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McElroy, Haynes, & Franjoine 2009
A group of disorders impacting the development of
movement and posture
Results in activity limitation
Accompanied by disturbances of:
Sensation
Cognition
Communication
Perception
Possibly behavior and/or seizure disorder
McElroy, Haynes, & Franjoine 2009
(Campbell S 2000, Miller F 2005, Bax M 2005 )
• Caused by a non-progressive
defect or lesion occurring in
an immature brain
• Insult occurs before or after
birth
• Single or multiple locations
McElroy, Haynes, & Franjoine 2009
(Campbell S 2000, Miller F 2005, Bax M 2005 )
Spastic or Hypertonic CP
Hemiplegia
Diplegia
Quadriplegia
• Ataxia
• Athetosis
• Hypotonia
McElroy, Haynes, & Franjoine 2009
Dimensions
+
Domains
-
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
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
M R Franjoine & M P Haynes
Dimensions
+
Domains
-
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
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
M R Franjoine & M P Haynes
Spastic Diplegia
41.5
Spastic Hemiplegia
36.4%
Dyskinesia or Athetosis 10%
Spastic Quadriplegia
Ataxia
McElroy, Haynes, & Franjoine 2009
7.3%
5%
(Campbell S 2000)
Lesion(s) impacts:
the motor cortex
and/or
white matter projections to and from
cortical sensorimotor areas of the brain
Causes:
Unknown prenatal condition
Asphyxia
Prematurity
Intracranial bleeds, infection, medical conditions
McElroy, Haynes, & Franjoine 2009
(Campbell S 2000)
Body Structure and Functions
Cognition
Neuromuscular System
Sensory System
Musculoskeletal System
Regulatory
Gastrointestinal
Cardiopulmonary
Integumentary
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
McElroy, Haynes, & Franjoine 2009
(Lundy-Ekman 2002, Kandel 2000)
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
McElroy, Haynes, & Franjoine 2009
(Crenna 1998, Lundy-Ekman 2002, Kandel 2000)
What is Spasticity?
Resistance to rapid muscle stretch
Velocity dependent
The phasic component of hypertonus
Often associated with:
Upper Motor Neuron Syndrome (UMNS)
Hyperactive deep tendon reflexes
(Kandel 2000)
Clonus
McElroy, Haynes, & Franjoine 2009
Impaired Muscle Activation
Excessive Co-activation
Impaired Muscle Synergies
Inability to Initiate,
Sustain, Terminate
McElroy, Haynes, & Franjoine 2009
Co-activation
Simultaneous 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-activation
Decreases movement speed
Limits flexibility of movement
responses
Increased energy costs and fatigue
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Muscle Synergies
A group of muscles working
together across multiple
joints and organized to act as
a functional unit
Simplifies the work of the
CNS
Strengthens with repetition
McElroy, Haynes, & Franjoine 2009
Impaired Muscle Synergies
Based on limited movement
repertoires
Difficult to vary or adapt to
meet the requirements of
different tasks
Produces stereotypical
movement patterns
McElroy, Haynes, & Franjoine 2009
Impaired Muscle Synergies
Movements are limited in
amount and frequency
Movements 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 IntraInterlimb 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 coordination
i.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
other
i.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 spasticity
Primary—impaired input from motor pathways
Secondary– 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 movement
Fail to anticipate postural needs prior to a movement
or task
Fail 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 from
Can easily adapt and modify repertoires for the task
Movements 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 segment
Inter-limb
Intra-limb
Limbs 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 problems
Field cuts
McElroy, Haynes, & Franjoine 2009
Ghasia, Brunstrom, Gordon & Tychsen,
2008
GMFCS levels I and II
Similar to typically developing children
Strabismus
Amblyopia (lazy eye)
GMFCS levels III to V
More severe deficits
Deficits 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 control
More impact seen in SQ than SD
McElroy, Haynes, & Franjoine 2009
Clearly atypical yet difficult to truly
assess
Propioception
Kinesthetic awareness
2 point discrimination
Stereognosis
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 impairments
Bone:
Boney deformities 2° atypical muscle pull
Decreased bone density of long bones (FX)
McElroy, Haynes, & Franjoine 2009
Considerable secondary impairments
Dislocations:
2° to atypical muscle pull and atypical bone shape
formation
Impacts many joints from jaw to foot
Scoliosis and rib cage deformities
McElroy, Haynes, & Franjoine 2009
Considerable secondary impairments
Muscle:
Shortening and contracture
Fiber type shift
Weakness
Connective tissue:
Increased stiffness due to atypical matrix within muscle
Over-lengthening or shortening of tendons
McElroy, Haynes, & Franjoine 2009
Dimensions
+
Domains
-
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
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
M R Franjoine & M P Haynes
Motor Functions
Effective Posture and Movement
Ineffective Posture and Movement
McElroy, Haynes, & Franjoine 2009
“Observable conditions that are neither
functional limitations nor system
impairments”
(Howle 2002)
•
•
•
•
Alignment of body segments
COM over BOS
Weight shift
Quality of movement (fast, slow)
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
Posture
Difficult position
Pulled into gravity
Flexor tone is biased (typical)
Lack of joint range
Movement
Asymmetrical neck hyperextension
OR
Not enough antigravity strength to lift head
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Posture
Preferred position
Stable
Have the possibility of viewing the world
Extensors are biased (typical)
Movement
Sometimes can kick reciprocally
Push with neck hyperextension
asymmetrically and may arch with body
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Posture
Very unstable position
Narrow base
Stabilization efforts create non-functional
alignment of hips, spine, neck, and head
Movement
Too unstable to seek movement
Increased full body stiffness when
movement is initiated
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Posture
Rarely can hold without assistance
Movement
Often can’t move at all
May pull with both arms—”combat crawl”
Occasional child may “bunny hop”
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Posture
Placed in standing
Base too narrow--adducted legs and
plantar-flexed ankles
Movement
Stiffens whole body to gain stability
May support weight stiffly and then both
“give”
Some may have reciprocal movements of
legs
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Dimensions
+
Domains
-
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
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
M R Franjoine & M P Haynes
• Weightbearing assisted
transfers will improve quality
of life
• Motorized mobility if
possible
COMMUNICATION • Establish early and simple
communication
• Think AT
• Fully dependent in most
BASIC ADL’S
skills
• Full time assistance
• Respite care for families
LOCOMOTOR
SKILLS
McElroy, Haynes, & Franjoine 2009
Dimensions
+
Domains
-
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
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
M R Franjoine & M P Haynes
Inclusion in family activities and outings
difficult
Special classroom or mainstreamed with
full-time paraprofessional
Participation is often limited due to:
Lack of interaction and communication
with others
Wheelchair access
Transportation that accommodates WC
McElroy, Haynes, & Franjoine 2009
Address decreased ROM
Lengthen
Incorporate into your activities
Accompany with activation
and/or
Compensate
Work upright whenever possible
McElroy, Haynes, & Franjoine 2009
Help establish an appropriate BOS
Usually need to widen
ALIGNMENT!
In relation to BOS
Segment to segment
Decrease asymmetries
Activate the trunk to free the extremities
Balanced flexors and extensors in the trunk
Work in the frontal and transverse planes
McElroy, Haynes, & Franjoine 2009
Keep them moving!
May need large ranges to know where they
are
BUT
They can only control small ranges
themselves
Repetition
Motor learning
Strength
McElroy, Haynes, & Franjoine 2009
Empower these children!!!
Treat age appropriately despite motor
abilities
Treat upright whenever possible
Forget the developmental sequence!!!
Attend to ALL the systems…Many impact
their health and quality of life
Have 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
Posture
Tends to stay on elbows until going to 4s
Lack of joint range at hips increases anterior
tilt of pelvis and stresses T-L joint
Movement
Lateral weightshifts are limited
Pulls with arms to move forward
Pushes with arms and keeps legs stiff to roll
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Posture
Plays with hands
LEs are stiff in hip flexion/adduction, internal
rotation, knee flexion, ankle plantar-flexion
Movement
Reciprocal kicking, poorly graded
Very 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
Posture
Like to sit
Narrow base is unstable so they seek
“W” sit
Support with UEs
Movement
Get into and out of sitting in the sagittal
plane
In “W” sitting, use both hands for play
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Posture
Hips flexed, anterior tilt to pelvis, lumbar
lordosis
UEs either used for support or posture to
increase trunk stability
Ankles often dorsiflex
Movement
Use this as a transition position to extend
both legs and attain standing
Stay in sagittal plane, lateral weight shifts
difficult
McElroy, Haynes, & Franjoine 2009
McElroy, Haynes, & Franjoine 2009
Posture
Difficulty 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
Posture
Base narrow--adducted legs and plantarflexed ankles
Supports on UEs
Often “sinks” to foot flat during quiet
standing
Can’t stand still
McElroy, Haynes, & Franjoine 2009
Movement
Reciprocal movements of LEs—often
abrupt
Difficulty 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 2009
Dimensions
+
Domains
-
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
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
M R Franjoine & M P Haynes
• Usually walk (with &
without assistive devices)
• WC may be necessary for
energy conservation
COMMUNICATION • Usually communicate
without difficulty
LOCOMOTOR
SKILLS
BASIC ADL’S
McElroy, Haynes, & Franjoine 2009
• Many become
independent
Dimensions
+
Domains
-
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
From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82
McElroy, Haynes, & Franjoine 2009
M R Franjoine & M P Haynes
Function well as a member of the family
though may difficulty keeping up with
siblings
Special classroom or mainstreamed.
Participation is often limited due to:
Fatigue
Speed and balance
Crutch, Walker, and WC access
Community accessabilty
Acceptance of peers
McElroy, Haynes, & Franjoine 2009
Address decreased ROM
Lengthen
Incorporate into your activities
Accompany with activation
and/or
Compensate
Help establish an appropriate BOS
Usually need to widen
McElroy, Haynes, & Franjoine 2009
ALIGNMENT!
In relation to BOS
Segment to segment
Decrease asymmetries
Get the trunk moving over the hip
Balanced flexors and extensors in the trunk
Work in the frontal and transverse planes
McElroy, Haynes, & Franjoine 2009
Keep the LEs dissociated from each other
Work for midrange control and eccentric
control
Repetition
Motor learning
Strength
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
McElroy, Haynes, & Franjoine 2009