1. KUNA, IDAHO

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

3. 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.

4. 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

5. 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

6. 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-

8. 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

9. 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

10. 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.

11. 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)

12. 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

13. 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

14. 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.

15. questions???

16. 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):
Aruin A. The effect of asymmetry of posture on anticipatory postural adjustments. Neurosci Lett. 2006;401(1/2):
Ada L, Dorsch S, Canning CG . Strengthening interventions increase strength and improve activity after stroke: a systematic review. Australian Journal of Physiotherapy :
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 (4):
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):
Kubota K, Eberly V, Weiss W. To brace or not to brace: making evidence-based decisions with our clients with neurologic impairment. February 2006.