Cerebral Palsy and Physical Therapy

• The content covers cerebral palsy (CP) and physical therapy

Learning Objectives

• To classify CP and discuss the influence on treatments and research.
• To analyze movements for CP patients and identify impairments that contribute to movement patterns.
• To develop treatment strategies grounded in experience and available evidence to improve movement for children with CP

CP Classification by Physical Involvement

• Diplegia is 66% spastic.
• Athetoid is 19% spastic.
• Ataxic is 8% spastic.
• Spasticity can be mixed and/or hypotonic.
• Degree can be mild, moderate or severe

Gross Motor Function Classification System (GMFCS) 6-12 yo (Palisano)

• Level I is walking without restrictions while having limitations in advanced gross motor skills
• Level 2 involves walking without devices but having limitations outdoors
• Level 3 presents walking with a device while having limitations outdoors
• Level 4 shows self mobility with limitations and power mobility outdoors
• Level 5 is severely limited self mobility

Motor growth curves

• A typically developing 5 year old scores 100% on the GMFM
• Children with CP plateau, change scores mean more as the child ages, especially when interpreting research

Research

• GMFCS levels I and II do not decline in function during adolescence to adulthood.
• GMFCS levels III, IV, and V decline with age.

Movement Analysis

• Observe movement and or skill a child wants to improve
• Mobility, also known as ROM
• Stability, also known as Strength
• Controlled Mobility, also known as Balance
• Motor control

Treatment

• Treat these issues as needed
• Finish by practicing the skill differently to incorporate improved impairments

Mobility in Children with CP

• Femoral antetorsion often occurs
• External/internal tibial torsion such as W-sit
• Pes planus/cavus can occur in Di vs. Hemi
• Hip instability
• Capsule tightness occurs with joint play issues:
  • ↓ femur inferomedial glide (abd)
  • ↓ femur anterior glide (ext/ER)
  • ↓ talus posterior glide (DF)

Problems with Mobility Continued

• Spasticity occurs in:
  • Iliopsoas
  • Adductors
  • Hamstrings
  • Rectus femoris
  • Gastroc-soleus

Equinus Deformity

• Common gait problem in children with CP

Causes of Equinus Gait

• Muscle imbalances and strong spastic plantarflexors overpower weak dorsiflexors, resulting in plantarflexor contractures

Stability and Strength in CP Patients

• Decreased fiber size and number within muscles
• Cross sectional area of spastic fibers is less than 1/3 of normal fibers
• Fibre are shorter than normal with type I (slow twitch) predominance

Muscle Imbalances Due to Spasticity

• Plantar Flexor (PF) 35% AB
• Dorsiflexion (DF) 50% AB
• Quadriceps and Hamstrings (HS) 60% AB
• Gluteus Maximus 20% AB

Spasticity tests include

• Hip adductors.
• Knee flexors.
• Ankle plantar flexors.
• Strength assessments involves:
  • Hip ab/adductors.
  • Knee fl/extensors.
  • Ankle df/plantarflexors.
• Also GMFM66 and gait speed measurement

Results from study on diplegic CP

• Strength was highly related to function in subjects with spastic diplegia CP
• Strength explained significantly more variance than spasticity for this subject group
• Hip abductor, knee flexor, and ankle dorsi-plantarflexor strength were the muscle groups most highly correlated with function

Assumptions about spastic muscles

• Spastic muscles are not especially strong and are sometimes the weakest
• Muscle imbalances do not necessarily occur in a predictable pattern based on spasticity

Spasticity Studies

• Spasticity is present with passive movement but there is less influence when actively moving
• Synergistic movement overshadows spasticity during function

Strength Training and CP

• Muscle strengthening is not effective in CP, because exercise recommendations (single joint resistance, overload, frequency) are often not followed
• Power training (high velocity) shows gains in walking performance

Considerations for strengthening Spastic Muscles

• Strengthening a spastic muscle through full range at higher speeds may result in better control over that muscle, reduced spasticity and improved ROM and function
• Practicing the skill differently to incorporate improved impairments

Practice for Development

• New walkers (12–19 months), use step counter
• Walk for 50% of their waking day
• Average is 2,368 steps/hour or about 14,000 steps/day
• Results in 4,200 meters of distance, that's 46 football fields
• New walkers fall about 17 times per hour in typical free play with short bouts of walking with variable paths

CP Interventions

• Strengthen all CP muscles, focus on antigravity muscles such as glut max, the quads and ankle plantarflexors
• If spasticity limits function, consider spasticity reducing interventions
• Supplement impairment treatments with functional skill practice

Equinus Treatment

• Get a plantigrade foot through ROM, (mob, stretch pFs, night splints, serial cast, daytime AFOs, or heelcord lengthening)

Treatment if spasticity is present

• Consider Botox, SDR
• Strengthen plantarflexors in a closed chain
• Strengthen dorsiflex in open chain
• Work on single limb balance
• Motor control, by getting long strides with ankle df/knee extension

Crouch Treatment

• ROM: stretch HS and use knee immobilizers at night and serial cast in the daytime.
• OrthoSx: HS, hip fl
• Consider Botox or SDR is tone is present
• Bracing: GRAFOs only if no knee flexion contracture, reinforced AFOs, KAFOs,
• Strengthen quads at end range as well as ankle plantarflexors, and glut max/med.
• Improve motor control by walking on TM with some weight unloaded, and focusing on taking big steps.

Body Weight Supported gait

• Body weight supported TM training vs strengthening group both showed gains and maintained improvement in cadence.

In-toeing/Scissor Treatment

• ROM: need external rotation and abduction range, mob, taping, positioning out of W-sit
• Strength: glut med posterior fibers, glut max
• Improve Balance by practicing single limb balance, sit stand with abd/ER, balance beam, roller skating, karate