EHR525 Week 09 Cerebral Palsy - Charles Sturt University PDF

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of th...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice School of Allied Health, Exercise and Sports Sciences 1 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 1 EHR525 EXERCISE FOR NEUROLOGICAL & MENTAL HEALTH CONDITIONS Cerebral Palsy Presenter: Darren Gray School of Allied Health, Exercise and Sports Sciences 2 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 2 What We Will Cover: ■ Epidemiology of Cerebral palsy. ■ Pathophysiology of Cerebral palsy. ■ Clinical features. Common motor deficits and associated secondary conditions. ■ Medications and surgical management strategies. ■ Effects of Cerebral palsy on physical function, fatigue and chronic disease risk. ■ Role of exercise management in Cerebral palsy. ■ General guidelines for exercise prescription in Cerebral palsy. School of Allied Health, Exercise and Sports Sciences 3 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 3 Introduction ■ Cerebral Palsy: General term for various motor function disorders caused by permanent, non-progressive, lesion/s within the developing brain. □ Present at birth or begins in early childhood (<3 years). ■ Non-curable, life-time condition. ■ Brain lesion/s may be congenital or acquired. ■ Variable aetiologies (95% of cases the cause is unknown). School of Allied Health, Exercise and Sports Sciences 4 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 4 Cerebral Palsy Statistics ■ Incidence in Australia: 2.1 per 1,000 live births (1 every 15-hrs). □ Males (57%) at higher risk than females (43%). ■ Approximately 34,000 people are living with cerebral palsy in Australia (47,601 by 2050). ■ Access Economics Report (2008) stated the direct financial cost of Cerebral Palsy in 2007 was $1.47 billion (0.14% of GDP). □ Cost of lost wellbeing (disability and premature death) was a further $2.4 billion. School of Allied Health, Exercise and Sports Sciences 5 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 5 Pathophysiology ■ Cerebral palsy= “brain paralysis”. □ Involves a series of causal pathways (i.e. sequence of events) that when combined can cause or accelerate injury to the developing brain. ■ Two main mechanisms: □ Development malformations: Brain fails to grow correctly. □ Neurological damage: Injury can occur before, during or after birth. ■ In 13 out of 14 cases the injury occurs either in the uterus or before 1 month of age. School of Allied Health, Exercise and Sports Sciences 6 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 6 Types of Cerebral Palsy Movement Anatomical Physiological School of Allied Health, Exercise and Sports Sciences 7 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 7 Spastic Cerebral Palsy ■ Most common form: 70-80% of cases. ■ Caused by damage to the motor cerebral cortex. ■ Increased muscle tone and increased deep tendon reflexes. ■ Causes difficulty with gait, changing positions, grasping/releasing and manipulating objects. School of Allied Health, Exercise and Sports Sciences 8 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 8 Main Areas for Spasticity ■ Increased muscle tone typically involving: □ Flexor muscle groups of the upper extremities: • Biceps brachii, brachialis, pronator teres. □ Extensor muscle groups of the lower extremities: • Quadriceps, triceps surae. ■ Antagonistic muscles of the hypertonic muscles are usually weak. School of Allied Health, Exercise and Sports Sciences 9 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 9 School of Allied Health, Exercise and Sports Sciences Ehrman et al. (2013) 10 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 10 Dyskinetic Cerebral Palsy ■ 20-30% of cases. ■ Caused by damage to the Basal Ganglia. ■ Movement disorders: athetosis, tremor, dystonia, chorea, ataxia, and rigidity. ■ Impaired gait and poor postural control. ■ Difficulties with speaking, feeding, reaching/grasping, and swallowing. ■ Disappears during sleep / increase with stress. School of Allied Health, Exercise and Sports Sciences 11 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 11 Movement Disorders in Dyskinetic Cerebral Palsy ■ Athetosis: Continuous stream of slow, sinuous, writhing movements, typically of the hands and feet. ■ Tremor: An involuntary, spasmodic movement of a body part. ■ Dystonia: Involuntary, sustained muscle contractions. ■ Chorea: Brief, irregular contractions that are not repetitive or rhythmic, but appear to flow from one muscle to the next. ■ Rigidity: Increase in muscle tone, leading to a resistance to passive movement. School of Allied Health, Exercise and Sports Sciences 12 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 12 Ataxic Cerebral Palsy ■ 10% of cases. ■ Caused by damage to the cerebellum. ■ Characterised by a lack of coordination and poor balance: □ Abnormalities of voluntary movement involving balance and position of trunk and limbs in space. □ Wide-based, unsteady gait, tendency to fall, stumble. □ Difficulty controlling hand and arm while reaching. □ Problems with timing of motor movements. ■ Completely unrelated to the disease and should not be confused with degenerative ataxias, such as PD. School of Allied Health, Exercise and Sports Sciences 13 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 13 Mixed Cerebral Palsy ■ Classification to diagnose individuals who do not perfectly fit into other types. ■ Display traits of: □ Spastic Cerebral Palsy □ Dyskinetic Cerebral Palsy. ■ Due to injury to both Pyramidal and extra pyramidal regions. School of Allied Health, Exercise and Sports Sciences 14 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 14 Associated Conditions ■ Epilepsy: If present, increases the prevalence of intellectual disability. ■ Visual and speech impairments common. ■ Scoliosis: Common in younger individuals and may need surgical correction in those severely affected. School of Allied Health, Exercise and Sports Sciences 15 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 15 Ehrman et al. (2018) School of Allied Health, Exercise and Sports Sciences 16 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 16 Secondary Conditions ■ Those resulting from cerebral palsy and leading to functional decline. ■ Often can be affected or improved by treatment. ■ Contractures: Decrease ROM and alter posture. ■ Overuse syndrome. ■ Poor joint alignment. School of Allied Health, Exercise and Sports Sciences 17 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 17 Ehrman et al. (2013) School of Allied Health, Exercise and Sports Sciences 18 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 18 Ehrman et al. (2013) School of Allied Health, Exercise and Sports Sciences 19 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 19 Risk Factors for Cerebral Palsy (Common) ■ Maternal health/infection/toxins. ■ Multiple gestations. ■ Infant illness. ■ Rh blood type incompatibility. ■ Breech birth. ■ Low birth weight/ pre-term. School of Allied Health, Exercise and Sports Sciences 20 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 20 Risk Factors for Cerebral Palsy (Premature) ■ Patent ductus arteriosus. ■ Neonatal seizures. ■ Hypotension. ■ Sepsis. ■ Blood transfusion. ■ Hyponatraemia. ■ Prolonged ventilation. ■ Total parenteral nutrition. ■ Pneumothorax. ■ Parenchymal damage. Murphy et.al. (1997). BMJ, 314; 404. School of Allied Health, Exercise and Sports Sciences 21 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 21 Risk Factors for Cerebral Palsy (Born at Term) ■ Placental abnormalities. ■ Birth asphyxia. ■ Major and minor birth defects. ■ Neonatal seizures. ■ Low birthweight. ■ Respiratory distress syndrome. ■ Meconium aspiration. ■ Instrumental ⁄ emergency caesarean delivery. ■ Hypoglycaemia. ■ Neonatal infections. McIntyre et.al. (2012). Develop Med Child Neurol, 55(6); 499-508. School of Allied Health, Exercise and Sports Sciences 22 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 22 Gross Motor Function Classification System (GMFCS) School of Allied Health, Exercise and Sports Sciences 23 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 23 Ehrman et al. (2018) School of Allied Health, Exercise and Sports Sciences 24 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 24 Medications and Management ■ Anti-seizure meds: □ Commonly prescribed. □ Side effects include mental confusion or irritability, weight loss, dizziness, nausea or alternatively, hyperactivity. □ Can blunt the physiological response to exercise. ■ Anti-spasmodic and muscle relaxants: □ Used to decrease muscle tone. □ Side effects include drowsiness and lethargy. □ Poor balance/instability may also result. School of Allied Health, Exercise and Sports Sciences 25 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 25 Botulinum Toxin ■ Botulinum Toxin (Botox) injections: □ Inhibits release of neurotransmitter causing relaxation of the muscle and a temporary reduction in spasticity □ Can last 3-4 months □ May be particular important in the treatment process for children □ Used in combination with physical therapy School of Allied Health, Exercise and Sports Sciences 26 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 26 Medications and Effect on Exercise Ehrman et al. (2018) School of Allied Health, Exercise and Sports Sciences 27 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 27 Surgery ■ Lengthening muscle or connective tissue: □ Needs to be accurately assessed. □ Followed by long periods of rehabilitation. □ More than one muscle/tissue may be lengthened at a time. ■ Selective Dorsal Rhizotomy (SDR): □ Involves selectively cutting dorsal roots □ Normally performed at L2-L5 level □ Results in an interruption of afferent limb of the stretch reflex and subsequently reduces muscle tone. School of Allied Health, Exercise and Sports Sciences 28 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 28 SDR Procedure School of Allied Health, Exercise and Sports Sciences 29 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 29 Effect of Cerebral Palsy on Physical Function Mesterman, et al. (2010). J Child Neurol, 25(1); 36-42. School of Allied Health, Exercise and Sports Sciences 30 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 30 Effect of Cerebral Palsy on Fatigue McPhee, et al. (2017). Develop Med Child Neurol, 59; 367-373. School of Allied Health, Exercise and Sports Sciences 31 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 31 Effect of Cerebral Palsy on Chronic Disease Risk ■ Presence of weakness, spasticity, pain, fatigue, orthopaedic impairments limit function and activity. ■ Cerebral palsy has a “progressive” impact on health status due to reduced activity levels. School of Allied Health, Exercise and Sports Sciences Peterson, et al. (2012). Obesity Revs, 14; 171-182. 32 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 32 Prevalence of Chronic Disease in Cerebral Palsy Peterson, et al. (2015). JAMA, 314(21); 2303-2305. School of Allied Health, Exercise and Sports Sciences 33 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 33 Benefits of Exercise in Cerebral Palsy Ehrman et al. (2013) School of Allied Health, Exercise and Sports Sciences 34 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 34 Pre-Exercise Screening and Assessment ■ Follow normal ESSA pre-exercise screening guidelines. □ Cardiovascular disease risk. ■ Physical examination: □ Muscle tone is likely may be abnormal (spasticity assessment). □ Reflexes may be primitive and/or hypersensitive. □ Assess upper body, lower, body and cerebellum. ■ Gait and posture assessment: □ Ability to ambulate varies greatly among those affected. □ Look for deformities, contractures, and gait deviations. ■ Balance assessment. School of Allied Health, Exercise and Sports Sciences 35 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 35 Pre-Exercise Screening and Assessment ■ Common postures: □ Internal shoulder rotation, elbow flexion, forearm pronation, wrist flexion, finger flexion, thumb in palm. □ Hip flexion, hip abduction, knee flexion, ankle equinus, hindfoot valgus, toe flexion. ■ Common gaits: □ □ □ □ Toe walking. Crouched gait. Jump knee gait. Scissoring. School of Allied Health, Exercise and Sports Sciences Watch for these common presentations 36 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 36 Effects Cerebral Palsy on the Exercise Response ■ Up to 50% lower max work capacity (due to mech efficiency). ■ Higher than expected cardiovascular and metabolic responses to exercise at a given submax workload. ■ Lower peak physiological responses that healthy controls (10-20%). ■ Mechanical inefficiency and transient increases in spasticity and ataxia after intense exercise. ■ Chronic response to exercise unchanged. School of Allied Health, Exercise and Sports Sciences 37 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 37 Recommendations for Exercise Testing ■ Aerobic exercise testing: □ ECG not generally required for prior to exercise participation. • May help better define an individual exercise prescription □ Mode is important and depends on level of disability: • Wheelchair ergometry, leg ergometry, arm ergometry, seated stepping (Dyskinetic). • Treadmill (use care at the final stages of the protocol when fatigue occurs and gait pattern may deteriorate). ■ Strength testing: □ RM test can be used; depending on individual, consider a 1RM versus 5RM versus 10RM versus 25 RM □ Number of reps in 1 min. □ May need to adapt equipment in those with grip deficits. □ Consider machine weights versus free weights for safety. School of Allied Health, Exercise and Sports Sciences 38 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 38 Recommendations for Exercise Testing ■ Flexibility and ROM testing: □ Joints and tissue can be injured if stretching not carefully and properly performed. □ Whole body with focus on areas of spasticity and contracture. □ Measure using goniometer, tape measure, sit-and-reach box. ■ Functional testing: □ Balance. □ Gait. □ Mobility. School of Allied Health, Exercise and Sports Sciences 39 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 39 Aerobic Exercise Prescription ■ Goal: To increase VO2, delay functional decline, and prevent secondary conditions. ■ Start with interval training and progress as appropriate. ■ Non-weight bearing recommended to avoid joint and muscle pain. ■ Consider swimming or other water activity, cycling, and so on. School of Allied Health, Exercise and Sports Sciences 40 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 40 Resistance Exercise Prescription ■ Goal: To slow or reverse muscle weakness and increase ability to stand longer and perform ADLs. ■ Can improve gait, muscular strength, and wheelchair ambulation. ■ Train weak muscle groups that oppose hypertonic muscle groups. ■ High-volume reps suggested. ■ Safety is important given client limitations. School of Allied Health, Exercise and Sports Sciences 41 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 41 Flexibility and ROM Exercise Prescription ■ Goals: To maintain current ROM, targeting specific ROM increases to improve functionality, and avoiding surgery. ■ Hypertonic muscles should be stretched slowly to their limits throughout the workout program to maintain length. ■ Stretching for 30 s improves muscle activation of the antagonistic muscle group, whereas sustained stretching for 30 min is effective in temporarily reducing spasticity in the muscle being stretched. ■ Consider beginning and ending an exercise session with ROM. ■ PNF technique is effective. ■ Ballistic stretching should be avoided. School of Allied Health, Exercise and Sports Sciences 42 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 42 General Considerations for Exercise in Cerebral Palsy ■ Considering using adaptive equipment for safety and optimal test/exercise conditions. ■ Be aware of early fatigue because of poor efficiency of movement and hypertonicity. ■ Training sessions will be more effective, particularly for individuals with high muscle tone, where: □ Exercise sessions short but frequent, rather than one long. □ Relaxation and stretching routines are included throughout the session. □ New skills are introduced early in the session. School of Allied Health, Exercise and Sports Sciences 43 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 43 Sport and exercise Considerations for Cerebral Palsy ■ The therapeutic goals of CP patients differ based on their GMCS classification. Classes IV to V have significant motor limitations and will struggle to perform structured exercise programs. Mild physical activity, such as range of motion exercises and stretching, should be recommended for this subtype as it reduces their sedentary activity. ■ CP should not exceed 2 hr/d engaging in nonoccupational leisure activities and should be encouraged to break up prolonged sedentary activities with 2 min of active movement every 30 to 60 min. School of Allied Health, Exercise and Sports Sciences 44 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 44 Sport and exercise Considerations for Cerebral Palsy ■ Cardiorespiratory activities to CP patients at a frequency of 23/wk, with an effort of 40% to 80% of heart rate reserve or 50% to 60% of peak oxygen consumption at a min of 20 min, for a duration of 8 wk to measure increases in endurance and other health benefits. ■ Resistance training employing progressive resistance exercise training (PRE) utilising a functional power-training program consisting of resistance training with exercise at high movement velocity demonstrated improved limb power ■ Toldi, James DO; Escobar, Joseph MD; Brown, Austin MD. Cerebral Palsy: Sport and Exercise Considerations. Current Sports Medicine Reports 20(1):p 1925, January 2021. | DOI: 10.1249/JSR.0000000000000798 ■ School of Allied Health, Exercise and Sports Sciences 45 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 45 General Exercise Prescription Review Ehrman et al. (2018) School of Allied Health, Exercise and Sports Sciences 46 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 46 Summary ■ Exercise Physiologists can play an important role in the management of cerebral palsy. ■ Goals of exercise training: □ Improve physical function. □ Prevention of secondary conditions. □ Improved QOL. ■ Innovation may be required for safety and effectiveness of cardiovascular and resistance training in those with cerebral palsy. School of Allied Health, Exercise and Sports Sciences 47 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 47