CP intervention class Flashcards
neurological interventions:
- oral baclofen
- intrathecal baclofen pump
- botox injections
- selective dorsal rhizotomy
orthopedic intervention:
single event multi-level surgery (SEMLS)
SEMLS: soft tissue procedures
tendon release/lengthening
distal rectus femoris transfer
SEMLS: bone procedures
femoral extension osteotomy
varus derotation osteotomy (VDRO) and acetabular osteotomy
hemi-epiphysiodesis
Novak 2020 – Evidence Alert Traffic Light System
framework for grading the strength of evidence for different interventions, particularly in the field of cerebral palsy (CP)
system uses a traffic light analogy to communicate the quality and effectiveness of interventions, with colors indicating the level of recommendation based on available evidence
Red light:
Don’t do it interventions- not recommended beyond traditional care, may not have enough evidence
Strong evidence suggests that the intervention is ineffective or even harmful
Yellow light:
Probably do it and probably don’t do it interventions (distinguished by the ‘worth it line’- fewer and lower quality articles
There is mixed or emerging evidence for the intervention, indicating it may be promising but requires further research to confirm its efficacy
Practitioners should proceed with caution and monitor outcomes closely
Green light:
Effective interventions- more high-quality articles
Strong evidence supports the intervention as beneficial
These are recommended interventions because high-quality studies, such as systematic reviews or randomized controlled trials
Green light motor interventions:
bimanual = hand function
CIMT = hand function, activity & participation
Hippo therapy = balance symmetry
Partial Body Weight Support Treadmill Training = walking speed
Goal directed training = hand function, gross motor
strength training = muscle strength
mobility training = walking speed
task specific training = gross motor
treadmill training = walking speed, walking endurance, gross motor
Bimanual Training (Hand Function):
Focuses on improving the coordination and use of both hands together
Significant improvements in dexterity, grip strength, and goal achievement
Constraint-Induced Movement Therapy (CIMT) (Hand Function, Activity, & Participation):
Involves restraining the less-affected hand to encourage use of the more-affected hand, promoting hand function and real-life task performance
Increased use of the affected limb, better outcomes in fine motor tasks, and greater engagement in bimanual activities
Hippotherapy (Balance and Symmetry):
using the movement of a horse to improve postural control, balance, and symmetry in patients with motor impairments
Positive changes in trunk control, pelvic stability, and overall symmetry in walking and sitting
It can also have a positive emotional and motivational effect
Partial Body Weight Support Treadmill Training (Walking Speed):
Involves using a treadmill with partial body weight support to enhance walking ability
Improvements in gait speed, step length, and walking endurance
Goal-Directed Training (Hand Function, Gross Motor Skills):
Tailored interventions focusing on specific goals important to the individual’s daily activities, involving practice in meaningful contexts
Improved outcomes in goal-specific tasks, including fine motor tasks (e.g., grasping) and gross motor tasks (e.g., sitting or walking)
Strength Training (Muscle Strength):
Focuses on increasing muscle strength through repetitive, resisted exercises
Gains in muscle power, endurance, and functional skills such as standing, walking, and transferring
Mobility Training (Walking Speed):
Involves focused practice on walking skills, often using walking aids or support to improve speed and quality of gait
Improved speed, cadence, and walking efficiency
Task-Specific Training (Gross Motor Skills):
Repetitive practice of functional tasks to improve gross motor skills, focusing on specific movements relevant to daily activities
Gains in posture, balance, and gait mechanics
Task-specific training increases muscle coordination and task execution by reinforcing neural pathways responsible for the movement
Treadmill Training (Walking Speed, Walking Endurance, Gross Motor Skills):
Using a treadmill to promote gait re-training and improve overall walking capacity
Enhances cardiovascular fitness, muscle strength, and walking distance
Green light contracture & alignment interventions:
lower limb casting = passive range
BoNT + casting = passive range
Lower Limb Casting (Passive Range of Motion):
Serial casting or static positioning of the lower limbs to improve or maintain passive range of motion (PROM) by lengthening shortened muscles and soft tissues
Significant improvement in passive dorsiflexion of the ankle
Often used to manage spasticity-related contractures, casting has been shown to temporarily improve alignment and gait patterns
ollow-up interventions like bracing, stretching exercises, or functional activity training
Botulinum Toxin (BoNT) + Casting (Passive Range of Motion):
Combines the effects of Botulinum Toxin (BoNT) injections, which reduce muscle spasticity, with serial casting to improve passive range of motion by further relaxing overactive muscles and lengthening them through casting
Enhanced PROM in targeted muscles (e.g., gastrocnemius for ankle dorsiflexion)
benefits in both joint alignment and muscle flexibilit
Green light self care/ function interventions:
goal directed training = self care
home program = self care
Goal-Directed Training (Self-Care):
Focuses on practicing and improving skills related to specific personal goals, particularly those essential for daily living and self-care, such as dressing, grooming, or feeding
Improved self-care abilities, such as dressing, bathing, and personal hygiene, through repeated practice of specific tasks
better task performance and independence
improving overall quality of life
facilitates motor learning by focusing on real-life, functional tasks
Home Programs (Self-Care):
Structured home-based exercise or activity programs designed to help individuals practice self-care tasks in their natural environment, promoting continuous progress outside of clinical settings
improvements in self-care task performance due to regular practice at home, where children and adults with CP can work on skills like feeding, dressing, or toileting with guidance
Helps maintain progress made in clinical settings and provides opportunities for more frequent repetitions of self-care tasks
better functional outcomes, greater independence, and more participation in daily routine
Green Light PT Interventions
Real-life tasks and activities (routine-based)
Self-generated active movements at high intensity
Motivation is essential – Goal is set by child
Successful, task-specific practice that is rewarding and enjoyable
Real-Life Tasks and Activities (Routine-Based Interventions):
focus is on using activities that are part of the individual’s daily routine or are meaningful to their everyday life
walking, dressing, or playing, are integrated into therapy sessions to promote functional skill development
Improvements in functional mobility and self-care skills
Increased independence in daily tasks and greater participation in social activities
Self-Generated Active Movements at High Intensity:
Encourages individuals to generate their own movements actively, focusing on high-intensity, repetitive practice to improve motor control and strength
based on neuroplasticity principles, where high-intensity, task-specific movements lead to better motor outcomes
Enhanced motor control, muscle strength, and endurance
Better outcomes in gross motor skills such as walking, running, or grasping objects
improve motor planning and problem-solving
Motivation is Essential – Goal is Set by the Child:
Therapy is more effective when the child is motivated by goals that they set themselves
Greater adherence to therapy and more enthusiastic participation
Higher levels of goal achievement and better functional outcomes
Children are more likely to practice independently and remain committed to therapy when the goal is personally meaningful
Successful, Task-Specific Practice that is Rewarding and Enjoyable:
meaningful tasks that the child finds enjoyable and rewarding
increases motivation, facilitates motor learning, and promotes mastery of specific skills
Significant improvements in motor function, such as balance, strength, and coordination
faster skill acquisition and better retention
boosts self-confidence and encourages continued effort and practice
CONTRACTURE MANAGEMENT
Serial casting or dynamic bracing
Strong evidence for changes in dorsiflexion
Typical Protocol: Serial casting for 4-6 weeks with weekly re-fittings or changes, followed by orthotics.
Serial Casting and Dynamic Bracing =
widely used for managing contractures, particularly in individuals with conditions like cerebral palsy, stroke, or brain injury
focus on improving joint range of motion by progressively stretching tight muscles and soft tissues, typically the lower limbs
Strong Evidence for Dorsiflexion Improvement =
especially in cases of equinus deformity (where the foot points downward) due to tight calf muscles
improving passive range of motion (PROM), particularly in the ankle joint, which contributes to better gait patterns and overall mobility
Typical Protocol Casting:
typically performed over a period of 4-6 weeks
casts are usually re-fitted or changed every 7 days to gradually increase the stretch on the tight muscles
e-fitting allows for small increases in range of motion as the muscle and soft tissue adapt to the stretch
Once the serial casting phase is complete, the patient is often transitioned to orthotic devices (e.g., ankle-foot orthoses, or AFOs) to maintain the gains in range of motion and prevent recurrence of the contracture
Task-Specific and Goal-Directed Therapy
Multiple terms in the literature:
Activity-focused
Task-oriented training
May need to address body structures/function before task practice
Motor control and learning principles come into play
Postural control components
Activity-Focused Therapy:
Emphasizes practicing functional activities that are part of daily life
Task-Oriented Training:
Refers to repetitive practice of specific tasks that are aimed at improving motor skills and functionality in real-life contexts
Motor Control:
The ability of the central nervous system to regulate and direct the mechanisms essential for movement
Task-specific therapy is grounded in principles of motor control, which focuses on how the brain controls movement patterns
Motor Learning:
Involves acquiring new skills through practice and experience
Principles such as repetition, intensity, and feedback are crucial to refining movement patterns and making them more efficient
10x10x10
Inclusion Criteria
10 degrees of wrist extension
10 degrees of thumb abduction
10 degrees of extension for at least two other fingers
Other considerations:
cognitive function, spasticity, balance
Components of Constraint-Induced Movement Therapy (CIMT)
emphasizes repetitive, task-oriented practice of the affected arm while constraining the unaffected arm
CIMT COMPONENTS
Typically provided daily over a period of 2 weeks and led by an OT, PT, or both
Constraining the unaffected arm
Repetitive task-oriented training (3-6 hours)
Behavioral Techniques for real-world situations
Behavioral techniques are utilized to promote motivation, engagement, and self-efficacy in real-world situations:
Goal setting: Helping patients set specific, measurable goals for their therapy
Positive reinforcement: Providing feedback and encouragement to boost confidence and motivation
Task adaptation: Modifying tasks to increase their relevance and challenge level, promoting engagement in meaningful activities
Functional transfer: Encouraging patients to apply skills learned in therapy to everyday activities in their home or community settings
BIMANUAL TRAINING
Promotes use of both hemiparetic and dominant hand together
Also known as Hand-Arm Bimanual Intensive Training (HABIT)
Consider pairing with CIMT
Home Program for Self Care
Practice of goal-directed tasks
Select routine-based activities
Support with reinforcement
HIPPOTHERAPY
Green light for balance and symmetry
Yellow for gross motor and hand function
PT/OT utilizing horse as modality, so not the same as therapeutic riding
Typical Protocol: At least 16 hours – 1 hr, 2x/wk for 8 wks
PEDIATRIC GAIT INTERVENTION:
green light
mobility training: walking speed
treadmill training: walking speed, walking endurance, gross motor
partial BWSTT: walking speed
PEDIATRIC GAIT INTERVENTION
Dosing:
2-5x/wk for 2-12 wks
(at least 10 sessions)
Prevention vs Remediation vs Compensation
Prevention
prevent the onset of secondary impairments or deterioration of functional abilities
Focus on educating families about proper body mechanics, safe mobility practices, and the importance of regular activity.
Incorporate activities that promote balance, strength, and coordination in playful and engaging ways.
Remediation
address and correct existing gait deviations or impairments that hinder functional mobility
Utilize task-specific training, where children engage in repetitive practice of gait-related activities that are functional and meaningful to them
Use assistive devices (e.g., walkers, orthotics) if necessary, to support the child in achieving more typical gait pattern
Techniques may include motor learning principles, such as feedback, guidance, and varied practice, to help children improve their gait mechanics.
Compensation
help children adapt to their limitations and improve functional mobility using alternative strategies or assistive devices
Train children to use compensatory strategies that allow them to navigate their environment safely and efficiently despite their gait limitations (e.g., learning to use a wheelchair or scooter)
Modify the environment to reduce barriers to mobility (e.g., using ramps instead of stairs, minimizing obstacles).
Partial Body Weight Support Treadmill Training
harness system allows for the adjustment of body weight support, typically between 20% to 60% of the individual’s body weight
reduction helps improve stability and balance during walking
Walking on a treadmill provides a controlled environment that allows for repetitive practice of gait patterns
Indications for PBWSTT:
Neurological Conditions: Such as stroke, traumatic brain injury, multiple sclerosis, and cerebral palsy.
Musculoskeletal Injuries: Where gait retraining is necessary post-surgery or injury.
Developmental Disorders: In children with conditions like spastic diplegia or other gait-related issues.
STRENGTH/POWER TRAINING
Typical Protocol:
8-12 weeks
2-3 sessions per week
45-60 min sessions
STRENGTH/POWER TRAINING
1RM Testing:
select weight for movement: guess a weight you think a child can successfully complete <5 times, then use calculator to estimate 1RM
adujst weight: child completed >5 reps of previous weight = increase weight, child unable to complete successful attempt = decrease weight
continue adjusting weight: child completes 1-5 reps = estimate 1RM, child unable to complete repetition or completes >5 reps = adjust
power training:
6 sets of 6 reps
60-80% of 1 rep max
FAST concentric, SLOW eccentric
strength:
3 sets of 5-8 reps
>80% 1 rep max
SLOW and CONTROLLED
STRENGTH/POWER TRAINING
Functional 1RM Testing:
Pushing, pulling, stairs, steps, walking
Distance/steps child can cover unweighted in 25 seconds
Add weight so the child can perform 50-70% of max effort (ie, distance, steps)
Power training in short bursts of approx. 25 seconds, 6-8 reps
Increase weight 10% when child can complete all reps in <25 seconds
Yellow Light Motor Interventions:
Assistive Technology
Electrical Stimulation
Orthoses
Stretching
ASSISSTIVE TECHNOLOGY
Standing/Weight-bearing devices
Virtual Reality & Gaming
Standing/Weight-bearing devices:
Target 60-90 minutes a day
designed to facilitate upright posture, promote weight-bearing through the lower extremities, and support muscle strengthening, balance, and coordination
Regular weight-bearing activities can help strengthen bones and reduce the risk of osteoporosis
Encouraging upright posture can enhance respiratory function and overall body alignment
enable children to engage more actively in their environment, promoting social interaction and participation in daily activities
Virtual Reality & Gaming:
At least 4 hours (20 min/session, 2x a week, 6 weeks)
provide immersive experiences that can motivate and engage children in therapeutic exercises, making rehabilitation more enjoyable and effective
improve cognitive skills (e.g., memory, attention) alongside motor skills, promoting dual-task performance which is essential in everyday life
FUNCTIONAL ELECTRICAL STIMULATION:
For better gait mechanics
↑ strength
↓ foot drop
↑DF in swing
↑heel strike
Monitor for comfort and skin reactions
ORTHOSES:
For better gait mechanics
↑ walking speed
↑ stride length
↑ DF in swing
↑ heel strike
Monitor for comfort and skin reactions
What type of shoes should be worn with LE orthoses?
extra depth
flexible & lightweight
substantial outsoles
firm heel counter
STRETCHING
Need sustained stretch to make meaningful changes – think serial casting
Manual stretching is not a skilled activity but can be used to warm up tissues for activity or for pain management
Can teach child/family how to incorporate longer duration stretches into their daily home program
Types of Stretching Techniques
Static
Dynamic
Prolonged
Static Stretching:
Involves holding a stretch in a comfortable position for an extended period (typically 15-60 seconds).
Effective for increasing flexibility and improving muscle length.
Dynamic Stretching:
Involves moving parts of the body through a range of motion in a controlled manner.
Useful as part of a warm-up to prepare muscles for activity.
Prolonged Stretching:
Similar to sustained stretching, it involves holding a stretch for a longer duration (e.g., 30 minutes to several hours).
Techniques such as splinting or the use of serial casts can facilitate this type of stretch.
Begin with green light interventions, based on ___
child/family goals
Yellow-light interventions may be considered based on ____
child/family goals, interests, and access
Incorporate ___ training principles
strength/power
Use functional tasks to target ___ and ___ control
reactive
anticipatory postural
