Case 4: Hemipolymicrogyria - Bracing for Gait (exam 2) Flashcards
T/F: The shaft to vertical angle is unaffected by the type of shoe the patient wears
F - it is affected
ideal angle is 10 degrees
All of the following are true regarding children with hemiplegia except:
A. They have an asymmetrical gait pattern.
B. They sometimes present with equinus deformity.
C. They always need bracing to normalize gait.
D. They have involvement of the arm and leg on the same side.
C, NOT TRUE
bracing may not always be needed, depending on amount of tone present
Children who present with increased tone may benefit from all except:
A. Medical management of tone
B. Strengthening programs
C. Bracing during movement
D. Increasing tone for stability
increasing tone in children with spasticity can lead to even MORE inefficient movements and increased energy expenditure
(Answer D)
A valid and reliable tool for measuring tone is:
A. GMFM
B. Modified Ashworth scale
C. Manual muscle testing
D. Palpation of the muscle
B: Modified Ashworth Scale
(only tool listed that measures tone)
GRADE C evidence: The ____ and ____ scales appear to have face validity for use with kids with polymicrogyria that have hemiparesis + increased tone
MAS and Tardieu scales
GRADE A evidence: In children with cerebral palsy (GMFCS Levels I-III), botulinum toxin injections followed by physical therapy temporarily reduce _____ so that_____ muscles can be strengthened and new motor plans can be learned.
reduce spasticity temporarily so antagonist mm can be strengthened
GRADE A: Bracing to ____ tone and normalize gait parameters is an effective intervention in children with _______spasticity, but the specific bracing type needs to be individualized to the child
reduce tone, normalize gait
lower extremity spasticity
key definitions
Category of ankle-foot brace that allows for anterior-posterior movement at the ankle (includes hinged and posterior leaf spring)
DYNAMIC AFO (DAFO)
key definitions
What is an EQUINUS DEFORMITY
limited ankle DF
Type of brace that keeps the foot in a neutral position, and does not allow movement at the ankle
solid ankle-foot orthosis (AFO)
Type of low-profile brace that limits ankle inversion and eversion, but generally allows dorsiflexion and plantar flexion
SMO
supramalleolar orthosis
What are PT general POC/Goals for young children with hemiparesis
- Maintain range of motion (ROM) and activity in hemiparetic side to obtain typical or near-typical developmental milestones
- address movement patterns to ensure that the child is using the most energy-efficient methods possible
- prevention of musculoskeletal complications
What are PT interventions for young children with hemiparesis
- WB and activation of antagonist muscles to reduce tone
- movement through typical progression and activation of hemiparetic side with activities that encourage participation in typical childhood activities
- constraint-induced therapy
- electrical stimulation
- functional movement
- dynamic bracing to allow functional movement without allowing movements into tonal patterns such as excessive plantar flexion
Hemipolymicrogyria/children with hemiparesis:
PT PRECAUTIONS for this population
- Significantly increased tone often requires pharmacologic management, such as oral medications for spasticity, botulinum toxin injections, or baclofen intrathecal pump to allow functional movement.
- Adverse drug reactions (ADRs) of these medications, such as decreased alertness and excessive weakness, must be monitored.
- Forcing movements against significantly increased tone can cause structural problems (e.g., forcing dorsiflexion can cause a midfoot break)
complications interfering with PT for children with hemiparesis
-significantly increased speed or activity can increase tone in hemiparetic side
-long- term use of constraint-induced therapy could interfere with bilateral limb use
-significant tone reduction could negatively affect movement, especially if child was relying on the tone for stability.
Condiiton related to formation of gyri or folds in brain before birth. Diagnosed when too many or smaller than normal gyri
polymicrogyria
(can be unilateral-mild, or bilateral-more severe)
Depending on the severity, the child w/ polymicrogyria may present with minimal signs and symptoms or severe developmental delay with hypertonicity/hypotonicity, seizures, and cognitive issues
T or F
true
Winters classification system is used to describe ______ in children with ______
4 distinct patterns of gait with children with spastic hemiplegia
Winters group 1
foot drop during swing
flat foot or great toe strike at IC
excessive hip + knee flexion during swing
adequate DF during stance
Winters group 2
As tone is more severe, there is more PF throughout gait cycle
Winters group 3
progressing to knee hyperextension and increased lumbar lordosis
Winters group 4
characterized by limited hip movement and significantly increased lordosis (most ssevere)
Studies evaluating the decreased efficiency and increased energy expenditure during gait in children with hemiplegia highlight compensations such as:
- hip retraction in stance
- increased push-off on the unaffected side
- early firing of the fibularis longus
- Other studies discuss the influence of excessive plantar flexion on pelvic retraction and hip rotation.
Should we strengthen children with hemipolymicrogyria?
yes
goal: normalize gait, minimize structural impact of atypical WB
Strengthening is MAJOR COMPONENT
Brace with just right amount of support
Therapeutic interventions could include:
active stretching
WB activities
others: aquatics, hippotherapy
following botox: strengthen mm while tone in antagonistic mm are decreased
TRUE OR FALSE
TRUE
active stretching
WB activities
others: aquatics, hippotherapy
following botox: strengthen mm while tone in antagonistic mm are decreased
T or F:
In both the original and modified Ashworth scales, test-retest reliability in children with CP varies from **poor to adequate **depending on the joint tested.
TRUE
Intra-rater reliability tends to be higher than inter-rater reliability
In use with children with CP, test-retest reliability varies from **adequate to excellent **in the lower extremity, and inter-rater reliability is adequate:
which spasticity measure is this?
Tardieu
Have studies assessed the reliability and validity of Tardieau and MAS in children with CP?
No
*but appears to have face validity in kids with increased tone + hemiparesis
Can you use the GMFM for this population?
Yes: can be used to show functional progress with use of bracing
*Winters may not be appropriate for children with very mild impairments
What could be a limitation of solid AFO vs Dynamic AFO?
solid: does not allow forward tibial translation during terminal stance, making gait unstable
*the physician was worried about midfoot break with DAFO, but they had a discussion
T or F: strengthening activities increase spasticity
F
there is growing recognition that children with_____show more functional improvement and better gait characteristics, such as heel strike, stride length, and cadence, in dynamic AFOs compared to solid AFOs
less significant tone
