KUNA, IDAHO

Hannah Nawaz, SPT Regis University A Case Study of an Adolescent with Congenital Hemiplegia Hannah Nawaz, SPT Regis University

Objectives Identify factors unique to hemiplegia in the pediatric population. Develop effective examination and evaluation strategies, selecting reliable and valid outcome measures. Discuss intervention strategies for pediatric patients with hemiplegia in an outpatient setting. Discuss the rationale and referral process associated with orthoses prescription in an outpatient setting.

Hemiplegia Typically a classification of cerebral palsy Congenital hemiplegia 2:1,000 births Usually classified using Gross Motor Functional Classification Scale (GMFCS) Abnormal posturing, spasticity/increased tone, muscle spasms, seizure disorders, gait deviations, poor balance and sensory awareness1 Pediatric Glasgow for infants to determine severity of damage to brain tissue Common impairment associated with this specific congenital condition

BRITTANY: 14 yoa female Medical History CVA in womb PT from ages 3-6 Aquatic therapy 2 different AFOs Hand brace Heel cord extension: age 8

EXAMINATION AROM MMT LOCATION LEFT RIGHT Ankle Dorsiflexion -16 degrees WNL Knee Extension -4 degrees Elbow Extension -18 degrees MMT LOCATION LEFT RIGHT Ankle Dorsiflexion 2+ 5 Knee Extensors 3+ Wrist Extensors 3 Finger Flexors 3-

http://www.youtube.com/watch?v=BtqWxBUd94I

Additional Examination findings Gait: foot drop during initial contact and loading phases; high guard position during walking and jogging Impaired balance in standing Denies history of muscle spasms and seizures Increased L sided tone; clonus absent Sensation grossly intact in both UE and LE Significant unilateral left sided atrophy Impaired proprioception and stability of trunk musculature Berg balance score2 = 40 Difficulty with weight shifting onto affected leg to kick soccer ball -should have done elements of GMFM…validated up to age 16

Patient identified problems Non-patient identified problems Difficulty playing sports in school including football, basketball, volleyball Difficulty riding scooter for prolonged periods of time Frequent falls secondary to poor anticipatory and reactive balance3 Impaired coordination during dynamic activity Decreased aerobic capacity Psychological implications of congenital abnormalities Family dynamics ADHD; maturity Social implications VERY COLORFUL family -acted as caregiver to younger siblings Problem lists

Diagnosis and prognosis Patient demonstrates left sided deficits in strength, range of motion, balance, and coordination which impair her ability to participate in recreational activities with peers. The patient’s rehabilitation potential is good given patient’s previous history with PT and her increased motivation to regain optimal function.

What to do? Progressive resistance exercises (Ada 2006) FES for improved force production (Donaldson, 2009) EMG biofeedback for tone reduction and proprioceptive training (Wolpaw, 1983) Constraint induced movement therapy (Gordon, et al 2005)

Interventions Stretching Strengthening Balance Coordination Gastroc/soleus Biceps Hamstrings Strengthening Ankle w/ theraband and NMES Quadriceps on leg press Trunk on exercise ball UE theraband exercises Balance Dynadisc bilateral stance Single leg balance Sitting balance on exercise ball/ single leg sitting balance Coordination Treadmill walking Ball toss while sitting on exercise ball Agility ladder Over 8 sessions…still being treated

Long term plan Specifically… -posterior leaf spring -trimmed posterior to malleolus7 Function: assist foot into DF during swing phase of gait and allows PF during stance Covered by Medicaid  Constraint induced therapy??? Decreased ankle strength Foot placement not affected Df stop not needed Df strength < 4 Script from physician for orthoses Clinic set up appointment with orthotist Medicaid coveres brace and all associated visits Long term plan

Who wants a silver synapse? What are some of the common impairments which patients with congenital hemiplegia present? T/F: According the algorithm, a dorsiflexion assist orthoses is appropriate when DF strength is <3.

questions???

Resources Cambell S, Vander Linden D, Palisano R. Physical Therapy for Children. 3rd ed. St. Louis, MS: Saunders Elsevier; 2006. Beninato M, Portney L, Sullivan P. Using the International Classification of Functioning, Disability and Health as a framework to examine the association between falls and clinical assessment tools in people with stroke. Phys Ther. August 2009;89(8):816-825. Aruin A. The effect of asymmetry of posture on anticipatory postural adjustments. Neurosci Lett. 2006;401(1/2):150-153. Ada L, Dorsch S, Canning CG . Strengthening interventions increase strength and improve activity after stroke: a systematic review. Australian Journal of Physiotherapy. 2006. 52: 241-248. Donaldson C, Tallis R, Miller S, Sunderland A, Lemon R, Pomeroy V. Effects of conventional physical therapy and functional strength training on upper limb motor recovery after stroke: a randomized phase II study. Neurorehab & Neural Repair.2009. 23(4): 389-397 Wolpaw J, O'Keefe J. Adaptive plasticity in the primate spinal stretch reflex: evidence for a two-phase process. J Neurosci. November 1984;4(11):2718-2724. Kubota K, Eberly V, Weiss W. To brace or not to brace: making evidence-based decisions with our clients with neurologic impairment. February 2006.