bottom up approaches in children with cerebral palsy

1Tehran CP Workshop, May 2017

کارگاه تخصصیدان در تاپآپ و باتمبررسی مقایسه ای رویکردهای

مداخالت کاردرمانی کودکان مبتال به فلج مغزی

زادهدکتر محمد خیاط : و تنظیمتهیه

1396بهار

Approaches To Evaluation and Therapy

Bottom Up approach

Top Down approach

Tehran CP Workshop, May 2017 2

Bottom Up Therapeutic approaches

A bottom up approach to assessment and treatment focuses on the deficits of components of function, such as strength, range of motion, balance, and so on, which are believed to be prerequisites to successful occupational performance or functioning.

An assumption inherent in the bottom-up approach is that acquisition or reacquisition of motor, cognitive, and psychological skills will ultimately result in successful performance of ADLs.


Traditional B-U approaches in CP

Patterning ( Delacato)

Feldenkrais (Feldenkrais)

Reflex Locomotion(Vojta)

Conductive Education (Peto)

PNF (Kabat, Knott, Voss)

Sensory Integration(Ayres)

Rood(Rood)

NDT ( Bobath and Bobath)

Orthotic Management

Botulinumtoxin -A (BTX-A)

Electrical Stimulation ( NMES, FES)

Strength Training

Selective Dorsal Rhizotomy(SDR)

Intrathecal Baclofen Pump

Surgery/ Single Event Multi Level Surgery(SEMLS)


Patterning


Patterning Temple Fay, C. H. Delacato, and Glenn Doman noted

that normal development progresses in an established sequence, e.g., crawling, then cruising, and then walking.

They argued that failure to properly complete any stage of neurological development adversely affected all subsequent stages.

They hypothesized that the development of a child who had a neurological injury could be improved by making him or her undergo normal sequences in a frequent, repetitious fashion.


Patterning effectiveness MacKay and Bridgman et al

found either no or only short lived improvements in children treated with patterning.

Parents who used patterning with their child often spent many hours a day, utilizing tremendous energy doing the patterning.

Controlled trails show no benefits


Feldenkrais Method(Moshe Feldenkrais)

8Tehran CP Workshop, May 2017

Feldenkrais concept The Feldenkrais Method is a form of somatic education

that uses gentle movement and directed attention to improve movement and enhance mental and physical functioning

With functional integration, a coach uses hands-on and light touch stimulations to guide a patient through various motion patterns.

In the awareness through motion approach, the teacher verbally directs participants through various movements, breaking down complex motions into smaller sequences and varying the order and types of motion.


Feldenkrais Effectiveness The goals are to improve

flexibility, posture, mental status, and comfort.

Proponents report that individuals may develop greater endurance, improved ease in walking, and a smoother gait.

However, there are very few studies of the Feldenkrais method and there is no evidence that it is effective for individuals with CP.


Reflex Locomotion(Václav Vojta)


Vojta therapy According to Vojta, reflex

locomotion is activated from the three main positions: prone, supine and side lying.

To stimulate the patterns of movement, there are available zones on the body and on the arms and legs.

Through a combination of different zones and changes in pressure and extension both patterns of movement, reflex rolling and reflex creeping, can be activated.


Reflex creeping The main position is

prone lying with the head creeping resting on the bed rotated to one side.

Reflex creeping can be fully activated from one zone; in older children and in adults, a combination of several pressure points is necessary


Reflex rolling Reflex rolling

transitions from supine to side lying and leads to crawling.

Therapeutically, reflex rolling is used in different phases of supine and side lying


Vojta therapy For Vojta Therapy to be successful,

it must as a rule be performed several times a day (up to four times where necessary).

A therapy session lasts between five and twenty minutes.

Since parents or caregivers perform the therapy daily, they play a significant role in the application of Vojta Therapy.


Vojta effectiveness No controlled studies are available

supporting Vojtaapproach in the treatment of children with CP.

The new-born babies will cry as pressure applied . This leads to parents feeling concerned, and makes them assume that it is “hurting” their child.

But their practitioner claim that this method is effective specially in newborn babies( below 1 year) as a early intervention.


Conductive Education(András Pető)


Conductive Education(CE) CE is taught in a group classroom

setting by a trained Conductorlike a school.

Conductors use repeated verbal reinforcement to promote and facilitate intended motor activity by the child.

A Conductor has a four year degree from the Peto Institute, which basically encompasses learning about the motor, sensory, speech, and processing of individuals with neurologically based motor impairments.


CE concepts It is based on the concept that children with motor disabilities learn

the same way as those with no disability. Participation in CE requires reasonable cognitive abilities to

comprehend the verbal instructions. The child is encouraged to participate and practice all daily activities

to the best of his or her abilities. CE is typically carried out in separate group sessions for school age

children.


CE effectiveness The effectiveness of CE in children with CP has not been established

by any controlled clinical trials.

The importance of group as a motivating factor is stressed.

The emphasis on verbal reinforcement before and during the task.

The emphasis on independence rather than on quality of movement.

Comparison between CE and traditional therapies showed little difference in functional outcomes but more contractures in CE group


PNF(Maggie Knott)


PNF philosophy PNF is an integrated approach: Each treatment is directed at the total

human being, not just at a specific problem or body segment.

Mobilizing reserves: Based on the untapped existing potential of all patients, the therapist will always focus on mobilizing the patient’s reserves.

Positive approach: The treatment approach is always positive, reinforcing and using what the patient can do, on a physical and psychological level.

Highest level of function: The primary goal of all treatments is to help patients achieve their highest level of function.

Motor learning and motor control: To reach this highest level of function, the therapist integrates principles of motor control and motor learning


Multisensory approach

Auditory ( Verbal instruction)

Visual (demonstration)

Somatosensory

1. Manual guidance/contact

2. stretch

3. Resistance

4. Approximation

5. Traction


Sequence of Treatment Guided resistance, manual

contact, verbal instruction, rhythmic initiation, combination of isotonic and replication can be used as possibilities to learn new skill.

Exercises will be done in functional diagonal patterns

Ultimately, the trainings situation is adapted to the daily life situation


PNF effectiveness PNF techniques mostly have been used for adult

people, but they can be used for adolescents and young adults with CP respectively.

It is an evolving and ever-changing approach

Although no clinical controlled trials are available supporting PNF approach in the treatment of children with CP, some techniques could be used as a preparatory methods to facilitate motor function.


Rood approach(Margaret Rood)


Rood approach

Rood's philosophy of treatment is concerned with the interaction of somatic, autonomic and psychological factors and their role in the regulation of motor behavior.

The basic points of Rood's Approach are:

1. Duality

2. Ontogenetic sequence

Effects upon the anterior horn cell(AHC)

Effects upon the autonomic nervous system (ANS)


Duality


Duality Using more contemporary terminology, Rood's light work

and heavy work muscles could correspond to muscles with

a predominance of phasic (fast glycolytic) and tonic (slow

oxidative) motor units, respectively.


Muscle fibers Type I: These fibers are also known as slow twitch fibers. They are red in

color due to the presence of large volumes of myoglobin and high numbers of Mitochondria. Due to this fact they are very resistant to fatigue and are capable of producing repeated low-level contractions by producing large amounts of ATP through an aerobic metabolic cycle.

Type IIa: These fibers are also sometimes known as fast oxidative fibers and are a hybrid of type I and II fibers. These fibers contain a large number of mitochondria and Myoglobin, hence their red color. They manufacture and split ATP at a fast rate by utilizing both aerobic and anaerobic metabolism and so produce fast, strong muscle contractions, although they are more prone to fatigue than type I fibers.

Type IIb: Often known as fast glycolytic fibers. they are white in color due to a low level of myoglobin and also contain few mitochondria. They produce ATP at a slow rate by anaerobic metabolism and break it down very quickly. This results in short, fast bursts of power and rapid fatigue.


http://www.teachpe.com/anatomy/aerobic_respiration.php

Ontogenetic sequence Mobility(reciprocal innervation)

Stability(co-innervation)

Mobility superimposed on stability(heavy work)

Distal mobility with proximal stability(Skill) The ontogenetic sequence are generally accepted as outdated.

Relearning of movement neither occurs from proximal to distal, nor does it return in adults in a style corresponding to development in children.

More contemporary models of treatment, especially those of motor control and motor learning focus treatment on the analysis of component parts of a movement, finally combined into a task.


Effects upon the anterior horn cell(AHC)Facilitation V Inhibition


Facilitation V Inhibition Although, Rood's Approach was based on a Reflex/Hierarchical

view of the nervous system, as a modular model, it has components which can be justified in light of current scientific evidence.

Critics of the Rood approach argue that if patients' movements are not self-initiated then they are not learned.

More attention on techniques focused on some proprioceptive and extroceptive ones such as: Quick stretch, prolonged stretch, resistance, slow stroking

Clinical use often involves the combination of several techniques, exteroceptive and proprioceptive, in order to maximize the effects through summation.

Some techniques such as Fact brushing or icing are not supported scientifically.


Effects upon the ANSSympathetic V Parasympathetic


ANS The ANS and emotional system are more complex

than rood oversimplified.

A more credible model is that central circuits involved in emotion and in motivation are strongly connected to autonomic and neuroendocrine systems, so that emotional states are accompanied by, and reflected in, autonomic and endocrine changes which, in turn, feed back to modulate the emotional state.

These central circuits, principally residing in the orbitofrontal cortex, limbic cortex, amygdala, hypothalamus and brainstem, influence somatic sensory and motor function as well.


Sensory Integration( Jean Ayres)


SI concept In this concept difficulties in planning and executing

organized behavior are attributed to problems of processing sensory inputs within the CNS, including vestibular, proprioceptive, tactile, visual and auditory.

Treatment focuses on integrating neurological processing by facilitating the individual to register and process the type, quality and intensity of sensation provided by the environment to enable effective behavior


Sensory Modulation Disorders Children may show a poor ability to register sensory

information and therefore seek sensory input, and those who are hypersensitive to sensory stimuli and therefore require desensitizing.

A significant number of children with CP have sensory impairments. SI may help processing and integration of this sensory information.

SI can be successfully combined with NDT in specific groups of children with CP.


SI Effectiveness Some studies find SI as a

useful treatment approach in children with CP, while others do not find any functional benefit.

Sensory processing approach seems more evidenced based than SI



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bottom up approaches in children with cerebral palsy

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