Cerebral Palsy Muscle Performance Quiz

Cerebral Palsy Orthoses

• Cerebral palsy (CP) is a group of disorders causing impairments in movement, posture, and muscle tone due to brain damage
• CP brain lesions in immature brains are not progressive
• CP problems in the MS system are progressive.
• Children with CP have an increased chance of developing complications like muscle contractures, skeletal deformities, and hip dislocation/scoliosis
• Two-thirds of children with CP walk with or without walking aids.
• Children with CP usually start walking later than their peers without CP, walk slower and with higher energy cost.

Musculoskeletal Problems in CP

• Progressive joint contractures
• Excessive muscle shortness
• Torsional deformities in the hip and foot
• Transfer and ambulation problems
• Inability to generate force
• Balance disorder
• Decrease in walking speed
• Decrease in stride length
• Increased energy consumption
• Limitations in participation in ADLS

Dynamic Muscle Imbalances

• Dynamic imbalance between the calf muscles that control foot and ankle alignment.
• Ankle plantar flexor muscles are overactive and ankle dorsiflexor muscles are ineffective.
• Variable imbalance patterns exist between foot and ankle supination and pronation muscles.
• Three common coupled foot and ankle malalignment patterns observed include equinus, equinoplanovalgus, and equinocavovarus.

Wolff's Law

• Bone growth and remodeling depend on loading. If loading increases, bone remodels to become stronger.

Normal Bone Growth vs. CP

• Normal bone growth involves typical developmental stresses and weight transfer.
• In CP, movement variation is absent. No load is placed on the bone.
• Bone and joint deformities are common.

Foot-Ankle Problems in CP

• Equinus deformity (most common)
• Varus deformity
• Planovalgus deformity
• Hyperdorsiflexion deformity
• In-toeing or out-toeing
• Finger problems
• Gait disorders leading to inability to walk
• Tone abnormalities, muscle imbalances, soft tissue contractures, bone torsion, and joint instability

Factors Causing Gait Disorders in CP

• Weak Muscles:
  • Tibialis anterior
  • Plantar flexors
  • Hip extensors
  • Hip flexors
  • Hip abductors
• Spastic Muscles:
  • Plantar flexors
  • Hip adductors
  • Quadriceps
  • Hamstrings

Equinus Deformity

• The most common foot deformity in individuals with CP.
• Characterized by plantar flexion malalignment of the hindfoot in relation to the ankle. Midfoot and forefoot alignment are normal in this condition.
• Results from tight calf muscles or Achilles tendons.

Orthosis Timing for CP

• At 18–24 months: Walking with equinus
• Until ages 4–5: Equinus walking without fixed contracture
• By 6–7 years: Fixed contracture begins to develop

Other CP Gait Related Issues

• Bilateral tiptoe walking can be a compensatory mechanism for hemiparetic cases.

Equinoplanovalgus Deformity

• Second most common foot deformity in individuals with CP.
• Includes equinus deformity of the hindfoot and pronation deformities in the midfoot and forefoot.

Equinocavovarus Deformity

• Includes equinus deformity of the hindfoot and supination deformities in the midfoot and forefoot.

Silfverskiold Test

• Used to distinguish accompanying muscle tension and assess the cause for ankle dorsiflexion limitation.
• The test is evaluated in knee extension and flexion.
• Increased dorsiflexion during knee flexion indicates gastrocnemius muscle tightness.
• No change in dorsiflexion during knee position change suggests tightness in deep structures like the soleus muscle or joint capsule.

Crouch Gait

• Weakness in the extensor muscles of the lower extremities is a characteristic of this type of gait
• Weakness in plantar flexors contributes to the Crouch Gait
• Knee extension deficit is evident
• Tight or spastic hamstrings
• Hip flexion contracture
• Iatrogenic gait due to surgeries

Purpose of Orthoses

• Prevent deformities and contractures
• Control muscle hypotonia and stiffness
• Prevent or delay surgery
• Support surgery
• Provide functionality

Tardieu et al. (1988)

• Contractures can be prevented with minimal 6 hours of stretching.

Orthosis Texture Types

• Rigid: prepared individually with rehearsal made of materials like polyethylene, carbon, lamination, and metals.
• Semi-rigid
• Soft: standard sizes prepared by series production. Made from materials like fabric, elastic fabric, and neoprene.

Foot Orthoses:

• Improves ground contact.
• Not effective in plantarflexion/dorsiflexion control.
• Used in planovalgus/planovarus deformities.
• Inframalleolar and supramalleolar types are used.

Inframalleolar Orthoses

• Doesn’t control sagittal plane movements of the ankle.
• Used to control moderate pes planovalgus deformity.

Supramalleolar Orthoses (SMO)

• Extends from toes to above the malleoli.
• Partially controls foot movements in the sagittal plane.
• Treats medio-lateral instability of the subtalar joint, varus/valgus deformity, mild to moderate spasticity.

Foot Orthoses: Indications and Contraindications

• Indications: Medio-lateral instability of subtalar joint, midfoot deformity, mild to moderate spasticity
• Contraindications: Lack of voluntary dorsiflexion control, lack of heel strike, fixed equinus deformity, moderate to severe spasticity

Ankle-Foot Orthoses (AFOs)

• Basic orthosis for children with spastic diplegia.
• Used to maintain ankle in 90-degree neutral position.
• Prevents drop foot during swing phase.
• Ensures appropriate range of motion and functional improvements.
• Can indirectly stabilize the knee and hip joints.
• Various types exist, prescribed based on specific needs

Solid AFO (SAFO)

• Prevents ankle movement.
• Covers the entire back of the leg.
• Extends from below the fibular head to metatarsal heads.
• Used for plantar flexor, invertor or evertor muscle spasticity
• Used for mild crouch gait and moderate/severe medio-lateral ankle instabilities
• Increases stability in the midstance phase.

Articulated AFO

• Contains a joint.
• Useful for CP children who have enough stability to walk with a walker.
• Prevents plantar flexion by gaining dorsiflexion.
• Used for cases where spasticity is under control and the child has selective movements

PF Spasticity and Genu Recurvatum

• Plantar flexion spasticity can cause genu recurvatum (knee hyperextension).
• A stop in plantar flexion at 2-5 degrees of dorsiflexion can help to control genu recurvatum.
• If possible, control the knee joint movements indirectly through the ankle joint. Avoid the usage of KAFO.

Circumduction Gait

• The aim and goal of orthosis should be functionality.
• Knee joint unable to flex, impacting the quality of walking.
• Resulting gait is circumduction.

Contraindications of Articulated AFO

• Crouch gait: Does not correct crouched posture with increased dorsiflexion and knee flexion.
• Strong extensor posture
• Passive dorsiflexion does not reach 5 degrees

Ground Reaction AFO (GRAFO)

• Inarticulated orthosis that is a closed version of AFO, from the front.
• Prevents tibia from shifting forward during stance.
• Creates extensor momentum that typically arises from the quadriceps muscle.
• Commonly used in crouch gait

Posterior Leaf Spring AFO

• Passes behind the malleolus.
• Formed by cutting off edges (from malleoli location) of a solid AFO.
• Allows for stretch.
• Resists plantar flexion
• Allows 10° of passive dorsiflexion in stance phase.
• Prevents drop foot in swing phase.

Dynamic AFO (DAFO)

• Often used in CP.
• Made from flexible, thin thermoplastic material.
• Provides medial/lateral ankle stability.
• Controls supination and pronation.
• Allows for dorsiflexion/plantarflexion.
• Thought to reduce abnormal PF movements and inhibit hypertonus.

Orthopedic Boots

• Use instead of orthotics? (no)
• Does not prevent equinus deformity.

KAFO (Knee-Ankle-Foot Orthoses)

• Rare orthosis type
• Aims to control knee movements via the ankle joint.
• Purpose: Preventing knee hyperextension; Providing knee extension; Helping standing.
• Does not provide functional mobility.

Immobilizer

• Resting splint for knee extension.

HKAFO (Hip-Knee-Ankle-Foot Orthoses)

• Usually for non-ambulatory children
• Maintain and increase hip joint range of motion.
• Position hip to prevent subluxation and dislocation

HKAFO (Ambulatory Children)

• Use for reducing hip hyperadduction in children with scissoring gait or to increase sitting balance.

Hyperabduction Device

• Used to improve sitting stability in children with scissor gait.
• Hip-abduction orthoses may improve sitting stability by increasing the base of support.

Gait Trainer

• For children at GMFCS levels 4-5.
• Increases activity and participation.
• No severe contracture is present.

Hart Walker

• Walking aid for children at GMFCS levels 4-5.
• Allows independent walking (hands-free).
• Provides external balance support.
• Aids participation efforts.

Upper Extremity Orthoses

• Used for upper extremity impairments, insufficient to be used solo to resolve issues.
• Prevents deformity, development, progression of contractures during and after post-operative rehabilitation.
• Used mainly for stabilization, mostly at night, in order to not restrict functionality.
• Avoid use on palm/volar area of the fingers, tactile and sensory stimulation to prevent neglect of damaged area.

Spinal Orthoses

• Used to support sitting independently.
• Thoracolumbosacral type orthoses used
• Not effective for scoliosis management

TheraTogs

• Flexible, dynamic orthotic garment.
• Improves posture stabilization.
• Purpose is to correct/prevent deformities and improve functionality.

Symmetrical Approach for Orthoses Selection

• Even with hemiplegia, focus on symmetrical weight transfer and support for both sides of the body.
• Bilateral orthoses are advised for effective support and gait.

Night-Time Orthosis Use

• Do not force orthosis use if it is not tolerated.
• Orthosis tolerance issues may spread through the day.

Orthosis Selection Principles

• Determine the best type of orthosis based on the individual needs of the child, not just on the disease/condition
• Not every orthosis works for all cases

Case Study -1

• 6-year-old boy with spastic diplegia.
• Equinus deformity present in both feet.
• Limited ankle dorsiflexion, but increases with knee flexion (Silfverskiold test positive)
• Toe-walking, short step length, decreased walking speed, dynamic imbalance.
• Tibialis anterior weakness; gastrocnemius spasticity

Case Study -2

• 7-year-old girl with spastic diplegia.
• Hyperflexed knees, fatigue during walking, imbalance when standing, difficulty in long distances.
• Crouch gait, constantly flexed knees and increased dorsiflexion in ankles with small hip flexion
• Hamstring spasticity, quadriceps weakness.
• Forward tibia displacement, causing energy consumption during gait.