1. Prim Haynes & Franjoine 2009 Child with Hemiplegia Margo Prim Haynes, PT, DPT, MA, PCS Mary Rose Franjoine, PT, DPT, MS, PCS 2009

2. Prim Haynes & Franjoine 2009 Spastic or Hypertonic CP –Hemiplegia –Diplegia –Quadriplegia Categories of Cerebral Palsy (CP)

3. Prim Haynes & Franjoine 2009 General Comments Hemiplegia means: Significantly more involvement on one side of the body Usually full term pregnancy of single births

4. Prim Haynes & Franjoine 2009 Pictures and Video

5. Prim Haynes & Franjoine 2009 General Comments Diagnosed early …. Why?  Asymmetry  Hold Bottle  Mom notices hands first  Pick up LE concerns later

6. Prim Haynes & Franjoine 2009 Pictures

7. Prim Haynes & Franjoine 2009 DimensionFunctional Domain Disability Domain A. Body structure & functions Structural & functional integrity Impairments A.Primary B.Secondary B. Motor functionsEffective posture & movement Ineffective posture & movement C. Individual functions Functional activities Functional activity limitations D. Social functionsParticipationParticipation restriction From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82 + Domains - Dimensions NDT Enablement Classification Model of Health and Disability

8. Prim Haynes & Franjoine 20092009 NDT Enablement Classification Model of Health and Disability DimensionFunctional DomainDisability Domain A. Body structure & functions Structural & functional integrity Impairments A.Primary B.Secondary B. Motor functionsEffective posture & movement Ineffective posture & movement C. Individual functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

9. Prim Haynes & Franjoine 2009 Damage (lesion) impacts- –the motor cortex –white matter projections to and from cortical sensorimotor areas of the brain Causes: –Unknown prenatal condition –Asphyxia –Prematurity Intracranial bleeds, infection, medical conditions (Campbell S 2000) Body Structure and Function

10. Prim Haynes & Franjoine 2009 Cognition Function: Intelligence Varies: –Dependent upon many factors: –Development of seizure activity in later years (7 years) Impairments: –Processing –Attention Deficit Disorders –Right vs Left Involvement (Trauner 2003)

11. Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Muscle Activation Excessive co-activation (stiffness increases) during task –Limits movement – speed –Limits flexibility of movement responses

12. Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Muscle Activation Impaired Muscle Synergies –Limited repertoire –Stereotyped patterns of movement –Performed in limited ranges

13. Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Muscle Activation Latency in initiating Difficulty sustaining postural muscles Often passive termination of muscles

14. Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Motor Execution Impaired Modulation & Scaling of Forces –Inability to slow down as approach target –Particular difficulties grading grip

15. Prim Haynes & Franjoine 2009 Neuromuscular System Impaired Timing and Sequencing Excessive overflow of Intra-Inter limb contractions –Decreases the capacity for isolated control during effort

16. Prim Haynes & Franjoine 2009 Neuromuscular System Insufficient Force Generation (muscle strength) : Asymmetrical Postural Muscles Movement Muscles

17. Prim Haynes & Franjoine 2009 Sensory System May have: –Hyposensitive: ↓ sensation one side –Hypersensitive: ↑ sensitivity –Total Disregard / Neglect

18. Prim Haynes & Franjoine 2009 Sensory System May have: –Sensory Processing Impairment: –Visually and auditory Impairments

19. Prim Haynes & Franjoine 2009 Video

20. Prim Haynes & Franjoine 2009 Musculoskeletal System Secondary Impairments Range of Motion Impairments: UE & LE Increased risk: scoliosis Increased risk: hip dislocation Monitor for limb length discrepancies both UE than LE ( UE < LE)

21. Prim Haynes & Franjoine 2009 NDT Enablement Classification Model of Health and Disability DimensionFunctional DomainDisability Domain A. Body structure & functions Structural & functional integrity Impairments A. Primary B. Secondary B. Motor functionsEffective posture & movement Ineffective posture & movement C. Individual functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

22. Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture Underlying postural tone low High tone extremities, low tone trunk Asymmetry = poor midline orientation

23. Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture One side of the body shows more variability than the other side of body Uses “stronger” UE and “stronger LE to support in upright

24. Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture Difficulty transferring objects using involved hand Limited movement of digits / unable to get stability around wrist. Difficulty performing end range supination with flexion for grasp and hold

25. Prim Haynes & Franjoine 2009 Pictures

26. Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Posture LE patterns: –Hip adduction, internal rotation (IR), knee flexion or extension, ankle positioned in plantar-flexion or pronated –Hip adduction, IR, knee extension, ankle positioned in varus

27. Prim Haynes & Franjoine 2009 Pictures

28. Prim Haynes & Franjoine 2009 Posture and Movement May see: Loss of independent ankle movement on involved LE Limited function of ant tibialis and toe extensors Splinting options important for this population

29. Prim Haynes & Franjoine 2009 Posture and Movement General Characteristics: Movement Most active movement in sagittal plane Moves with asymmetrical phasic bursts Initiates movement with asymmetrical extension

30. Prim Haynes & Franjoine 2009 Video

31. Prim Haynes & Franjoine 2009 Speech and Language Speech and Language delays appear to resolve by school age (Trauner 2003) Children with LH damage more impaired in expressive language (Thal 2009, Trauner 2003) Children with RH damage more impaired in receptive language (Thal 2009, Trauner 2003) See facial asymmetry when crying, feeding and smiling- at rest see symmetry

32. Prim Haynes & Franjoine 2009 Prone Postures: Positions on one elbow using stronger arm for play Movement Pull with strong arm and push with leg to get toys

33. Prim Haynes & Franjoine 2009 Pictures and Video

34. Prim Haynes & Franjoine 2009 Supine Postures: Plays in this position until move upright Movement Rolls and transition from this position moving over stronger side

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36. Prim Haynes & Franjoine 2009 Sitting Postures Sitting is a functional position Independent in a number of positions (“w” position, side sit, modified long sit) Asymmetry

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38. Prim Haynes & Franjoine 2009 Sitting Movement Often prefers to move in sitting position –“Hitch” across floor

39. Prim Haynes & Franjoine 2009 Video

40. Prim Haynes & Franjoine 2009 Quadruped Posture: Quadruped Select position when UE is strong enough to handle the movement Movement: May see Asymmetrical commando crawl Asymmetrical reciprocal creep = pelvis behind knees

41. Prim Haynes & Franjoine 2009 Pictures and Video

42. Prim Haynes & Franjoine 2009 Kneeling Posture Hips flexed, pelvis in anterior position, ankles planter flexed or dorsi flexed Transition to stand from kneel position Movement Stabilize with upper body to move

43. Prim Haynes & Franjoine 2009 Pictures

44. Prim Haynes & Franjoine 2009 Standing Postures Enjoy being upright Asymmetrical stance

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46. Prim Haynes & Franjoine 2009 Walking Movement Ambulation – 80% ambulate by 2 years of age – 100% ambulate by 3 years of age

47. Prim Haynes & Franjoine 2009 Video

48. Prim Haynes & Franjoine 2009 NDT Enablement Classification Model of Health and Disability DimensionFunctional DomainDisability Domain A. Body structure & functions Structural & functional integrity Impairments A. Primary B. Secondary B. Motor functionsEffective posture & movement Ineffective posture & movement C. Individual functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

49. Prim Haynes & Franjoine 2009 Activities & Activities Limitation Locomotor SkillsOften independently ambulatory (3 years of age) CommunicatesCommunicates with /without articulation issues Basic ADL’sMay be independent with self help skills FeedingIndependent

50. Prim Haynes & Franjoine 2009 NDT Enablement Classification Model of Health and Disability DimensionFunctional DomainDisability Domain A. Body structure & functions Structural & functional integrity Impairments A.Primary B.Secondary B. Motor functionsEffective posture & movement Ineffective posture & movement C. Individual functions Functional activitiesFunctional activity limitations D. Social functionsParticipationParticipation restriction + Domains - Dimensions From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82

51. Prim Haynes & Franjoine 2009 Function well as member of family: may have difficulty keeping up with siblings Mainstreamed or special classroom May continue to higher education and full time employment Participation

52. Prim Haynes & Franjoine 2009 Treatment Strategies 1.Provide somatosensory input to assist with building movement repertoire 2.Reinforce with visual and auditory clues. 3.Facilitate symmetrical posture and movement in functional tasks.  Midline alignment  Symmetrical strength

53. Prim Haynes & Franjoine 2009 Treatment Strategies 4.For hand function: choose activities that use individual finger digits (puppet play, finger tip activities) 5.Treat using rhythm and music.

54. Prim Haynes & Franjoine 2009 Treatment Strategies 6. Encourage child to explore world thought loading upper extremities 7. Don’t push upright position until ready to go. 8. Introduce variety and speed.

55. Prim Haynes & Franjoine 2009 References Thal DJ, Marchman, V, Stiles J, Aram D, et al. Early lexical development in children with focal brain injury. Brain Lang 2003; 40: 491-527 Trauner D. Hemispatial neglect in young children with early unilateral brain damage. Developmental Medicine & Child Neurology 2003; 45: 160-166

56. Prim Haynes & Franjoine 2009 Child with Hemiplegia Margo Prim Haynes, PT, DPT, MA, PCS Mary Rose Franjoine, PT, DPT, MS, PCS 2009