PowerPoint Presentation · –Prenatal fetal movement –Poly or Oligohydramnios –Maternal health...

6
8/21/2016 1 Mark J. Romness, MD Associate Professor of Orthopaedic Surgery uvaortho.com University of Virginia Orthopaedic Surgery Anatomic Diplegia Quadriplegia Hemiplegia Other: Asymmetric Diplegia Monoplegia Double Hemiplegia Physiologic Spastic - velocity induced resistance to movement Extrapyramidal - dystonia, athetosis , ballismus /chorea, ataxia Mixed Tone Classifications of Cerebral Palsy University of Virginia Orthopaedic Surgery Hypertonia Spasticity Dystonia Rigidity Negative Motor Signs Weakness Poor control Tone Patterns Hyperkinetic Dystonia Chorea Athetosis Monoclonus Tremor Tics Stereotypies Sanger TD, et al. Mov Disord. 2010 Aug 15;25(11):1538-49 Taskforce on Childhood Motor Disorders University of Virginia Orthopaedic Surgery Weakness Inability to generate normal voluntary force Poor Control Reduced selective motor control Ataxia: Incorrect patterns for movement Apraxia: Impaired patterns for a task Dyspraxia: Lack of age - appropriate motor actions Negative Signs Sanger TD, et al. Pediatrics 2006 Nov;118(5) Definition and Classification of Negative Motor Signs in Childhood. Taskforce on Childhood Motor Disorders University of Virginia Orthopaedic Surgery Hypotonia not well defined Was not included in the Sanger Task Force Difficult to distinguish from Weakness Diffuse laxity Personally, I would say “inappropriately low resistance to passive stretch, manifested by reduced reflex response to unexpected perturbations Definition Sanger TD – Personal Communication University of Virginia Orthopaedic Surgery

Transcript of PowerPoint Presentation · –Prenatal fetal movement –Poly or Oligohydramnios –Maternal health...

8212016

1

Mark J Romness MDAssociate Professor of Orthopaedic Surgery

uvaorthocom

University of Virginia Orthopaedic Surgery

bull Anatomicndash Diplegia

ndash Quadriplegia

ndash Hemiplegia

ndash Other bull Asymmetric Diplegia

bull Monoplegia

bull Double Hemiplegia

bull Physiologicndash Spastic - velocity induced resistance to movement

ndash Extrapyramidal - dystonia athetosis ballismuschorea ataxia

ndash Mixed Tone

Classifications of Cerebral Palsy

University of Virginia Orthopaedic Surgery

bull Hypertonia

ndash Spasticity

ndash Dystonia

ndash Rigidity

bull Negative Motor Signs

ndash Weakness

ndash Poor control

Tone Patterns

bull Hyperkinetic

ndash Dystonia

ndash Chorea

ndash Athetosis

ndash Monoclonus

ndash Tremor

ndash Tics

ndash Stereotypies

Sanger TD et al Mov Disord 2010 Aug 1525(11)1538-49Taskforce on Childhood Motor Disorders

University of Virginia Orthopaedic Surgery

bull Weakness

ndash Inability to generate normal voluntary force

bull Poor Control

ndash Reduced selective motor control

ndash Ataxia Incorrect patterns for movement

ndash Apraxia Impaired patterns for a task

ndash Dyspraxia Lack of age-appropriate motor actions

Negative Signs

Sanger TD et al Pediatrics 2006 Nov118(5) Definition and Classification of Negative Motor Signs in Childhood Taskforce on Childhood Motor Disorders

University of Virginia Orthopaedic Surgery

bull Hypotonia not well defined

bull Was not included in the Sanger Task Force

bull Difficult to distinguish from

ndash Weakness

ndash Diffuse laxity

bull Personally I would say ldquoinappropriately low resistance to passive stretch manifested by reduced reflex response to unexpected perturbationsrdquo

Definition

Sanger TD ndash Personal Communication

University of Virginia Orthopaedic Surgery

8212016

2

University of Virginia Orthopaedic Surgery

bull Decreased strength

bull Decreased activity tolerance

bull Delayed motor skills development

bull Rounded shoulder posture with leaning onto supports

bull Hypermobile jointsincreased flexibility

bull Poor attention and motivation

bull Martin K et al Pediatr Phys Ther 2005 Winter17(4)275-82

Characteristics of Hypotonia

University of Virginia Orthopaedic Surgery

bull Hypotonia v Laxity

bull Central v Peripheral

bull History amp Exam

bull Tests

Diagnosis

University of Virginia Orthopaedic Surgery

bull Beighton score

Laxity

hypermobilityorg

University of Virginia Orthopaedic Surgery

bull Central nervous system

bull Peripheral nervous system

bull Neuromuscular junction

bull Muscle diseases

in order of prevalence

Hypotonia Etiology

Harris SR Dev Med Child Neurol 2008 Dec50(12)889-92

University of Virginia Orthopaedic Surgery

bull Central disorders

ndash Neonatal seizures

ndash Hypoxic-ischemic events

ndash Neonatal encephalopathy

bull Peripheral disorders

ndash Diminished reflexes

ndash Decreased anti-gravity limb movements

Central v Peripheral

University of Virginia Orthopaedic Surgery

bull Transient Hypotonia

ndash Preterm infants

ndash Perinatal drug exposure

ndash Acute infectious state

8212016

3

University of Virginia Orthopaedic Surgery

bull Family Historybull Prenatal History

ndash Prenatal fetal movementndash Poly or Oligohydramniosndash Maternal health during pregnancy

bull Drugsalcohol infections illness

bull Perinatalndash Apgar scoresndash Respiratory problemsndash Feeding difficulties

bull Infantsndash Motor milestones

History

University of Virginia Orthopaedic Surgery

bull Head circumference

bull Reflexesbull Primitive

bull DTRs

bull Muscle tone

bull Standardized Testsbull Neurological Assessment of the Preterm and Full-term Newborn Infant

bull Test of Infant Motor Performance ndashTIMPndash 34 weeks postconceptional age to 4 months post-term

bull Harris Infant Neuromotor Test ndash HINTndash 25 to 125 months

httpthetimpcom

Examination

University of Virginia Orthopaedic Surgery

bull Musclenerve biopsy

bull EMGndash denervation in the muscle

ndash muscle irritability

bull CTMRI

bull Ultrasound sheer wave elastography Joline E Brandenburg MD

ndash Quantifies the elasticity of tissue

ndash Used to show increased passive muscle stiffness in children with CP

ndash Hypotonia pending

Interventional Assessment

University of Virginia Orthopaedic Surgery

Hypotonia

Ginny Paleg PT DScPT

ginnypalegcom

I measure hypotonia using a scale of 6 items

suggested by Dr Andrew Morgan from Peoria

Illinois (Morgan-Paleg Hypotonia Scale)

1 Head Control

2 Vertical Suspension

3 Sitting

4 Hip Abduction

5 Ankle Dorsiflexion

6 Standing

8212016

4

Score each item 0 1 or 2 points

1 = normal

2 = eh

3 = oy vey

Add score divide by 6

Thatrsquos the total score

Recommend services 2xmo

Hip Helper

compression

shorts $15

Seating Device

Stander

Supported Stepping andor treadmill training

Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)

Orthotics

Theo at 9

months

Gericke 2006

Paleg 2013

Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years

Itrsquos not done yet

Treadmill will be green light ldquoGOrdquo

Orthotics ldquomightrdquo be Green Light

8212016

5

Exercise and Physical Therapy came out well (but no one type)

Whole Body Vibration came out well but fell out when we went to younger children

Video taken at Dr

Rainer Blankrsquos

clinic in Germany

Compression GarmentsLycra Suits

Bicycle

Massage

Kinesiotaping

Power Toy Car and Power Chair

VestibularSensory Training including Wii

Already adapted

Comes with wireless remote

Lil Rover

$70 from toysruscom

Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children

Damiano said this intervention should be standard of care for children with Down syndrome

Hi intensity is better than low intensity

If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age

R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam

8212016

6

Start at 9 months if child is not yet sitting independently to play

Start at 12-15 months if child is not yet pulling to stand and cruising

Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V

(Martinsson 2011 Macias 2015 aampb)

Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)

Wear 50 of waking time

No orthotics = handplay

w orthotics = postural play

(Martin and Looper CSM 2015)

No evidence

Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo

Children without head control may benefit supportive seating at 3-6 months of age

Try dynamic setaing

We need a definition

Is it CP

We need a valid reliable measurement tool

We need outcome measures

Once we have these we can better evaluate interventions

Email Ginny for handouts Ginnypalegcom

8212016

2

University of Virginia Orthopaedic Surgery

bull Decreased strength

bull Decreased activity tolerance

bull Delayed motor skills development

bull Rounded shoulder posture with leaning onto supports

bull Hypermobile jointsincreased flexibility

bull Poor attention and motivation

bull Martin K et al Pediatr Phys Ther 2005 Winter17(4)275-82

Characteristics of Hypotonia

University of Virginia Orthopaedic Surgery

bull Hypotonia v Laxity

bull Central v Peripheral

bull History amp Exam

bull Tests

Diagnosis

University of Virginia Orthopaedic Surgery

bull Beighton score

Laxity

hypermobilityorg

University of Virginia Orthopaedic Surgery

bull Central nervous system

bull Peripheral nervous system

bull Neuromuscular junction

bull Muscle diseases

in order of prevalence

Hypotonia Etiology

Harris SR Dev Med Child Neurol 2008 Dec50(12)889-92

University of Virginia Orthopaedic Surgery

bull Central disorders

ndash Neonatal seizures

ndash Hypoxic-ischemic events

ndash Neonatal encephalopathy

bull Peripheral disorders

ndash Diminished reflexes

ndash Decreased anti-gravity limb movements

Central v Peripheral

University of Virginia Orthopaedic Surgery

bull Transient Hypotonia

ndash Preterm infants

ndash Perinatal drug exposure

ndash Acute infectious state

8212016

3

University of Virginia Orthopaedic Surgery

bull Family Historybull Prenatal History

ndash Prenatal fetal movementndash Poly or Oligohydramniosndash Maternal health during pregnancy

bull Drugsalcohol infections illness

bull Perinatalndash Apgar scoresndash Respiratory problemsndash Feeding difficulties

bull Infantsndash Motor milestones

History

University of Virginia Orthopaedic Surgery

bull Head circumference

bull Reflexesbull Primitive

bull DTRs

bull Muscle tone

bull Standardized Testsbull Neurological Assessment of the Preterm and Full-term Newborn Infant

bull Test of Infant Motor Performance ndashTIMPndash 34 weeks postconceptional age to 4 months post-term

bull Harris Infant Neuromotor Test ndash HINTndash 25 to 125 months

httpthetimpcom

Examination

University of Virginia Orthopaedic Surgery

bull Musclenerve biopsy

bull EMGndash denervation in the muscle

ndash muscle irritability

bull CTMRI

bull Ultrasound sheer wave elastography Joline E Brandenburg MD

ndash Quantifies the elasticity of tissue

ndash Used to show increased passive muscle stiffness in children with CP

ndash Hypotonia pending

Interventional Assessment

University of Virginia Orthopaedic Surgery

Hypotonia

Ginny Paleg PT DScPT

ginnypalegcom

I measure hypotonia using a scale of 6 items

suggested by Dr Andrew Morgan from Peoria

Illinois (Morgan-Paleg Hypotonia Scale)

1 Head Control

2 Vertical Suspension

3 Sitting

4 Hip Abduction

5 Ankle Dorsiflexion

6 Standing

8212016

4

Score each item 0 1 or 2 points

1 = normal

2 = eh

3 = oy vey

Add score divide by 6

Thatrsquos the total score

Recommend services 2xmo

Hip Helper

compression

shorts $15

Seating Device

Stander

Supported Stepping andor treadmill training

Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)

Orthotics

Theo at 9

months

Gericke 2006

Paleg 2013

Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years

Itrsquos not done yet

Treadmill will be green light ldquoGOrdquo

Orthotics ldquomightrdquo be Green Light

8212016

5

Exercise and Physical Therapy came out well (but no one type)

Whole Body Vibration came out well but fell out when we went to younger children

Video taken at Dr

Rainer Blankrsquos

clinic in Germany

Compression GarmentsLycra Suits

Bicycle

Massage

Kinesiotaping

Power Toy Car and Power Chair

VestibularSensory Training including Wii

Already adapted

Comes with wireless remote

Lil Rover

$70 from toysruscom

Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children

Damiano said this intervention should be standard of care for children with Down syndrome

Hi intensity is better than low intensity

If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age

R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam

8212016

6

Start at 9 months if child is not yet sitting independently to play

Start at 12-15 months if child is not yet pulling to stand and cruising

Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V

(Martinsson 2011 Macias 2015 aampb)

Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)

Wear 50 of waking time

No orthotics = handplay

w orthotics = postural play

(Martin and Looper CSM 2015)

No evidence

Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo

Children without head control may benefit supportive seating at 3-6 months of age

Try dynamic setaing

We need a definition

Is it CP

We need a valid reliable measurement tool

We need outcome measures

Once we have these we can better evaluate interventions

Email Ginny for handouts Ginnypalegcom

8212016

3

University of Virginia Orthopaedic Surgery

bull Family Historybull Prenatal History

ndash Prenatal fetal movementndash Poly or Oligohydramniosndash Maternal health during pregnancy

bull Drugsalcohol infections illness

bull Perinatalndash Apgar scoresndash Respiratory problemsndash Feeding difficulties

bull Infantsndash Motor milestones

History

University of Virginia Orthopaedic Surgery

bull Head circumference

bull Reflexesbull Primitive

bull DTRs

bull Muscle tone

bull Standardized Testsbull Neurological Assessment of the Preterm and Full-term Newborn Infant

bull Test of Infant Motor Performance ndashTIMPndash 34 weeks postconceptional age to 4 months post-term

bull Harris Infant Neuromotor Test ndash HINTndash 25 to 125 months

httpthetimpcom

Examination

University of Virginia Orthopaedic Surgery

bull Musclenerve biopsy

bull EMGndash denervation in the muscle

ndash muscle irritability

bull CTMRI

bull Ultrasound sheer wave elastography Joline E Brandenburg MD

ndash Quantifies the elasticity of tissue

ndash Used to show increased passive muscle stiffness in children with CP

ndash Hypotonia pending

Interventional Assessment

University of Virginia Orthopaedic Surgery

Hypotonia

Ginny Paleg PT DScPT

ginnypalegcom

I measure hypotonia using a scale of 6 items

suggested by Dr Andrew Morgan from Peoria

Illinois (Morgan-Paleg Hypotonia Scale)

1 Head Control

2 Vertical Suspension

3 Sitting

4 Hip Abduction

5 Ankle Dorsiflexion

6 Standing

8212016

4

Score each item 0 1 or 2 points

1 = normal

2 = eh

3 = oy vey

Add score divide by 6

Thatrsquos the total score

Recommend services 2xmo

Hip Helper

compression

shorts $15

Seating Device

Stander

Supported Stepping andor treadmill training

Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)

Orthotics

Theo at 9

months

Gericke 2006

Paleg 2013

Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years

Itrsquos not done yet

Treadmill will be green light ldquoGOrdquo

Orthotics ldquomightrdquo be Green Light

8212016

5

Exercise and Physical Therapy came out well (but no one type)

Whole Body Vibration came out well but fell out when we went to younger children

Video taken at Dr

Rainer Blankrsquos

clinic in Germany

Compression GarmentsLycra Suits

Bicycle

Massage

Kinesiotaping

Power Toy Car and Power Chair

VestibularSensory Training including Wii

Already adapted

Comes with wireless remote

Lil Rover

$70 from toysruscom

Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children

Damiano said this intervention should be standard of care for children with Down syndrome

Hi intensity is better than low intensity

If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age

R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam

8212016

6

Start at 9 months if child is not yet sitting independently to play

Start at 12-15 months if child is not yet pulling to stand and cruising

Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V

(Martinsson 2011 Macias 2015 aampb)

Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)

Wear 50 of waking time

No orthotics = handplay

w orthotics = postural play

(Martin and Looper CSM 2015)

No evidence

Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo

Children without head control may benefit supportive seating at 3-6 months of age

Try dynamic setaing

We need a definition

Is it CP

We need a valid reliable measurement tool

We need outcome measures

Once we have these we can better evaluate interventions

Email Ginny for handouts Ginnypalegcom

8212016

4

Score each item 0 1 or 2 points

1 = normal

2 = eh

3 = oy vey

Add score divide by 6

Thatrsquos the total score

Recommend services 2xmo

Hip Helper

compression

shorts $15

Seating Device

Stander

Supported Stepping andor treadmill training

Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)

Orthotics

Theo at 9

months

Gericke 2006

Paleg 2013

Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years

Itrsquos not done yet

Treadmill will be green light ldquoGOrdquo

Orthotics ldquomightrdquo be Green Light

8212016

5

Exercise and Physical Therapy came out well (but no one type)

Whole Body Vibration came out well but fell out when we went to younger children

Video taken at Dr

Rainer Blankrsquos

clinic in Germany

Compression GarmentsLycra Suits

Bicycle

Massage

Kinesiotaping

Power Toy Car and Power Chair

VestibularSensory Training including Wii

Already adapted

Comes with wireless remote

Lil Rover

$70 from toysruscom

Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children

Damiano said this intervention should be standard of care for children with Down syndrome

Hi intensity is better than low intensity

If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age

R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam

8212016

6

Start at 9 months if child is not yet sitting independently to play

Start at 12-15 months if child is not yet pulling to stand and cruising

Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V

(Martinsson 2011 Macias 2015 aampb)

Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)

Wear 50 of waking time

No orthotics = handplay

w orthotics = postural play

(Martin and Looper CSM 2015)

No evidence

Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo

Children without head control may benefit supportive seating at 3-6 months of age

Try dynamic setaing

We need a definition

Is it CP

We need a valid reliable measurement tool

We need outcome measures

Once we have these we can better evaluate interventions

Email Ginny for handouts Ginnypalegcom

8212016

5

Exercise and Physical Therapy came out well (but no one type)

Whole Body Vibration came out well but fell out when we went to younger children

Video taken at Dr

Rainer Blankrsquos

clinic in Germany

Compression GarmentsLycra Suits

Bicycle

Massage

Kinesiotaping

Power Toy Car and Power Chair

VestibularSensory Training including Wii

Already adapted

Comes with wireless remote

Lil Rover

$70 from toysruscom

Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children

Damiano said this intervention should be standard of care for children with Down syndrome

Hi intensity is better than low intensity

If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age

R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam

8212016

6

Start at 9 months if child is not yet sitting independently to play

Start at 12-15 months if child is not yet pulling to stand and cruising

Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V

(Martinsson 2011 Macias 2015 aampb)

Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)

Wear 50 of waking time

No orthotics = handplay

w orthotics = postural play

(Martin and Looper CSM 2015)

No evidence

Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo

Children without head control may benefit supportive seating at 3-6 months of age

Try dynamic setaing

We need a definition

Is it CP

We need a valid reliable measurement tool

We need outcome measures

Once we have these we can better evaluate interventions

Email Ginny for handouts Ginnypalegcom

8212016

6

Start at 9 months if child is not yet sitting independently to play

Start at 12-15 months if child is not yet pulling to stand and cruising

Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V

(Martinsson 2011 Macias 2015 aampb)

Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)

Wear 50 of waking time

No orthotics = handplay

w orthotics = postural play

(Martin and Looper CSM 2015)

No evidence

Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo

Children without head control may benefit supportive seating at 3-6 months of age

Try dynamic setaing

We need a definition

Is it CP

We need a valid reliable measurement tool

We need outcome measures

Once we have these we can better evaluate interventions

Email Ginny for handouts Ginnypalegcom