Cerebral+Palsy

Please use this wiki to compile resources, links, and files related to your final project case study. You may use and organize this wiki however you wish, but please note that the following items are required:
 * Information about the child's diagnosis
 * Evidence-summary table and links to articles, websites, abstracts, etc (from the Nov 16 EBP lab) on a clinical question of your choice (related to the child's diagnosis, condition, limitations, and/or restrictions)
 * Educational material of your choice (such as a brochure, home exercise program, inservice presentation) related to the child's diagnosis, condition, restrictions/limitations

Remember, you MAY NOT include any identifying information on this page. Do not include the child's name or birth date, any personal information about the child, photographs or video of the child, or the WHO-ICF model completed about the child.

__Pathophysiology of cerebral palsy__
Cerebral Palsy is a permanent disorder that is non progressive but has caused damage in the developing fetal or infant brain. Insults affecting the brain during prenatal, perinatal, and postnatal time frames are associated with the cause of Cerebral Palsy (CP). These insults can be hypoxic, ischemic, infectious, congenital, or traumatic events within any of the three time frames listed above. Other related factors could be atypical uterine growth, premature birth, genetic factors, and multiple births. It is recognized that multiple factors contribute to the cause of CP in more children than one single event causing the disorder. There are differences in nature, location, and timing of insult to the brain throughout the diagnosis of CP. The brain lesion in CP is non progressive but secondary impairments of the musculoskeletal system can be progressive and are seen in most children. Muscle or tendon contracture, hip displacement, bony torsion, and spinal deformity can all occur with CP and lead to functional limitations.

__Types of cerebral palsy summary__
Three classification types are used to describe CP. The first is topographical distribution of limbs affected. Type of motor disorder is a second way to classify CP, and functional ability of the child is the third classification type. These different classification types can be combined and used together to describe CP, they are not seperate. A child can for instance have Spastic Diplegic CP and be GMFCS Level 1. So these different classification systems do not work independent of one another but work together to specify the location, motor classification, and functional ability.
 * Topographical classifications can besplit into three categories. First is diplegia, where the lower limbs are more affected than the upper limbs. Next is hemiplegia or hemiparesis, when the lower and upper limbs on one side of the body are more affected. Finally there is quadriplegia or tetraplegia, which is involvement of all limbs.
 * Motor disorders are separated into 4 different categories, depending on which area of the brain is damaged. (1) Spastic CP involves the motor cortex of the brain and the white matter going to and from the sensorimotor area. This creates muscle spasticity and hyper-reflexia. These can lead to abnormal movement and posture. (2) Dyskinesia is another classification by motor disorder in which the basal ganglia is affected. Involuntary, recurring, uncontrolled, and stereotyped movements occur with Dyskinetic CP. Dyskinetic CP can then be broken down into two other subtypes of dystonic and Athetotic. Dystonic movement patterns are involuntary intermittent or sustained muscle contractions and repetitive movements. Athetotic movements are slow and continuous writhing motions. (3) Ataxic CP is when there is a cerebellar lesion. Ataxia is when normal or intentional movement cannot be achieved voluntarily. Accurate, rhythmic, and coordinated movements cannot be achieved with Ataxic CP. (4) In mixed CP both dyskinesia and spasticity symptoms are present.
 * Functional abilities used to be separated into mild, moderate and severe. However these were not well defined or reliable. Now the Gross Motor Function Classification System (GMFCS) is used to describe the functional gross motor capabilities or disabilities of children with CP. The GMFCS has 5 different levels with level 1 being the least severe where the child can walk independently, climb stairs, run and jump with limitations of speed, balance, and coordination. Level 2 a child can walk shorter distances and climb stairs with a hand rail, some assistance is needed for longer distances and limited abilities of running or jumping. Level 3 categorizes children who use hand held assistance for short distances and use wheeled mobility for longer distances. Level 4 children can use power mobility or require physical assistance. Level 5 is then the most severe where the child is dependent for mobility and must be pushed in a wheel chair. This is just an abbreviated version of what classifies a child into which GMFCS Level.

__Physical presentation of spastic deplegic cerebral____palsy__
The physical presentation of a child with Spastic Diplegic CP could be quite variable. The major disfunction in children with spastic diplegic cerebral palsy is the spasticity and hypertonia seen in the lower extremities. The level of spasticity could vary from one individual to another, and no two individuals will have the exact same presentation. During gait they have excessive tone and tightness in the legs that makes walking very challenging. Most children are able to ambulate on their own either with or without an assistive device. However, in some with higher levels of severity will require a wheelchairs. The classic presentation would be the scissoring gait where higher tone in the adductors pulls the legs across midline during gait. Tight hip flexors and tight plantar flexors often lead to a flexed position of the hip and knee while walking more on the balls of their feet or toes. Hypertonicity often goes with spasticity, and in the case of spastic diplegia that is in the muscles of the lower extremities.

Above the hips, most people with spastic diplegia are relatively normal. They retain normal tone and range of motion in their upper extremities. Depending on severity some may have some tone and spasticity effecting the trunk and arms, but if all limbs are equally effected that is known as spastic quadriplegia. Because ambulation may be difficult and require the use of assistive devices and using the upper extremities, secondary muscle tension may develop in the arms, shoulders, and chest

__**Example of typical Gait Pattern seen in Spastic Diplegia**__ media type="youtube" key="_el2-BWW_Ms" height="315" width="420"

=__Information for providers__=

Treatment Plan for Child with Cerebral Palsy
Short Term Goal 1: In three months, child will be able to pick up objects off of the floor without falling 8 out of 10 times when tested
 * __Goals__**

Short Term Goal 2: In 6 months, patient will demonstrate heel strike in gait as reported by therapists, teachers and Family

Short term goal 3: In 6 months, Patient will have less than 5 falls per week

Long term Goal 1: Patient will walk 150 feet independently throughout school hallways and classroom with less than 1 fall per week.

˖ Progression: Increase time, have reach up high over head to get objects, remove manual cues from pelvis ˖ Progression: move objects further away from base of support, start with objects at hip level and put higher or lower progressing to over head reaching and recovering objects from floor, change weight of objects, have reach with 2 hands to one side to rotate whole body ˖ Progression: perform game on a non-stable surface, require more dynamic tasks ˖ Progression: add more unstable surfaces, heavier objects to move, progress from walking to running, hopping, and jumping ˖ Progression: remove cueing, kick a moving ball, kick to a target ˖ Practice varying speeds, remove any manual cues, practice without foot orthotics
 * __Treatment Plan__**
 * Outcome measure**: 6 minute walk test- the distance that the child walks in 6 minutes and how many times she falls will be recorded at the start of therapy to get a baseline measure, this measure will be repeated quarterly to track progress toward distance and safety goals
 * Laying Prone** to play games and practice reaching in order to strengthen back extensor muscles used for posture. Therapist will provide stabilization at pelvis while child is learning task
 * Reaching outside of base of support** to weight shift and recover objects from different heights
 * Simon Says**, while standing on flat firm surface to provide opportunities for balance, posture, and coordination
 * Obstacle course** to practice stepping on and off of different surfaces, and stepping over and around different obstacles
 * Kicking a static ball** with manual pelvic cueing to participate in PE, recess, and work on ddynamic balance skills for safety
 * Gait Training**- stepping on objects to increase stride length and encourage heel strike
 * Kineso Taping** to postural muscles as a kinesthetic reminder. If she is stable enough without an AFO but still needs a dorsiflection reminder, may Kineso Tape at the ankle also
 * __Adjunct therapies__**
 * Hippa Therapy**- for postural strengthening
 * Aquatic therapy**- for postural strengthening, balance, respiratory strength, endurance

Connolly, BH, Montgomery, PC, Therapeutic Exercise in Developmental Disabilities. 3rd ed. 3005

__In-service__
In-service on Appropriate Exercise Tests for Children with Cerebral Palsy- a presentation summarizing the Article //Identification of a core set of exercise test for children and adolescents with cerebral palsy: A Delphi survey of researchers and clinicians// by Verschiren, Olaf et. al. 2011

__Purpose__ A group of 15 experts- 10 physical therapists/ researchers, and 5 exercise physioloigists, participated in a Delphi survey to achieve a consensus of most appropriate exercise tests for children with Cerebral Palsy (CP). Based on the results of the survey, a core set of measures was identified for level I through IV of the Gross Motor Function Classification System (GMFCS).

__Why are exercise tests important for children with Cerebral Palsy?__ Many children with Spastic CP often have poor physical fitness- This may compromise daily functioning Exercise testing can be used as a primary outcome measure of therapy Can be used to evaluate exercise performance

__The Research__ Twenty one tests were identified from the literature and 6 additional tests were suggested by the group of researchers and professionals, leading to a total of 27 outcome measures that were to be examined. Psycometric properties were then analyzed for each outcome measure, and then tests were rated on a 10 point sale based on 4 items: safety, suitability, user friendliness, and overall rating for each GMFCS level. Lastly, the median scores were used to establish a core set of exercise test to be used for children with CP.

__The core set of Exercise tests__ arm cranking (lab test) || + - || + + || + + || arm cranking (lab test) || + - || + + || - + || MWT= minute walk test, SRT= shuttle run test __Recommendations For Clinical Practice__ Children with CP should be exercise tested to examine exercise health and provide outcome measures With proper safety precautions, symptom limited maximal exercise testing is safe for children and adolescents with CP. Maximal exercise testing is the preferred method to determine the exercise performance-limiting factors to exercise. The type of testing tool needs to be similar to the type of activity that the therapist is interested in. The child needs to know exactly what is expected of them to perform the test. The test procedure needs to be standardized.
 * Type of exercise || Exercise Test || Mode of Test || GMFCS levels I&II || GMFCS levels III&IV || GMFCS levels IV&V ||
 * submax || 6MWT || Walking (field test) || + || + || - ||
 * submax || Arm Cranking ergometer protocol || Arm Cranking (lab test) || - || + || - ||
 * Maximal || 10m SRT || Walking (field test) || + || - || - ||
 * Maximal || McMaster all-out protocol cycle test || Cycling (lab test)
 * Maximal || 7.5m SRT || Walking (field test) || - || + || - ||
 * Anaerobic || Muscle Power Sprint test || Walking (field test) || + || - || - ||
 * Anaerobic || 30s Wingate Cycle test || Cycling (lab test)

Is Kineso Tape an Appropriate Intervention for Children with Cerebral Palsy or other Neurological Disorders?
on Gross Motor Function in Children with Cerebral Palsy || 18 children with quadriplegic CP, GMFC levels IV  System for Cerebral Palsy levels IV || Two treatment groups: taping + PT vs. PT alone. Tape was worn for periods of 72 hours over the paraspinal region. Effects were measured using the Gross Motor Function Measure. Measures were taken at baseline, 6 weeks and 12 weeks. || There was no significant difference found in postural control found between the two treatment groups. ||
 * ** Author ** || ** Source ** || ** Date ** || ** Title ** || ** Sample ** || ** Methodolgy/Main Idea ** || ** Results ** ||
 * Simsek TT, et al. || Disabil Rehabilitation || Jan. 2011 || The effects of Kinesio Taping on sitting posture, functional independence and gross motor function in children with cerebral palsy || 31 children, levels III, IV, and V according to GMFCS || Random assignment to 2 groups: one group received PT and taping, and the control group received only PT. Intervention was 12 weeks; tape applied along the posterior trunk. GMFM, WeeFIM, and Sitting Assessment Scale (SAS) were used as outcome measures. || Compared to baseline, both groups showed a significant decrease in GMFCS sitting subscale, GMFCS total score, and SAS scores. WeeFIM scores were increased significantly in the experimental group compared to baseline; the control group showed no change in WeeFIM scores. SAS scores showed a significant difference in favor of the experimental group and no change in the control group. ||
 * Iosa M, et al. || Dev Med Child Neurol || Jun. 2010 || Functional taping: a promising technique for children with cerebral palsy || 8 children, diagnosed spastic unilateral CP || Pilot Study to look at effectiveness of functional taping to limit instability, contractures, and deformities. The taping lasted 6 months on this small sample group. All participants were taped and no control group was kept. || Baseline, post study, and 6 months post study measurements were taken. Subjects had Increased GMFM scores, and had observable gait improvements that were still maintained at 6 months post study. ||
 * Footer CB || Pediatric Physical Therapy || 2006 Winter || The Effects of Therapeutic Taping
 * Yasukawa, Audrey et. al. || American Journal of OT || Jan/Feb 2006 || Pilot Study: Investigating the effect of Kineso Taping in an Acute Pediatric Rehabilitation Setting || 15 children, with diagnoses of encephalitis, brain tumor, cerebral vascular accident, traumatic brain injury, and SCI || Pilot study to describe the use of Kineso Taping method for the UE in enhancing functional motor skills in children admitted to acute rehab. the Melbourne assessment was used at baseline, immediately after taping, and 3 days after taping || Improvement between pre and post testing with Melbourne test were statistically significant ||

__Information for caregivers__
Online links and resources for caregivers to find out more information about Cerebral Palsy and their child.
 * Great source for parents/caregivers to visit for information about CP: [|My Child with Cerebral Palsy]
 * Advocates for life without limits in those children with CP and disabilities: [|United Cerebral Palsy]
 * Another source to look at for facts about CP and answer questions: [|About Cerebral Palsy]

__ **Adaptive equipment information** __

There are many options for adaptive equipment when it comes to children with cerebral palsy and their needs. The best equipment choices will depend on the individual child's characteristics, physical and social environment, and goals.

Orthotics are one common type of equipment used for this population. One company which manufactures orthotics is [|Cascade]. Their website is a comprehensive resource for families and health care providers, and it includes a [|library] of resources. One helpful feature for physical therapists is the "Guide to Brace Selection." There is an interactive Guide, or a PDF if a hard copy is desired for clinic use:

The website also has information for providers about how to write a letter of medical necessity. The example can be found here:

The website has a number of videos of children walking with and without their orthotics. The following links to a video of a child using a Tami 2 DAFO, which is the AFO we recommended for our patient: [|walking video]. There are other videos concerning fit and anatomy--check it out!

Other equipment that may be used includes wheelchairs, scooters, standers, walkers, seats, computers (for communication or as part of a game during intervention), and toys. The following link takes to you Adaptive Mall's website, where you can [|shop by need]: lying, crawling, balance, sensory integration, etc. Most websites are for companies (i.e., ".com"), so be careful to find quality sources for your equipment needs.