KUNA, IDAHO

Hannah Nawaz, SPTRegis University

A Case Study of an Adolescent with Congenital Hemiplegia

Identify factors unique to hemiplegia in the pediatric population.

Develop effective examination and evaluation strategies, selecting reliable and valid outcome measures.

Discuss intervention strategies for pediatric patients with hemiplegia in an outpatient setting.

Discuss the rationale and referral process associated with orthoses prescription in an outpatient setting.

Typically a classification of cerebral palsy Congenital hemiplegia

2:1,000 births Usually classified using Gross Motor

Functional Classification Scale (GMFCS) Abnormal posturing, spasticity/increased

tone, muscle spasms, seizure disorders, gait deviations, poor balance and sensory awareness1

Medical History CVA in womb PT from ages 3-6

Aquatic therapy 2 different AFOs Hand brace

Heel cord extension: age 8

LOCATION LEFT RIGHT

Ankle Dorsiflexion -16 degrees WNL

Knee Extension -4 degrees WNL

Elbow Extension -18 degrees WNL

AROM

LOCATION LEFT RIGHT

Ankle Dorsiflexion 2+ 5

Knee Extensors 3+ 5

Wrist Extensors 3 5

Finger Flexors 3- 5

MMT

http://www.youtube.com/watch?v=BtqWxBUd94I

Gait: foot drop during initial contact and loading phases; high guard position during walking and jogging

Impaired balance in standing Denies history of muscle spasms and seizures Increased L sided tone; clonus absent Sensation grossly intact in both UE and LE Significant unilateral left sided atrophy Impaired proprioception and stability of trunk

musculature Berg balance score2 = 40

PATIENT IDENTIFIED PROBLEMSNON-PATIENT IDENTIFIED PROBLEMS

Difficulty playing sports in school including football, basketball, volleyball

Difficulty riding scooter for prolonged periods of time

Frequent falls secondary to poor anticipatory and reactive balance3

Impaired coordination during dynamic activity

Decreased aerobic capacity

Psychological implications of congenital abnormalities

Family dynamics

Patient demonstrates left sided deficits in strength, range of motion, balance, and coordination which impair her ability to participate in recreational activities with peers.

The patient’s rehabilitation potential is good given patient’s previous history with PT and her increased motivation to regain optimal function.

Progressive resistance exercises (Ada 2006)

FES for improved force production (Donaldson, 2009)

EMG biofeedback for tone reduction and proprioceptive training (Wolpaw, 1983)

Constraint induced movement therapy (Gordon, et al 2005)

Stretching Gastroc/soleus Biceps Hamstrings

Strengthening Ankle w/ theraband

and NMES Quadriceps on leg

press Trunk on exercise ball UE theraband

exercises

Balance Dynadisc bilateral

stance Single leg balance Sitting balance on

exercise ball/ single leg sitting balance

Coordination Treadmill walking Ball toss while sitting

on exercise ball Agility ladder

Specifically…-posterior leaf spring-trimmed posterior to malleolus7

Function: assist foot into DF during swing phase of gait and allows PF during stance

Covered by Medicaid Constraint induced therapy???

What are some of the common impairments which patients with congenital hemiplegia present?

T/F: According the algorithm, a dorsiflexion assist orthoses is appropriate when DF strength is <3.

1. Cambell S, Vander Linden D, Palisano R. Physical Therapy for Children. 3rd ed. St. Louis, MS: Saunders Elsevier; 2006.

2. Beninato M, Portney L, Sullivan P. Using the International Classification of Functioning, Disability and Health as a framework to examine the association between falls and clinical assessment tools in people with stroke. Phys Ther. August 2009;89(8):816-825.

3. Aruin A. The effect of asymmetry of posture on anticipatory postural adjustments. Neurosci Lett. 2006;401(1/2):150-153.

4. Ada L, Dorsch S, Canning CG . Strengthening interventions increase strength and improve activity after stroke: a systematic review. Australian Journal of Physiotherapy. 2006. 52: 241-248.

5. Donaldson C, Tallis R, Miller S, Sunderland A, Lemon R, Pomeroy V. Effects of conventional physical therapy and functional strength training on upper limb motor recovery after stroke: a randomized phase II study. Neurorehab & Neural Repair.2009. 23(4): 389-397

6. Wolpaw J, O'Keefe J. Adaptive plasticity in the primate spinal stretch reflex: evidence for a two-phase process. J Neurosci. November 1984;4(11):2718-2724.

7. Kubota K, Eberly V, Weiss W. To brace or not to brace: making evidence-based decisions with our clients with neurologic impairment. February 2006.