motor dysfunctions in cerebral palsy

8/2/2019 Motor Dysfunctions in Cerebral Palsy

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Contents Definition

Classification

Impairments & Dysfunctions

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history First recorded in medical literature during 19th

century

Before 19th century

-

William Little indicated that the cause of spasticity andparalysis was due to brain damage during infancy

- CP was also k/a Littles Disease

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Differentiated congenital deformities

Grouped clinical presentations as

- Hemiplegic rigidity

- Paraplegia

- Generalized rigidity

Hammond (1871) athetosis

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Osler (1889) gave the following classification:- Infantile hemiplegia

-

Bilateral Spastic hemiplegia (spastic diplegia)- Spastic paraplegia

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1900 - 2000

Batten (1903) ataxic CP

Phelps ( 1941) grouped all movement disorders

under term dyskinesia that included followingsub categories

- Spasticity- Athetosis

- Overflow/ synkinesia

- Incoordination / ataxia

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Ingram ( 1955) separated hemiplegia, double

hemiplegia and diplegia from diskineticcategories ( dystonia, chorea, athetosis)

Evans et al ( 1987)- Hypertonia

- Hypotonia

- Dyskinesia

- Ataxia

Palisano et al 1

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From 2000

To be classified

- Neurologically ?

- Topographically ?

- Functionally ?

After 150 yrs of discussion.no conclusion

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definition Cerebral Palsy (CP) is defined as a group of disorders

of the development of movement and posture,

causing activity limitation, that are attributed to non-

progressive disturbances that occurred in the

developing fetal or infant brain

Developmental Medicine & Child Neurology 2005

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Classification

Hypertonic

Hypotonic

Dyskinetic

Ataxic

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impairments Neuromuscular

Sensory / Perceptual

Musculoskeletal

Respiratory

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hypertonic

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3. Grading agonist/antagonist

.Abnormal ability to grade between cocontractionand reciprocal inhibition

Can a quadriplegic have a hypotonic trunk???

4. Limited synergies

. Timing and ordering of basic synergies altered

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Sensory / Perceptual systems

1. Vision

o Primary impairments

- Strabismus

- Errors of refraction and accommodation

o Secondary impairments

- Upward gaze

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HIP

Subluxed/dislocated hip

- Retention of shape of acetabulum and femur

- Imbalance of muscle activity

KNEE

Flexion contracture Knee hyperextension

ANKLE & FOOT

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LONG BONES

Decreased bone density

Increased incidence of fractures

Small stature

MUSCLE DEVELOPMENT

Altered distribution of fast and slow twitch motor

units

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Respiratory system

Shallow respiration with an immobile ribcage

Incoordination between breathing, speech &

movement

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dysfunctions

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quadriplegia Head , Neck, Tongue & Eyes

Asymmetric extension of head , neck & trunk

Upward visual gaze, tongue retraction & jaw extension

Loss of ROM in the upper cervical spine flexion

Difficult chin tuck

Graded control of jaw absent

Inability to control C-spine in any other position thanextension

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Thoracic spine, ribcage & UE

Problem in pushing against a surface with UE whilelifting the head up

Lower trunk Easiest synergy

- Lumbar extension with hip flexion

- Sagittal plane flexion ( rectus abdominis) Switch their postures based on position

Unstable trunk

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How are the children with quadriplegia similar tohypotonics wrt trunk???

Lack of activity in postural muscles

Lack thoracic extension control

Lack of abdominal use

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Pelvic girdle & lower extremities

Sustained overactivity of hip flexors, adductorsand IR

- Narrow BOS

- Limited mobility- Tightness & contracture of overactive muscles

- Weakness & inactivity of antagonists

- Early hip dislocation

- Malformation of hip jt

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diplegia

Head , Neck, Tongue & Eyes Able to initiate, maintain and terminate muscle

activity

Coordinate functional movement synergies Effective use of sensory perceptual information

but

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Able to use UE weight bearing like normals

with a difference???

No lower thoracic extension

- Difficulty in overhead reaching

- Erect sitting

- Lower trunk wt shifting

Ribcage elevation, lower rib flaring

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Upper body substitutes for lower body

- Arms gets stiffer

- Thoracic spine increases in flexion

- Pectorals & RA overwork to pull the COM

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Lower trunk

Common patterns

Upper lumbar extension

Specific wt shifting strategy

No coordination between upper & lower trunk tocontrol COM

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Limited synergies

Poor grading with excessive co contraction

Poor ability to terminate

Abnormal timing, W sitting is common

Gets into sitting and standing earlier than a

quadriplegic

Good or Bad???

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hemiplegia

Head , Neck, Tongue & Eyes

Subtle asymmetrical head position

May have hemianopsia

Difficulty in perception of both tactile and

propriceptive info between two halves

Neck extension and lateral flexion

Affected visual scanning & reduced mobility of

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Increased muscle contractions

Typical hemiplegic posture

Does the unaffected arm suffer???

Sensory perceptual impairments

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Lower trunk

Asymmetry hemiplegic side shortened, pelvis

elevated & pulled back

Extreme extension in lumbar spine.is it same as

seen in diplegics???

Sitting postures

Scooting

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Asymmetry seen in 2 planes

Functional or true leg length discrepancy may be

present

Different standing postures

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hypotonic

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Decreased segmental moto-neuron pool excitability

Shumway cook, 1985

Other children which may exhibit many of the samecharacteristics :

Downs syndrome

Hydrocephalus

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Neuromuscular System

1. Reflexes / Tone

. May be increased or decreased

2. Muscle contraction

. Phasic burst of movement

. Problem in initiating, sustaining andterminating movement

3 3

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. Cannot generate cocontraction

4. Synergies

. limited and predictable

-. Difficulty in using postural muscles to initiate &sustain antigravity work

-. Substitute by using more superficial muscles

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1. Vision

o. Primary impairments

-. Strabismus

-. Errors of refraction and accommodation

o. Secondary impairments

- Use of eyes for postural control assistance rather

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Do not use information normally from

proprioceptive and tactile systems

Musculoskeletal system

1. Bony changes in spine and rib cage

2. Changes in other bones and joints ( shoulderand hip)

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Tightness in the muscle groups that remain in

shortened position

- Superficial & two joint muscles

-

In response to childs constant, unchangingposition

Uses skeletal stability, closed packed positions tosubstitute for muscular control and strength

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Respiratory system Shallow respiration with an immobile ribcage

Incoordination between breathing, speech &movement

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dysfunctions


On attempting head extension, it falls forward or restson the occiput

Both have different implications

Shoulder elevation is a substitute for cervical control

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1. Holding the head up

-. Lack of development of active capital flexion on

an extended C-spine

-. Over lengthening of cervical flexors

-. A shift in the position of laryngeal system

-. Use of upward gaze to help lift the head

-. Passive opening of the jaw with tongue retraction

& overstretching of the facial muscles

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2. Falling of head

- Lack of development of active chin tuck

- Over lengthening of cervical & upper thoracic

extensors

- Partial obstruction of airway

- Little use of vision

- Passive opening of jaw ( drooling)

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Movement is started with a wide base inextremities & more contact of trunk in both

supine and prone

Unable to develop thoracic extension & graded

shoulder mobility Arms substitute for trunk control, not for

exploration

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Lower trunk

Two common postures :

1. Rounding of thoracic spine into lumbar spine

-. Unstable open packed position

-. Requires much more physical effort for stability

2. Sharp upper lumbar extension

-. Seen in prone or standing

-. Stability at the expense of not moving the lowertrunk

-

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Which child assumes which position???

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Serve function of stability with wide BOS

BOS is so wide that it mechanically blocks

movement from other parts of the body

Poor ability to change positions

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dyskinetic

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athetosis

Constant succesion of slow, writhing, involuntary

movements of

- Flexion / extension

- Pronation / supination

Of fingers and hands and sometimes of toes and feet

Dorland, 1994

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chorea

Irregular, spasmodic, involuntary movements ofthe limbs or facial muscles

A ceaseless occurrence of a wide variety of rapid,highly complex, jerky movements that appear tobe well coordinated but are performed

involuntarily

Dorland, 1994

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dystonia

A state of abnormal tonicity in any of the tissues

Stedman, 1995

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impairments


1. Reflexes / Tone

Likely to show depressed DTRs

2.Muscle contraction Antagonist is overactive

Differing problems in initiating, sustaining and

terminating movement

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Alternations between flexion and extension in

movement efforts in posture

4. Limited synergies

Same as seen in subjects with hypotonics

Nashner, 1983

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1. Vision


-. Nystagmus may be present


-. Able to control eye movements forcommunication better than other CPs

-

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2. Less impaired kinesthetic and vestibular senses

3. Tactile hyper responsiveness may be present

. Musculoskeletal system

1. Develop fewer contractures

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2. Excessive mobility can result in

Instability of the jaw with TMJ joint deformitypossible

Overlengthening of infrahyoid muscles

Instability of cervical spine Instability of shoulder joint (mostly inferior)

Hyperextension at the elbow

Hyperextension of the IP joints of fingers

Overlengthening of

- Ant hip capsule & ligaments

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Secondary impairments

Hip dislocation Narrowing of the spinal cord

Spondylosis , radiculomyelopathy

Severely increased kyphosis

Scoliosis

Shift of the hyoid bone & laryngeal system

Develop adequate strength in the muscles usedfrequently and repetitively

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Respiratory system

Bursts of phonatory activity

Incoordination between breathing, speech &

movement

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dysfunctions The clinical signs are generally seen after firstyear of life :

- Bursts of movement

- Extraneous movement- Alternations between flexion/ extension

Most of the children stay hypotonic for manymonths past first or second year of life

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asymmetric extension of head & neck

Once movement begins, quick bursts of extension

in all positions

(Upward visual gaze, jaw extension & tongue

retraction)

Tongue protrusion ??

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Forceful cervical flexion is sometimes used to

- Holding head to counterbalance strong extension

- Develop for certain postures and movements like To move prone from W-sitting

To stabilise vision

Speaking

To stand

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(Problem in pushing against a surface with UEwhile lifting the head up)

In sitting & standing, the already flexed thoracicspine becomes a counterbalance for the forcefulextension of the cervical & lumbar extension

Because of UE attitude, wt bearing is seen on thedorsum of hand

Head is used to initiate limb position

Mobility of arm movements comes from mobilityof scapula over ribcage

(restricted movements, poorly aligned scapula)

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On reaching,

Wrist flexion

MP & proximal IP hyperextension

No use of intrinsic muscles

No palmar arches

May use head and trunk flexion and extension to

control finger movements

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Most efficient way of movement scooting in

supine, bunny hopping in sitting

Lower trunk Lumbar & cervical extension Asymmetry of lumbar spine Shortening of lumbar extensors and lengthening

of abdominals Lower trunk cannot hold the COM

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Legs anchor trunk in moving from supine to proneand vice versa by providing a wide, stable BOS or themovement

Consistent, weight bearing position of LE decreaseextraneous, non functional movements

No pattern of hip flexion, adduction and IR seen inthese children

The starting position is hip flexion, abduction & ERwith knees in some degrees of flexion and feet ineversion and dorsiflexion

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Posture in W sitting is different from that of

spastic CP

Gait pattern :

Arms clasped or crossed in front of them toprevent losing balance forward

Wide BOS

Small degrees of hand, eye or jaw movements toshift weight just enough that a foot can move

forward slightly Lack of reciprocity of movement

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ataxic

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Ataxia

failure of muscular coordination, irregularity of

muscle action

Lack of coordination with tremor and dysmetria

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impairments


1. Reflexes / Tone

Depressed or normals DTRs

2.Muscle contraction

Agonist activity is reduced in force

Problems in initiating, sustaining and terminatingmovement

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Normal ability to use patterns of cocontraction

and reciprocal inhibition

Abnormal timing & smooth gradation

Hypermetria

4. Synergies

Use a variety of synergies

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1. Vision


-. Nystagmus may be present

-. Lack smooth visual pursuits


-. Excessive visual fixation

o. The visual system is their best system in learningof postural control and movement gradation

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Deficits are seen in central sensory feedback

mechanism Alarming behaviour

Auditory processing delays

Musculoskeletal system

Least difficulties

Some limb muscles may become shorten

Adequate strength necessary for functional tasks

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Respiratory system

Incoordination between breathing, speech &movement

Marked delay in the onset of voicing with eachattempt to speak

Dysarthric speech

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dysfunctions

The clinical signs are generally seen after firstyear of life :

- Tremor

-

Dysmetria- Severe sensory perceptual problems

Most of the children stay hypotonic for manymonths past first year of life

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Inconsistent responses in terms of grading force

during activity

Usually fixate visually before moving

Excessive drooling, mouthing, biting & tearing

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Similar to that seen in hypotonic children exceptthat they are active

Tremors and overshooting may be seen whenthey approach any target

Problems using sensory information to guide andcorrect movements

Rib cage elevation, tight intercostals, use ofaccessory muscles, poor speech

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Lower trunk

Similar to the children with hypotonia

Some children keep the trunk in rigid extension

Keep upper body forward to avoid posterior

weight shift

Avoid moving out of midline posture

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Two common postures are seen while standing

1. Hips flexed, abducted, ER, knees flexed, often

pronated feet. Seen in children with more hypotonia

. Two compensations are seen that assures them of

their stability-. A wide BOS

-. Lowered COG

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2. Stiffen lower limbs using voluntary cocontraction

To prevent movement To dampen tremors

Although ambulatory skills are limited but this posture

allows for upright skills

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Thank you !

motor dysfunctions in cerebral palsy

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