McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
A group of disorders impacting the development of movement and posture
Results in activity limitation
Accompanied by disturbances of:SensationCognitionCommunicationPerceptionPossibly behavior and/or seizure disorder
(Campbell S 2000, Miller F 2005, Bax M 2005 )
McElroy, Haynes, & Franjoine 2009
• Caused by a non-progressive defect or lesion occurring in an immature brain
• Insult occurs before or after birth
• Single or multiple locations
(Campbell S 2000, Miller F 2005, Bax M 2005 )
McElroy, Haynes, & Franjoine 2009
Spastic or Hypertonic CPHemiplegiaDiplegiaQuadriplegia
• Ataxia• Athetosis• Hypotonia
McElroy, Haynes, & Franjoine 2009M R Franjoine & M P Haynes
Dimension Functional Domain Disability Domain
A. Body structure & functions
Structural & functional integrity
Impairments
A.Primary
B.Secondary
B. Motor functions Effective posture & movement
Ineffective posture & movement
C. Individual functions
Functional activities Functional activity limitations
D. Social functions Participation Participation restriction
+ Domains -
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009M R Franjoine & M P Haynes
Dimension Functional Domain Disability Domain
A. Body structure & functions
Structural & functional integrity
Impairments
A.Primary
B.Secondary
B. Motor functions Effective posture & movement
Ineffective posture & movement
C. Individual functions
Functional activities Functional activity limitations
D. Social functions Participation Participation restriction
+ Domains -
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
Spastic Diplegia 41.5
Spastic Hemiplegia 36.4%
Dyskinesia or Athetosis 10%
Spastic Quadriplegia 7.3%
Ataxia 5%
(Campbell S 2000)
McElroy, Haynes, & Franjoine 2009
Lesion(s) impacts: the motor cortex
and/or white matter projections to and from cortical sensorimotor areas of the brain
Causes:Unknown prenatal conditionAsphyxiaPrematurity
Intracranial bleeds, infection, medical conditions(Campbell S 2000)
McElroy, Haynes, & Franjoine 2009
Body Structure and FunctionsBody Structure and Functions
CognitionNeuromuscular SystemSensory SystemMusculoskeletal SystemRegulatoryGastrointestinalCardiopulmonaryIntegumentary
McElroy, Haynes, & Franjoine 2009
VARIABLE CHILD BY CHILD
Dependent on:• Lesion(s)• Secondary effects of various systems• Seizures• Access to environment
McElroy, Haynes, & Franjoine 2009
What is muscle “tone”?• Amount of tension in a resting muscle• Resists being lengthened• Has neural components• Has mechanical and elastic components;
muscle and connective tissue
(Lundy-Ekman 2002, Kandel 2000)
McElroy, Haynes, & Franjoine 2009
What is Hypertonicity?• Abnormally high resting tension• An abnormally high resistance to being
lengthened• Still has both neural and mechanical
components• The tonic component of hypertonus
(Crenna 1998, Lundy-Ekman 2002, Kandel 2000)
McElroy, Haynes, & Franjoine 2009
What is Spasticity?Resistance to rapid muscle stretchVelocity dependentThe phasic component of hypertonusOften associated with:
Upper Motor Neuron Syndrome (UMNS)Hyperactive deep tendon reflexesClonus (Kandel 2000)
McElroy, Haynes, & Franjoine 2009
Excessive Co-activation
Impaired Muscle Synergies
Impaired Muscle Activation
Inability to Initiate, Sustain, Terminate
McElroy, Haynes, & Franjoine 2009
Co-activationSimultaneous activation of agonists and antagonists at a joint influencing movement in the same plane
Normally used to increase joint stability or for proximal stability to support precise distal movements
Allows for graded movement
McElroy, Haynes, & Franjoine 2009
Excessive Co-activationDecreases movement speed
Limits flexibility of movement responses
Increased energy costs and fatigue
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Muscle SynergiesA group of muscles working together across multiple joints and organized to act as a functional unitSimplifies the work of the CNSStrengthens with repetition
McElroy, Haynes, & Franjoine 2009
Impaired Muscle SynergiesBased on limited movement repertoiresDifficult to vary or adapt to meet the requirements of different tasksProduces stereotypical movement patterns
McElroy, Haynes, & Franjoine 2009
Impaired Muscle SynergiesMovements are limited in amount and frequencyMovements tend to be in more limited ranges
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Initiate, Sustain, Terminate
Quick response of muscles to the decision to move
Easily maintain posture against gravity
Relax muscles
Quick response of muscles to the decision to cease movement
McElroy, Haynes, & Franjoine 2009
Difficulty with Initiate, Sustain, Terminate
Delay between desire to activate and ability to initiate muscular movement (latency)
Difficulty holding against gravity…especially postural muscles
Can’t turn off muscles in time
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
• Impaired Motor Execution
Impaired Modulation and Scaling of Forces
Impaired Timing and Sequencing
Excessive overflow of Intra-Interlimb contractions
McElroy, Haynes, & Franjoine 2009
Modulation and Scaling of Forces
Controlled acceleration or deceleration
Using the proper amount of force
Constant balancing of agonists and antagonists during movement
McElroy, Haynes, & Franjoine 2009
Impaired Modulation and Scaling of Forces
Inability to slow down as they approach a target
Reduces accuracy (overshoots)
Particular difficulties grading grip
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Timing and Sequencing
McElroy, Haynes, & Franjoine 2009
Impaired Timing and Sequencing
Unable to turn on and off muscles or patterns of muscles at the appropriate times
i.e. agonist and antagonist coordinationi.e. the hamstrings during gait
Incorrect sequence of activation for a task
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Overflow of Intra-Interlimb contractions
When learning a new skill
With increased effort
Within a limb or elsewhere in the body
Decreases as proficiency is gained
Can be actively overridden
McElroy, Haynes, & Franjoine 2009
Excessive overflow of Intra-Interlimb contractions
Bobaths described “associated movements”i.e. while grasping with one arm, will posture with the otheri.e. when flexing the hip, the ankle dorsiflexes
Occur at times similar to typical but with a generally lower threshold
Decreases the capacity for isolated control during effort
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Impaired Force Generation
Strength: the ability to contract a muscle to a sufficient degree to impact the task
Can be masked by tone and spasticityPrimary—impaired input from motor pathwaysSecondary– atrophy and resultant fiber type and connective tissue changes
Postural
Movement system
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Anticipatory Postural Control
TYPICAL: Postural set prior to initiating a task or movement
ATYPICAL: Posture is not linked to movementFail to anticipate postural needs prior to a movement or taskFail to generate adequate proximal posture for distal function
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Poverty of Movement
TYPICAL:Large variety of movement repertoires to chose fromCan easily adapt and modify repertoires for the taskMovements are fluid, flexible, and complex
ATYPICAL:Movement repertoires are limited in number“Stereotypic”Repertoires are difficult to change Adapt poorly to various tasks
McElroy, Haynes, & Franjoine 2009
Fractionated or Dissociated Movements
TYPICAL:“Isolated movement” or “dissociated movement”
ATYPICAL:Difficulty isolating movement
Segment to segmentInter-limbIntra-limbLimbs from trunk
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Vision
Vestibular
Somatosensory
McElroy, Haynes, & Franjoine 2009
Varies greatly
Cortical blindness to refractory errors
Strabismus (eyes not properly aligned)
Esotropia (the eye turns in)Exotropia (the eye turns out)
Nystagmus
Visual tracking problemsField cuts
McElroy, Haynes, & Franjoine 2009
Ghasia, Brunstrom, Gordon & Tychsen, 2008
GMFCS levels I and IISimilar to typically developing childrenStrabismusAmblyopia (lazy eye)
GMFCS levels III to VMore severe deficitsDeficits not observed in typically developing children i.e. dyskinetic strabismus and Cerebral Visual Impairment
McElroy, Haynes, & Franjoine 2009
Difficult to separate from vision and postural controlMore impact seen in SQ than SD
McElroy, Haynes, & Franjoine 2009
Clearly atypical yet difficult to truly assess
PropioceptionKinesthetic awareness2 point discriminationStereognosis
McElroy, Haynes, & Franjoine 2009
“ the ability of the nervous system to perceive, interpret, modulate, and organize sensory input for use in generating or adapting motor responses… (Miller & Lane 2000)
McElroy, Haynes, & Franjoine 2009
Considerable secondary impairmentsBone:
Boney deformities 2° atypical muscle pullDecreased bone density of long bones (FX)
McElroy, Haynes, & Franjoine 2009
Considerable secondary impairments
Dislocations: 2° to atypical muscle pull and atypical bone shape formationImpacts many joints from jaw to foot
Scoliosis and rib cage deformities
McElroy, Haynes, & Franjoine 2009
Considerable secondary impairmentsMuscle:
Shortening and contractureFiber type shiftWeakness
Connective tissue: Increased stiffness due to atypical matrix within muscleOver-lengthening or shortening of tendons
McElroy, Haynes, & Franjoine 2009M R Franjoine & M P Haynes
Dimension Functional Domain Disability Domain
A. Body structure & functions
Structural & functional integrity
Impairments
A.Primary
B.Secondary
B. Motor functions Effective posture & movement
Ineffective posture & movement
C. Individual functions
Functional activities Functional activity limitations
D. Social functions Participation Participation restriction
+ Domains -
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
Motor FunctionsMotor Functions
Effective Posture and Movement
Ineffective Posture and Movement
McElroy, Haynes, & Franjoine 2009
• Alignment of body segments• COM over BOS• Weight shift• Quality of movement (fast, slow)
“Observable conditions that are neither functional limitations nor system impairments” (Howle 2002)
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Little variation
Influenced by limited joint range
Tone influenced by position in space
High tone extremities, low tone trunk
McElroy, Haynes, & Franjoine 2009
Uses increased tone to gain stability
Eyes adjust to posture rather than posture being driven by vision
McElroy, Haynes, & Franjoine 2009
Limited amount
Limited variety
Stiffen extremities to attain postural stability
Poor dissociation
McElroy, Haynes, & Franjoine 2009
Trunk moves with either flexors or extensors
Most active movement is in sagittal plane
Difficulty organizing movements in relation to the BOS
Uses eyes and mouth to increase postural stability
McElroy, Haynes, & Franjoine 2009
PostureDifficult position
Pulled into gravityFlexor tone is biased (typical)Lack of joint range
MovementAsymmetrical neck hyperextension OR
Not enough antigravity strength to lift head
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PosturePreferred position
StableHave the possibility of viewing the worldExtensors are biased (typical)
MovementSometimes can kick reciprocallyPush with neck hyperextension asymmetrically and may arch with body
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PostureVery unstable positionNarrow baseStabilization efforts create non-functional alignment of hips, spine, neck, and head
MovementToo unstable to seek movementIncreased full body stiffness when movement is initiated
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PostureRarely can hold without assistance
MovementOften can’t move at allMay pull with both arms—”combat crawl”Occasional child may “bunny hop”
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PosturePlaced in standingBase too narrow--adducted legs and
plantar-flexed ankles
MovementStiffens whole body to gain stabilityMay support weight stiffly and then both “give”Some may have reciprocal movements of legs
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009M R Franjoine & M P Haynes
Dimension Functional Domain Disability Domain
A. Body structure & functions
Structural & functional integrity
Impairments
A.Primary
B.Secondary
B. Motor functions Effective posture & movement
Ineffective posture & movement
C. Individual functions
Functional activities Functional activity limitations
D. Social functions Participation Participation restriction
+ Domains -
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
LOCOMOTOR SKILLS
• Weightbearing assisted transfers will improve quality of life• Motorized mobility if possible
COMMUNICATION • Establish early and simple communication• Think AT
BASIC ADL’S • Fully dependent in most skills• Full time assistance• Respite care for families
McElroy, Haynes, & Franjoine 2009M R Franjoine & M P Haynes
Dimension Functional Domain Disability Domain
A. Body structure & functions
Structural & functional integrity
Impairments
A.Primary
B.Secondary
B. Motor functions Effective posture & movement
Ineffective posture & movement
C. Individual functions
Functional activities Functional activity limitations
D. Social functions Participation Participation restriction
+ Domains -
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
Inclusion in family activities and outings difficultSpecial classroom or mainstreamed with full-time paraprofessionalParticipation is often limited due to:
Lack of interaction and communication with othersWheelchair accessTransportation that accommodates WC
McElroy, Haynes, & Franjoine 2009
Address decreased ROMLengthen
Incorporate into your activitiesAccompany with activation
and/orCompensate
Work upright whenever possible
McElroy, Haynes, & Franjoine 2009
Help establish an appropriate BOSUsually need to widen
ALIGNMENT!In relation to BOSSegment to segmentDecrease asymmetries
Activate the trunk to free the extremitiesBalanced flexors and extensors in the trunkWork in the frontal and transverse planes
McElroy, Haynes, & Franjoine 2009
Keep them moving!May need large ranges to know where they are
BUTThey can only control small ranges themselves
RepetitionMotor learningStrength
McElroy, Haynes, & Franjoine 2009
Empower these children!!!
Treat age appropriately despite motor abilities
Treat upright whenever possibleForget the developmental sequence!!!
Attend to ALL the systems…Many impact their health and quality of lifeHave a long term perspective
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Upper extremities show more variability than LEs
UE posturing may increase in unstable situations
Uses UEs for support in upright instead of trunk
McElroy, Haynes, & Franjoine 2009
LEs: Hip adduction, internal rotation, knee flexion, ankle plantar-flexion
LEs influenced by limited joint range
McElroy, Haynes, & Franjoine 2009
Active children
Pull themselves around with their arms
Poor dissociation of LEs from trunk and from each other
McElroy, Haynes, & Franjoine 2009
Most active movement is in sagittal plane
Quadruped and walking progression is achieved by moving the COM outside the BOS
Walking speed is achieved by using LE spasticity instead of strength
McElroy, Haynes, & Franjoine 2009
PostureTends to stay on elbows until going to 4sLack of joint range at hips increases anterior tilt of pelvis and stresses T-L joint
MovementLateral weightshifts are limitedPulls with arms to move forwardPushes with arms and keeps legs stiff to roll
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PosturePlays with handsLEs are stiff in hip flexion/adduction, internal rotation, knee flexion, ankle plantar-flexion
MovementReciprocal kicking, poorly gradedVery mild children may have hands to knee and hands to feet play Move into and out of position using UEs
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PostureLike to sitNarrow base is unstable so they seek “W” sitSupport with UEs
MovementGet into and out of sitting in the sagittal planeIn “W” sitting, use both hands for play
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PostureHips flexed, anterior tilt to pelvis, lumbar lordosisUEs either used for support or posture to increase trunk stabilityAnkles often dorsiflex
MovementUse this as a transition position to extend both legs and attain standingStay in sagittal plane, lateral weight shifts difficult
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PostureDifficulty controlling midrange hip and knee ranges so “sits” on heels
Movement“Bunny Hop”Moves both UEs together then both LEs together
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
PostureBase narrow--adducted legs and plantar-flexed ankles
Supports on UEs
Often “sinks” to foot flat during quiet standing
Can’t stand still
McElroy, Haynes, & Franjoine 2009
MovementReciprocal movements of LEs—often abruptDifficulty dissociating LEs from each other
LE posturing may increase during gait
Difficulty with lateral weight-shift so often use trunk
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009M R Franjoine & M P Haynes
Dimension Functional Domain Disability Domain
A. Body structure & functions
Structural & functional integrity
Impairments
A.Primary
B.Secondary
B. Motor functions Effective posture & movement
Ineffective posture & movement
C. Individual functions
Functional activities Functional activity limitations
D. Social functions Participation Participation restriction
+ Domains -
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
LOCOMOTOR SKILLS
• Usually walk (with & without assistive devices)• WC may be necessary for energy conservation
COMMUNICATION • Usually communicate without difficulty
BASIC ADL’S • Many become independent
McElroy, Haynes, & Franjoine 2009M R Franjoine & M P Haynes
Dimension Functional Domain Disability Domain
A. Body structure & functions
Structural & functional integrity
Impairments
A.Primary
B.Secondary
B. Motor functions Effective posture & movement
Ineffective posture & movement
C. Individual functions
Functional activities Functional activity limitations
D. Social functions Participation Participation restriction
+ Domains -
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
Function well as a member of the family though may difficulty keeping up with siblingsSpecial classroom or mainstreamed. Participation is often limited due to:
FatigueSpeed and balanceCrutch, Walker, and WC accessCommunity accessabiltyAcceptance of peers
McElroy, Haynes, & Franjoine 2009
Address decreased ROMLengthen
Incorporate into your activitiesAccompany with activation
and/orCompensate
Help establish an appropriate BOSUsually need to widen
McElroy, Haynes, & Franjoine 2009
ALIGNMENT!In relation to BOSSegment to segmentDecrease asymmetries
Get the trunk moving over the hipBalanced flexors and extensors in the trunkWork in the frontal and transverse planes
McElroy, Haynes, & Franjoine 2009
Keep the LEs dissociated from each other
Work for midrange control and eccentric control
RepetitionMotor learningStrength
McElroy, Haynes, & Franjoine 2009
Protect their hands and other joints
Remember biomechanics when they get on their feet
Increased function increases risk of deformities
Have a long term perspective
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