franjoine 2009 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 Prim Haynes & Franjoine 2009 Pictures Prim Haynes & Franjoine 2009 Standing Postures • Enjoy being upright • Asymmetrical stance Prim Haynes & Franjoine 2009 Pictures Prim Haynes & Franjoine 2009 Walking Movement • Ambulation – 80% ambulate by 2 years of age – 100% ambulate by 3 years of age Prim Haynes & Franjoine 2009 Video Prim Haynes & Franjoine 2009 Dimensions NDT Enablement Classification Model of Health and Disability + Domains 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 Prim Haynes & Franjoine 2009 Activities & Activities Limitation Locomotor Skills Communicates Basic ADL’s Feeding Often independently ambulatory (3 years of age) Communicates with /without articulation issues May be independent with self help skills Independent Prim Haynes & Franjoine 2009 Dimensions NDT Enablement Classification Model of Health and Disability + Domains 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 Prim Haynes & Franjoine 2009 Participation • 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 Prim Haynes & Franjoine 2009 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 Prim Haynes & Franjoine 2009 Treatment Strategies 4. For hand function: choose activities that use individual finger digits (puppet play, finger tip activities) 5. Treat using rhythm and music. Prim Haynes & Franjoine 2009 Treatment Strategies 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. Prim Haynes & Franjoine 2009 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 Prim Haynes & Franjoine 2009 Child with Hemiplegia Margo Prim Haynes, PT, DPT, MA, PCS Mary Rose Franjoine, PT, DPT, MS, PCS 2009 Prim Haynes & Franjoine 2009
