SPASTIC QUADRIPLEGIA CEREBRAL PALSY

Deniz Erdem Muhammet Kocabyk PHYSICAL MEDICINE & REHABILITATION IV.CLASS V.COURSE Ahmet Demirel Engin etin Ahmet pek Murat Ko

What s the Spastic Quadriplegia ?

Spastic quadriplegia is amongst the severest forms of cerebral palsy. It may arise as a result of drug use or complications during the mother's pregnancy, the infant's delivery or the early development of the infant. Complications include prematurity, bleeding in the brain, severe asphyxiation, aspiration, severe meningitis, shaken baby syndrome, low birth weight, and drug overdose. There are different kinds of quadriplegia and they may vary in severity. A child with severe spastic quadriplegia will not be able to walk even with a walker or other form of assistance, cannot move independently into a wheelchair, will have difficulty sitting and usually is not capable of feeding himself.

CASE

Patient - 13 months old, premature , birth at 31 gestation weeks, weight at birth- 1.6 kg, height 45 cm. Cant sit independently, makes half rotation from the back , poor hold the head (while leaning forward middle line of the head coincides with the axial line of torso). Hip add , hip posterior group and triceps muscles spasticity is expressed. In spontaneous position ,,Chandelier pose and opistotonus are expressed ( back extension muscles excessive activity)

Normal Reflex Reflex Babinski Blinking Grasping Moro Stimulation Sole of foot stroked Flash of light or puff of air Palms touched Sudden move; loud noise Response Fans out toes and twists foot in Closes eyes Grasps tightly Startles; throws out arms and legs and then pulls them toward body Turns toward source, opens mouth and sucks Moves feet as if to walk Sucks on object Makes coordinated swimming movements Makes fists and turns head Duration Disappears at nine months to a year Permanent Weakens at three months; disappears at a year Disappears at three to four months

Rooting Stepping Sucking Swimming Tonic neck

Cheek stroked or side of mouth touched Infant held upright with feet touching ground Mouth touched by object Placed face down in water Placed on back

Disappears at three to four months Disappears at three to four months Disappears at three to four months Disappears at six to seven months Disappears at two months

Examinations
Patient Instructions: Ask the patient to move their leg to the inside toward their opposite leg Starting Position: Patient is supine. The leg is in full adduction Goniometer Alignment Axis anterior superior iliac spine (ASIS). Stationary arm aligned with opposite ASIS Moving arm aligned with femur (center of patella). Remember to adjust due to the goniometer starting at a reading of 90 degree Normal Range - The normal ROM is 15 to 25 degrees

HIP EXTENSION Test Position: Subject prone . Stabilize pelvis to prevent rotation and extend hip Goniometer Alignment Axis greater trochanter. Stationary arm aligned with midline of pelvis. Moving arm aligned with femur (lateral epicondyle) Normal Range: 12.0o + or - 5.4o

HIP ABDUCTION Test Position: Subject supine. Stabilize pelvis and abduct hip with the hips and knees in flexion (Add. Longus) Goniometer Alignment Axis anterior superior iliac spine (ASIS). Stationary arm aligned with opposite ASIS. Moving arm aligned with femur (center of patella) Normal Range: 41.0o + or - 6.0o

Test for abduction contracture Evaluate range of abduction. Hips in extension and knees in flexion (Add. Magnus)

Goniometer Alignment Axis anterior superior iliac spine (ASIS). Stationary arm aligned with opposite ASIS. If hip abduction is limited in both Moving arm aligned with femur (extension and flexion) position , the (center of patella) Normal Range: cause is hip add. spasticity 41.0o + or - 6.0o

Lower extremities evaluation in extension - m. Gracilis If abduction is limited when the hips are extended, but abd. is better when hips and knees are flexed, the add. contracture is caused by gracilis and medial hamstring spasticity

Test for triceps (gastrocnemius/ soleus) contracture. Lie the patient in supine position . Measure ankle dorsiflexion first with the knee in flexion (soleus testing) then in extension (gastrocnemius/ soleus)

Evaluation of muscle spasticity

Ashworth Scale For Grading Spasticity (Measures Resistance To Passive Stretch) Lovett Scale - Performed Against Gravity And Against Resistance motor
scale

Selective

control

Trost Sitting Balance

Functional

examination

Hop test

Treatment Planning

Teaching head control Inhibition of Chandelier positions Inhibition spastisty of lower extremity Range of motion Streching spastic muscle and strengthening antagonist muscle Motor control Postural control and balance Gait (walking) Transitions Use of assistive devices

Head Control

Stretching

Gait

Assistive Devices

Bobath Neurodevelopmental Therapy

This is the most commonly used therapy method in CP worldwide. It uses the idea of reflex inhibitory positions to decrease spasticity and stimulation of key points of control to promote the development of advanced postural reactions and to prevent contracture formation. Bobath therapy aims to normalize muscle tone, inhibit abnormal primitive reflexes and stimulate normal movement .

Intervention

strategies

and

techniques for

NDT

consist

of:

Therapeutic handling - is used in order to influence the quality of the patients' movements Facilitation is a key technique used by Bobath practitioners to promote motor learning. It is the use of sensory information (tactile cue through manual contacts, verbal directions) to reinforce weak movement patterns and to discourage overactive ones.

Supports the child in the sitting position - Children who use the upper extremities for support when sitting can not develop hand function - Provide a seating support for better head and trunk control and give the child the opportunity to play. To develop head and trunk control. With forearms supination and arms external rotation we can stimulate trunk extension

The Vojta Method

The observation of these movements against resistance by the fixed spastic patient, announced the discovery of innate and global locomotor systems:the reflex creeping and the reflex rolling. The reflex locomotion is used since 1959 forthe treatment of the child's motor disorders, it was later used with babiesto prevent the installation of these disorders. Reflex locomotion patterns (ref.creeping and ref. rolling) are global; during these activities, the totality ofthe musculature is activated according to a coordinate mode. The different levels of the CNS are concerned by this activation . The reflex locomotion is provoked by specific stimulations (pressures) applied on definedzones.

MAIN STIMULATION POINTS

Medial epicondyle of humerus at the arm face side Processus stiloideus radii at the arm after the occipital side Medial condyle of femur at the face side Tubercul of calcaneus at the leg after the head

ACCESSORY STIMULATION POINTS

Medial side of scapula Between 7.-8. costas Under the jaw Acromion Gluteals SIAS

EXAMPLES OF THERAPEUTIC SITUATIONS

EXAMPLES OF THERAPEUTIC SITUATIONS

Advice Of Parents

1. Keeping the head in centred position: 2. Stop salivation:

Parents should keep their childs head in a centred position when it lies, sits or stands.

In such a condition, parents can hold children head in a vertical position, knocking and pressing around children mouth and cheek with index and middle fingers.

3. Take a side-lying position:

CP children are supposed to take a side-lying position while lying or sleeping in bed, which can bring benefits of relief of spastic muscle tone and limb symmetry

4. Thumb adduction (clasped thumb) correction:

Almost 100% of CP children have thumb adduction. Therefore, in order to correct thumb adduction, parents are supposed to give children round toys to grasp, or small balls to pull the thumb to extend outside the center of palm, or make thumb gloves to promote thumb extension.

5. Holding children in arms properly:

CP children lack autonomic movement, and therefore parents still hold them in the arm though they are no longer infants or young children. When CP children can not hold their neck, or control their own body very well, the holder should put forth one hand to hold childrens back, the other hand to support the bottom, and let childrens legs be on both sides. On the other hand, when CP children can hold their neck and keep their own body under control, parents should support childrens bottom to keep them in sitting posture.

6. Appropriate sitting posture:

Deformity of spine can be easily caused by bad sitting position. Therefore, in order to make spastic CP children sit straight, parents can kneel behind them, pass upper limbs through the armpit to prevent bladebone adduction, and separate their legs and press knee joint to make lower limbs stretch straight.

7. Hand function exercise:

Most CP children suffer more from lower limb dysfunction than that of upper limbs. Therefore, its better for parents to let children grasp objects and play with toys. Such exercise can bring benefits to both hand function and mental development.

8. Developing personal care capability:

Taking the physical disability into consideration, some parents offer full assistance for CP children to ensure they have an easier and better life. However, it brings negative effects to CP children in developing their personal care ability, since they become overdependent on parents.

Thank you