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AlWasl Hospital - Rehabilitation Section Rehabilitation Approach of Children with Cerebral Palsy Presented by Amal AlShamlan Head of Rehabilitation Section AlWasl Hospital Dubai Health Authority

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outline Definitions Model of care Classification Outcome measures Intervention strategies & philosophies AlWasl Hospital - Rehabilitation Section

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What is Cerebral Palsy? It is a group of conditions results in permanent disorders of movement & posture due to damage in fetal or infant brain Features: 1.epilepsy. 2. involuntary movement 3. abnormal sensation & cognition 4- abnormal vision, hearing & speech. 5- mental retardation. 6. abnormal movement / behaviour. AlWasl Hospital - Rehabilitation Section

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What is Rehabilitation ? Rehabilitation is combined and coordinated use of medical, therapeutic, social, educational and vocational measures for training or retraining the individual to highest possible level of function Holistic Approach QOL AlWasl Hospital - Rehabilitation Section

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Aims Improve functional status Prevent secondary impairments & functional limitations Efficiently use resources when there is reasonable prognosis for improvement Facilitate integration into the community AlWasl Hospital - Rehabilitation Section

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Model of care Functional & social vs disease-based Growth & development Child-focused & family centered. AlWasl Hospital - Rehabilitation Section

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International Classification of Functioning, disability and Health (ICF) condition Body Function & structure ActivitiesParticipation Environmental FactorsPersonal Factors World Health Organization, 2001

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AlWasl Hospital - Rehabilitation Section International Classification of Functioning, disability and Health (ICF) C.P. Impairments Muscle weakness Muscle hypoextensibility Poor balance Poor endurance Activity Limitation Walking on slopes Walking in crowds Climbing on equipment Participation Walking to class room Play during recess P.E class Environmental Factors Teachers concern Distance to play ground Children crowded in equipment Personal Factors Childs attitude toward: being transported Adult assistance

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Multidisciplinary Team AlWasl Hospital - Rehabilitation Section client Social workerpsychologistPhysicianOrthotists Speech /language therapists Occupational Therapists Physiotherapists

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referralscreeningInitiate therapy Cross referral - therapy Interdisciplinary clinic Discharge / long term follow up Care Pathway AlWasl Hospital - Rehabilitation Section

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Interdisciplinary Approach Working for common goals Pooling of expertise Opportunity for personal growth & development Forum for problem solving AlWasl Hospital - Rehabilitation Section

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Classification of CP Etiology Body involvement Movement disorder AlWasl Hospital - Rehabilitation Section impairment

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GMFCS for children with CP GMFCSDescription Level IWalks without restrictions; limitation in more advanced gross motor skills Level IIWalks without assistive devices; limitations are walking outdoors and in the community Level IIIWalks with assistive mobility devices; limitations are walking outdoors and in the community Level IVSelf-mobility with limitations; children are transported or use powered mobility outdoors or in the community Level VSelf-mobility is severely limited even with the use of assistive technology AlWasl Hospital - Rehabilitation Section

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Outcome measures Validate progress Provides accountability to child/family/third-party payers for intervention used Aides in plan of care Provides normative data to obtain developmental levels e.g. age equivalent, standard score AlWasl Hospital - Rehabilitation Section

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Tests Measuring Developmental Age, Activity, or participation Abilities TestDevelopmentalFunction/ActivityParticipation AIMSXX GMFMX PDMS IIXX TIMPX QuestX LAPIX PEDIXX AlWasl Hospital - Rehabilitation Section

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Assess postural control & alignment needed for age appropriate functional activities in early infancy 34 wks gestational age to 4 mths post full term delivery date Assess postural control & alignment needed for age appropriate functional activities in early infancy 34 wks gestational age to 4 mths post full term delivery date Assess gross motor function including maturation of skills and postural alignment of of infants from birth to 18 mths of age Specifically designed for CP, developed to measure change over time. Consists of activities in 5 dimensions: lying & rolling, sitting, creeping & kneeling, standing & walking, running & jumping. Assessment of motor tone & oromotor function for preterm babies More than 33 wks corrected age 1 mths post term Assessment of motor tone & oromotor function for preterm babies More than 33 wks corrected age 1 mths post term Used to evaluate quality of UE functions in 4 domains: dissociated movement, grasping, protective extension & weight bearing Assesses normative performance of gross/fine motor function for children from birth to 72 months of age

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communication rating scale skill% Pointing0 10 Gestures11- 20 Gestures with speech sounds 21- 30 Speech sounds31- 40 Single words41 50 Phrases51 60 Short sentences61 70 Complete sentences71 80 Complex sentences81 90 paragraphes91 - 100 AlWasl Hospital - Rehabilitation Section

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Spasticity Spasticity is one of the most common UMN lesion problem seen in children with CP resulting in postural control & movement disorder thereby limitting, delaying or arresting the sensory motor development.(also other areas like communication, cognition, social, perception etc). AlWasl Hospital - Rehabilitation Section

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What is spasticity? Spasticity is a motor disorder characterized by a velocity dependent increase in stretch reflexes(muscle tone) with exaggerated tendon jerks resulting from hyper excitability of the stretch reflex as one component of the UMN syndrome (Lance, 1980). Spasticity is a movement disorder affecting both the neural & non-neural characteristics of postural tone and can be described by the positive & negative UMN symptoms (D. Burke, 1988).

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Neural components of UMN symptoms Positive symptoms Spasticity. Spasms (flexor & extensor). Exaggerated tendon reflexes. Clonus. Babinski response. Negative symptoms Weakness. Loss of dexterity. Fatigability. AlWasl Hospital - Rehabilitation Section

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Non-neural component of UMN symptoms Altered muscle length (elasticity): muscle fibres shorten (hypoextensible). Altered muscle structure (viscosity): filaments become sticky affecting muscle glide(stiffness). Abnormal co- contraction (reciprocal innervation) : due to bio- mechanical effects of abnormal position. (too much stability & not enough mobility). Changes in visco-elastic properties leads to stiffness, tightness & contracture. AlWasl Hospital - Rehabilitation Section

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Normal postural tone Normal patterns of movement Success in normal patterns of movement repetitions Normal functional Skills achievements

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AlWasl Hospital - Rehabilitation Section CP? Abnormal postural tone Abnormal patterns of movement Success in abnormal patterns of movement/ stereotyped repetition Deformity/ less functional skills acheivments

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AlWasl Hospital - Rehabilitation Section Intervention Philosophies & strategies Evidence based? There is no evidence that any one treatment method is superior to another. Therapists select from the variety of treatments available those that best meet the childs and familys need.

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Analyzing Analysing the postural tone & patterns of movement. What the child can do? How? /cant do ? why? Choosing appropriate intervention/frequency depends on: Age ( infant, toddlers, preschool, adolescent etc ) Distribution of postural tone ( diplegic, hemiplegic, quadriplegic etc) Quality of postural tone ( mild, moderate or severe ). Associated problems.( vision, hearing, cognitive, seizure, SPD etc) AlWasl Hospital - Rehabilitation Section

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Early intervention Studies focused on child and family reported favorable outcomes. The analysis also suggested that parent participation might have a greater impact on childs outcomes for children younger than 3 yrs.

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AlWasl Hospital - Rehabilitation Section Neonatal physiotherapy is an advanced practice subspecialty area of paediatric physiotherapy and involves a highly complex set of skills in observation, examination and intervention procedures for the extremely fragile NICU population. Main objective to identify developmental delay in 1 st year of life Early intervention can change abnormal movement pattern in mild to moderate cerebral palsy Those whom deemed to be delay remain delay if no intervention started. Neonatal Developmental screening

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AlWasl Hospital - Rehabilitation Section All high risk preterm infants with meeting criteria: 1. Gestation 32 weeks and below 2. Birth weight < 1.5 kg 3. IVH GR.3&4, PVL 4. Chronic lung disease or O2 dependency 5. Ventilated for RSD

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Neonatal Developmental screening NICU : LAPI Outpatient : TIMP, AIMS, PDMS 2008 37 - 11 detected 2009 57 - 17 detected AlWasl Hospital - Rehabilitation Section

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Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit AlWasl Hospital - Rehabilitation Section

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Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies Neurodevelopmental Therapy ( NDT) Moving through normal movement patterns to experience normal movement Major components : reflex-inhibiting posture, inhibition of abnormal reflexes, normalization of muscle tone, and adherence to normal developmental sequence of motor progression AlWasl Hospital - Rehabilitation Section

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NDT Inhibiting abnormal movement patterns. Facilitating normal movement patterns. No strong evidence that supports the effectiveness of NDT for children with CP with respect to normalizing muscle tone, increasing rate of attaining motor skills, and improving functional motor skills Butler C, Darrah J: Effects of Neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence report. Dev Med Child Neurol 2001 ; 43: 778 - 790 AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies Sensory Integration Therapy Principle: a neurobiological process organizes sensation from ones own body and from environment and makes it possible to use the body effectively within environment Emphasis on importance of three body centered sensory systems : tactile, proprioceptive & vestibular AlWasl Hospital - Rehabilitation Section

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SI Therapy AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies Constrained - Induced Movement Therapy Constraining non-affected arm to encourage performance of therapeutic task with the affected arm, which children normally tend to disregard. Systematic review has found the effectiveness of CIMT for children with hemiplegic CP. AlWasl Hospital - Rehabilitation Section

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Serial casting Serial casting may serve to reduce spasticity in muscles by decreasing the strength of abnormally strong tonic foot reflexes.(Bertoli 1996). Serial casting in the CP population has been shown to improve ROM.( Brouwer 2000) Casting provides stability and prolonged stretch of a muscle which is immobilized in a lengthened position(Mosley 1997). At least 6 hrs of prolonged stretch is needed for effectiveness(Tardieu 1987).

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AlWasl Hospital - Rehabilitation Section Botox + serial casting Botox reduces spasticity and improves ambulatory status.(Flett 1999) When used in combination with serial casting it has shown to help maintain and improve muscle length and passive ROM.(Kay 2004) Without conservative interventions such as serial casting, (with & without botox injection) more expensive procedures may be necessary. (Flett 1999)

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Intervention Philosophies & strategies Body Weight Supported Treadmill Training AlWasl Hospital - Rehabilitation Section Uses theories of motor learning & importance of early task specific training Theory : activate spinal & supraspinal pattern generators for gait

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Intervention Philosophies & strategies Strengthening Progressive resisted exercise improves muscle performance & functional outcomes in CP children Research had supported effectiveness on increasing force production in CP Dodd et.al. systematic review of strengthening for individuals with cerebral palsy. Arch Phys Med Reh,83:1157-1164, 2002 AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies NMES Multiple studies have demonstrated the effectiveness of NMES, Reduce spasticity. Increase ROM & strength. Increase force production. Promote initial learning of selective motor control. AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies Orthotic devices, splints, cast Goals : Maintenance or increase ROM Protection or stabilization of a joint Promotion of joint alignment Promotion of function AlWasl Hospital - Rehabilitation Section

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Ankle Foot Orthosis Compared with barefoot gait, AFOs enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature PF and improved progression of foot contact during stance. AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies Assistive Technology & Adaptive Equipment Optimizes alignment, posture & function. Inhibits spasticity patterns. Facilitates more normal movement.

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Adjunct therapies Hippotherapy. Aquathearpy. suits. Theratogs. AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies Speech & Language Therapy Oralmotor function using strengthening / Intraoral stimulation verbal ( PROMPT) & non-verbal communication skills ( AAC & PECS, macatone) auditory training for HI audiometry screening swallowing function AlWasl Hospital - Rehabilitation Section

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Intervention Philosophies & strategies Psychological Assessment & Management Social support AlWasl Hospital - Rehabilitation Section

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Out of 32 patients received botox 69% attended PT & 31% did not attend AlWasl Hospital - Rehabilitation Section

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Out of 22 patients, 91% fully attended PT Mx. AlWasl Hospital - Rehabilitation Section

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% of patients who improved in ROM post botox 3-6 weeks & 3-6 months. AlWasl Hospital - Rehabilitation Section

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Benefits of communication Case selection. Goal setting. Educating parents/caregiver in active participation Compliance AlWasl Hospital - Rehabilitation Section

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Thank you AlWasl Hospital - Rehabilitation Section