Understanding CP_Part B_Handouts (1).pdf

9/24/2023 Exercise Rehabilitation for Cerebral Palsy Part B Assessment and Treatment James Czencz [email protected] Physiotherapist 1 Case Study A - Khaled • Male, 7 years old • Diagnosis: No formal diagnosis • Syrian refugee (speaks English at appropriate age level, however family do n...

9/24/2023 Exercise Rehabilitation for Cerebral Palsy Part B Assessment and Treatment James Czencz [email protected] Physiotherapist 1 Case Study A - Khaled • Male, 7 years old • Diagnosis: No formal diagnosis • Syrian refugee (speaks English at appropriate age level, however family do not) • Lives with parents, and brothers (6 & 10 years) • Hobbies: Cricket, Football Father concerned regarding poor balance on L) LL, favours R) for all kicking activities, starting to walk between his first and second birthday and noticed he would 'toe walk' and was slower at reaching milestones than his brothers Past Medical History: Born pre-term at 37 weeks, below normal birthweight ~ 2200 grams 2 Is this client appropriate for exercise physiology? Review by a paediatric physiotherapist / or paediatrician to rule out / in developmental conditions ? CP Khaled was diagnosed with spastic hemiplegia CP (GMFCS I) affecting just his left leg several months later Referred to Exercise Physiology for strength and balance 3 1 9/24/2023 Quiz We are told that Khaled has Spastic Hemiplegia CP, thinking back to your pre-reading and online module, What type would Khaled have if all four limbs were affected * Quadriplegia Bilateral * Diplegia / Bilateral * Hemiplegia / Unilateral 4 Quiz We are told that Khaled has Spastic Hemiplegia CP, thinking back to your pre-reading and online module, What type would Khaled have if all four limbs were affected * Quadriplegia / Bilateral * Diplegia / Bilateral * Hemiplegia / Unilateral 5 Types of Cerebral Palsy 6 2 9/24/2023 Quiz What is the most common form of CP, by motor type? * Spastic * Dyskinetic * Ataxic * Mixed type 7 Quiz What is the most common form of CP, by motor type? * Spastic * Dyskinetic * Ataxic * Mixed type 8 What assessments would you like to carry out? Why? • Male, 7 years old • Diagnosis: Spastic CP - Hemiplegia • Syrian refugee (speaks English at appropriate age level, however family do not) • Lives parents, and younger brothers (6 & 10 years) • Hobbies: Cricket, Football Father concerned regarding poor balance on R) LL, favourites R) for all kicking activities, when younger (1 - 2 years) and starting to walk noticed would 'toe walk' and was slower at reaching milestones than his brothers Past Medical History: Born pre-term at 37 weeks, below normal birthweight ~ 2200 grams 9 3 9/24/2023 Assessments • Medical History and PA History • Goals • Pain • Pre-Screeners (ESSA Screener) • Aerobic Capacity: Treadmill Tests, Arm Ergometry Tests, Shuttle Run (Beep) Tests, 6MWT • Muscular Strength (Functional) & Endurance: Sit to Stand, Lateral Step up test, max plank hold, hand grip (Dynamometer), Push up test • Mobility: Observation, 6MWT, 10 metre walk test • Balance: Berg, TUG, Tap Test • Hobbies? Likes? Dislikes? ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, G. Moore, J.L. Durstine, P. Painter. 2016 10 What exercise treatments would you like to try? What barriers could you foresee could impact treatment? 11 Exercise and Physical Activity recommendations For children and adolescents, and young adults with CP Cardiorespiratory Endurance Training Muscle Strengthening Daily Physical activity (Mod to Vigorous / sedentary) Frequency 2 - 3 / week 2 – 4 times a week (nonconsecutive days) > 5 days / week / 7 days / week Intensity 60 – 95% MHR 40 – 80% HRR 65% peak oxygen uptake 1 – 3 sets 6 – 15 reps (50% – 85%) 1RM Mod to vigorous / sedentary (<1.5 METs) Time 20 minutes (minimum) No specific guidelines regarding training session 60 min / <2h/d or break up sitting for 2 min every 30 – 60 min 8 weeks (minimum) 12 – 16 weeks Type Any involving major muscles in continuous and rhythmic nature i.e. running, step-ups, stairs, cycling, arm ergometry, propelling a wheelchair, swimming Progress single joint machine based, to machine based plus free weights, multi-joint resistance exercises (CKC) Evidence RCTs + ACSM guideline RCTs + NSCA + ACSM guideline A variety of activities Non-occupational, leisure time sedentary activities * O. Verschuren, M. D. Peterson, A. C. Balemans and E. A. Hurvitz 12 4 9/24/2023 Complexity expanded While Khaled’s gross motor presentation may not be ‘severe’ or ‘complex’, what other factors could be considered so? 13 Quiz What elements from the case study would make Khaled’s exercise intervention more complex? * Culture * Language * Service Availability * Funding * Parental expectations 14 Quiz What elements from the case study would make Khaled’s exercise intervention more complex? * Culture * Language * Service Availability * Funding * Parental expectation 15 5 9/24/2023 Beyond sets and reps? 16 Quiz Cerebral palsy only affects children? True or false 17 Quiz Cerebral palsy only affects children? false Deloitte Access Economics, 2019 18 6 9/24/2023 Case Study B – Mrs P • Age: 56 • Diagnosis: Cerebral Palsy – Spastic diplegic • GMFCS III * • Married, with three adult children, and recently a grandmother • Supported by local disability provider (personal care, shopping, housekeeping) • Reduced fitness, persistent lower back pain and R) knee pain, recent R) TKR, spent four weeks at inpatient rehab facility. Recently discharged home • Mobility: Scooter for outside mobility, and four wheel frame for indoors and short distances (15mtrs), currently can only step transfer • Past Medical History: Cerebral Palsy, R) TKR (2023), incontinence, HTN 19 What assessments/treatments would you like to carry out? What barriers could you foresee could impact treatment? • Age: 56 • Diagnosis: Cerebral Palsy – Spastic diplegic • GMFCS III * • Married, with three adult children, and recently a grandmother • Supported by local disability provider (personal care, shopping, housekeeping) • Reduced fitness, persistent lower back pain and R) knee pain, recent R) TKR, spent four weeks at inpatient rehab facility. Recently discharged home • Mobility: Scooter for outside mobility, and four wheel frame for indoors and short distances (15mtrs), currently can only step transfer • Past Medical History: Cerebral Palsy, R) TKR (2022), incontinence, HTN 20 Cerebral Palsy – aging across the lifespan - CP is not just a childhood disability, people growup! - As they age, their needs and wants change - During transition to adult services, services are not often as coordinated Adults have different concerns - Pain (Callahan, Winitzer, & Keenan, 2001) - Fatigue - Depression / Anxiety - Falls - Functional decline (van Gorp et al., 2020) 21 7 9/24/2023 Cerebral Palsy – Exercise in Adulthood 22 23 Aim: To identify the effect of exercise on quality of life and participation for adults with CP Primary: Do exercise-based interventions improve (i) Participation? (ii) Quality of life? Secondary: (iii) functional mobility (iv) Fatigue, pain, self-efficacy and mood (v) Sustainability of outcomes? Czencz et al, under review 24 8 9/24/2023 Database Search - Process Search: September 2020 Updated: 2021 Endnote 1,675 studies 17 included Mean, SD, ES, CI Czencz et al, under review 25 Participant Characteristics 2% 7% 17% Participants: 532 (244 females) 44% 30% GMFCS I GMFCS II GMFCS III GMFCS IV GMFCS V Average Sample: 31 Mean Age: 16 to 47.6 years Czencz et al, 2022 26 Intervention Characteristics Combined 6% Dance 6% Setting Swimming 6% Strength 41% Aerobic vs. Strength 12% Community 5 Clinic 6 Not reported 4 Home 1 Aerobic (Treadmill) 29% Czencz et al, 2022 27 9 9/24/2023 Implications • Effect of exercise on quality of life, participation, pain, mood – are unknown • Community based exercise may have a positive effect on mental health and fatigue * • Choice of exercise should be based on client preference, service availability and convenience • Community based exercise for adults is recommended, adjust environment and contextual factors to support the individual to participate Czencz et al, 2022 28 Safe? Morgan et al, 2023 29 Case Study C - Pepito 30 10 9/24/2023 References 1. Cerebral Palsy Alliance Research Foundation. (2018). What is Cerebral Palsy. Retrieved from: https://research.cerebralpalsy.org.au/about-cerebral-palsy/ 2. Czencz, et al. (2022). Does exercise affect quality of life and participation of adults with cerebral palsy: a systematic review. 2022. 3. Deloitte Access Economics. The cost of cerebral palsy in Australia in 2018. 2019:67. 4. Jackman, et al. (2022). Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline. Developmental medicine and child neurology, 64(5), 536–549. https://doi.org/10.1111/dmcn.15055 5. Moore, et al. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities (4thEd.). (2016) Human Kinetics, USA. 6. Morgan, Cleary, Dutia, Bow, & Shields, N. (2023). Community-based physical activity interventions for adolescents and adults with complex cerebral palsy: A scoping review. Developmental Medicine & Child Neurology. 7. Palisano, et al, Content validity of the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurol. 2008 Oct;50(10):744-50. 8. Verschuren, et al. Exercise and physical activity recommendations for people with cerebral palsy. Dev Med Child Neurol. 2016 Aug;58(8):798-808. 31 11