Athetoid CP- Therapy Strategies in CP.pptx

Strategies to treat Athetoid children

1. Athetoid CP: Therapy Strategies

2. Athetosis: Therapy Strategies General Principles Goal-Directed Therapy Facilitate symmetrical positioning (prevent asymmetry)- to enhance motor control, Optimize seating and positioning with good stability/support, Orthosis and splints- to increase stability and coordination, Consider needs for communication supports.

3. Athetoid CP: Therapy Strategies Therapy Aims Minimize development of secondary problems (contractures and deformities) Reduce/normalize tone , facilitate optimal stretch to muscles, and increase active ROM; Strengthen weak muscles ; Improve mobility and acquire functional motor skills; P romote functional independence- at house , school and in community .

4. Athetoid CP: THE KEY for Physical Therapy Interventions Must Manage BOTH Excessive Co-contraction and THEN, No Contraction at ALL for few Seconds . Due to these, treatment TECHNIQUES and STRATEGIES CHANGES FREQUENTLY .

5. Understanding Movement Impairments in Athetoid CP is IMPORTANT to Structure Therapy Sequences

6. Impairments in ATHETOID CP Difficulty with Muscle contractions: Problems in control of starting and stopping muscle contractions, Poor ability to initiate movements (due to overactive antagonist) and terminate activity (due to excessive contraction that tends to increase with effort, and initiation of antagonist rather than intended agonist), During functional tasks, some children sustain too much muscle activity and few can not sustain enough to complete the task , some sustain too much in some areas of the body and not enough in others, or at different times child sustain sufficiently- too much or too little. Due to Basal Ganglia involvement, TIMING and INITIATION of movements are ABNORMAL.

7. Impairments in ATHETOID CP Grading Agonist/Antagonist activity: Extreme variability during movements that require interaction of antagonists, Recurrence of unpredictable force and initiation of movements with opposite muscle groups during INTENDED/SPONTANEOUS movements, EMG activity of elbow movements showed RAPID, BALLISTIC MOVEMENTS (Triphasic burst of activity, 1 st from AGONIST- 2 nd from ANTAGONIST and then - AGONIST again [ RECIPROCAL INTERACTION OF FLEXORS AND EXTENSORS ]), Some children use more co-contraction with effort that makes the movements less functional , hence they NEED TO QUIT THE OVERACTIVITY OF THE ANTAGONIST , before beginning to move.

8. Impairments in ATHETOID CP 3. Limited synergies used to produce posture and movement: In Athetoid CP- Proximal muscles of lower body fire first, and additionally contraction time variability present between synergists, But in children without disability Distal muscles fire prior to proximal in lower body, and precisely time the muscle contraction of synergists to stabilize the body when balance is required.

9. Athetoid CP: Sensory and Perceptual Changes Imbalance of Eye Muscle, Controlled Eye Movement for communication, Uses extreme Asymmetrical posture with Upward Visual Gaze, Controls Head and Eye to move, Uses Gaze Aversion during reaching or motor skills- Looking away while reaching ( Part of an Strategy to gain Postural Stability), Absent or Abnormal Ocular reflex.

10. Athetoid CP: Kinesthetic Sensation Athetoid CP Reduced Kinesthetic Sensation (compared to Hypertonic ). Responds well to Kinesthetic information (provided actively through therapy) and with repetition, helps to remember joint position and movement gradation (after being shown how a movement should be performed), paired with suitable verbal and visual cues TEACHING FUNCTIONAL SKILLS EASY ( because Athetoid have intact perceptual skills than motor execution skills).

11. Athetoid CP: Tactile Sensation Very Strong and Repetitive responses- to Tactile Inputs Not Tactile Defensive, but Tactile Over-responsive (means any tactile input causes prolonged and repetitive response of exaggerated movement [increased movement frequency or both] ). Often opposed to bracing, splinting and wheelchair designs that provide intermittent skin contact (because they move inside or against it). ( Tend to pull away after contact with the equipment and often refuse to use it - due to tactile sensitivity)

12. Athetoid CP: Tactile Sensation Responds positively to Lycra®splinting , because it gives firm contact with skin and its design allow movements while supporting the joints. Blair E, Balluntyne J, Housman S, chauvel , p. (2008). A study of a dynamic proximal stability splint in the management of children with cerebral palsy. developmental medicine & child neurology, 3:544–554 . Lycra®splinting: Reduces Involuntary movements, gives stable head and trunk with less asymmetry- by reducing tactile hyper-responsiveness through deep pressure in to the proprioceptive system.

13. Athetoid CP: Musculoskeletal System Athetoid develop f ewer tightness/contracture (because they move more frequently and through larger ranges ) compare to hypertonia. Tightness/contracture develop, where muscles are not able to move the joints due to fixed posture (may cause bones or joint deformities) . Common muscles develop tightness/contractures are: UE: Pectorals, Upper Cervical Extensors, Latissimus Dorsi, Scapular Elevators, Rectus Abdominus, Intercostals, Forearm Pronators, Wrist and Finger Flexors, Thumb Extensors and abductors; LE: Hamstrings, Ankle Dorsiflexors, Ankle Evertors and Toe Flexors.

14. Athetoid CP: Secondary Impairments in Musculoskeletal System Instability of TMJ Overlengthening of Infrahyoid Muscles Instability of Cervical Spine Instability or Dislocation (mainly Inferior) of Shoulder Joint Hyperextension of Elbow Hyperextension of IP joints of Fingers and Thumb Overlengthening of Anterior Hip Capsule and Ligaments Overlengthening of Plantar Flexors and Invertors

15. Athetoid CP : Secondary Impairments in Musculoskeletal System Hip Dislocation Anterior Hip Dislocation- due to pushing of Lumbar spine and hips in to EXTENSION IN SUPINE OR SITTING - (anteriorly hip Ligaments and joint capsule are strong so it takes time to dislocate)- Hip flexion becomes difficult causing difficulty in sitting (if not impossible). Posterior Hip Dislocation- Extension and Abduction of hip is severely limited in standing and leg become functionally shorter. Children with Spastic Athetosis may dislocate one hip anteriorly and other posteriorly . Anterior Posterior

16. Athetoid CP : Secondary Impairments in Musculoskeletal System Cervical Spine Instability Excessive or Abnormal Head Movement in Athetoid over years (adulthood age) may cause: Malalignment Spinal Canal Narrowing Spondylosis Radiculomyelopathy Note: May develop Spinal Cord type clinical symptoms!

17. Athetoid CP : Secondary Impairments in Musculoskeletal System Thoracic Kyphosis and Scoliosis Increased Kyphosis as compensatory posture due to child’s strong cervical and Lumbar/Hip Extension. to bring the COM back over the BOS in sitting and standing to counterbalance extension in cervical and lumbar spine that tend to knock the child over backward. Child uses strong (tight) pectorals and Latissimus Dorsi to internally rotate the elevated shoulder girdle and to bring the thoracic spine in flexion. Scoliosis in Athetoid CP may be due to Open-Packed, unstable position of thoracic spine and severe asymmetry of posture and movements.

18. Athetoid CP : Secondary Impairments in Musculoskeletal System Shift of Hyoid Bone and Laryngeal System Due to pushing of CERVICAL SPINE INTO STRONG EXTENSION with asymmetry, Anterior surface of Neck Overlengthen causes Overlengthening of Masseter muscle and Elevation + Forward tipping (anteriorly) of Hyoid and Laryngeal system (affecting posterior stability of Tongue and Laryngeal system) causes child to push tongue against the Palate to gain stability, that compromises the PHONATION AND SWALLOWING. Normal Position of Hyoid bone, Suprahyoid muscles and Larynx in 8M old Child. Elevation of Tongue Posteriorly to the Palate for Stability Normal Position Note: Correcting the alignment- from CERVICAL EXTENSION TO FLEXION , may interfere with ability to BREATHE.

19. Athetoid CP : Secondary Impairments in Musculoskeletal System Poor muscle strength throughout the ranges in all the joints due to: Lack of use, Lack of ability to sustain muscle activity, Poor alignment of body segments for the development of muscle tension, Poor nutrition- energy expenditure due to uncontrolled, extraneous movements causing average increase in resting metabolic rate of 534Kcal/day ; difficulty in GRADING JAW MOVEMENTS for feeding and POOR ABILITY OF THE TONGUE SURFACE TO PROVIDE PRECISION FOR EATING – adds difficulty in calories intake for muscle building.

20. Athetoid CP : Secondary Impairments in Musculoskeletal System Why Athetosis children develop Tightness and Strength in Selected Muscles? Muscles commonly working in shortened ranges- 1. PECTORALS assist Tx- spine in Flexion to balance the strong cervical and lumbar/Hip extension used frequently and repetitively by Athetoid children (and develop adequate strength ). 2. Medial Hamstrings (MH) used frequently to flex knees in STANDING and TO HOLD IN SITTING to counterbalance the powerful extension (Quadriceps) and help to prevent from falling backward MH sustain muscle activity in shortened ranges for these activities and become quite strong, CAUSING; MH to become very tight and very strong in shortened ranges .

21. Athetoid CP : Secondary Impairments Respiratory System Arrhythmical respiration, difficulty in controlling exhalation with voicing,- may attempt to voice at the end of exhalation, Difficulty in Coordinating breathing with onset of voicing and swallowing, Shows burst of Phonatory activity (if making sound), similar to the burst of muscular activity [unable to produce sound- need augmentative communication system], Preserved eye movement, uses eye pointing to access system for communication. Note: Mid-line orientation of Head- most important for communication, while Speaking.

22. Athetoid CP : Typical Posture and Movement Strategies Appearance of typical bursts of movements, Extraneous movements, and alteration between Flexion-Extension- Not seen until 1 st year of life . Some children who develop ATHETODIS- stay clinically Hyp otonic for many months even after 1-2 years and do not show any burst extension movement from an asymmetrical position- may be due to severe involvement, where all movement is impossible to generate.

23. Athetoid CP : Typical Posture and Movement Strategies Newborn with No Disability: Lie Prone with Hips Flexed and Head and spine asymmetrically positioned, and weight is on Cheek of the Face.

24. Athetoid CP: Typical Posture and Movement Strategies Child with Athetosis- Learns to lift and hold Head up (if he can do) from an asymmetrical base, Child with Hypertonia and Mild to Moderate Hypotonia- Lift and hold Head up (if he can do ), but with reduced asymmetry,

25. Athetoid CP: Typical Posture and Movement Strategies But a child with Severe Hypotonia, who may later develop Athetosis, rest weight on the EARS (large and heavy occiput is pulled into gravity with no muscular resistance). St arting point for child with Athetosis to attempt to learn, TO LIFT AND HOLD HEAD UP. Severe Hypotonic Child- Little or no activity in POSTURAL TRUNK MUSCLES- limb rests against support surface and are very inactive- child may pull little with HIP FLEXORS- Arms taking no weight or push against the surface and legs remain extremely ABDUCTED- Head rotated to one side and will INITIATE EXTENSION FROM ASYMMETRICAL HEAD POSITION - SETTING UP STRONG ASYMMETRY IN ATHETOSIS.

26. Athetoid CP: Typical Posture and Movement Strategies The EXTENSION may be so forceful, that CERVICAL AND LUMBAR SPINE will extend simultaneously, causing STRONG ARCHING OF SPINE . Child may stay in this position for months, if placed in PRONE or lie with similar asymmetry in SUPINE. If placed in an infant seat, the strong asymmetry will be evident, as child falls into GRAVITY. Once child begins to move, the impairment due to Athetosis, enables him to generate quick, forceful unsustained movements. Since, EXTENSION is usually used first in all babies, Athetosis children Learn to use QUICK BURST OF EXTENSION IN ALL POSITIONS .

27. Athetoid CP: Typical Posture and Movement Strategies CERVICAL FLEXORS are quickly and forcefully over-lengthened with strong, asymmetrical cervical extension, mainly Infrahyoid, that initiates the MALALIGNMENT OF HYOID AND LARYNGEAL SYSTEM . This over-lengthening may be ASYMMETRICAL , since Children with Athetosis, may LIFT HEAD WHILE ROTATED TO ONE SIDE . Eyes follow or lead the movement (used in peripheries)- because of asymmetrical head position Upward Gaze (Eye Extension)- used often to lead and assist head movement- hold head up longer. Uses eye extension to lead any body movement Eyes are not available for seeking and scanning or social contact and to help in controlling posture and movements. t herefore

28. Athetoid CP: Typical Posture and Movement Strategies Jaw Extension Jaw Extension (Mouth opening)- [forceful through full ranges] Often, part of the Head Extension Assist to sustain open Jaw position and cannot release until the head drops Since, jaw extension is done with asymmetrical head position, so jaw opens asymmetrically Abnormal lateral movements to begin at TMJs. FACIAL GRIMACING – that is associated with FORCEFUL ASYMMETRICAL JAW OPENING . Causing Causing

29. Athetoid CP: Typical Posture and Movement Strategies Tongue Retraction Initiates Strong T ongue R etraction in attempt to assist head extension and to hold head against gravity In Infant Suprahyoid muscles are tight at birth, causing babies to use tongue retraction during CRY and with efforts to move antigravity. Child with Athetosis does the same thing, but more forcefully and with increased frequency . Clinically tongue protrusion in children with Athetosis is, A WAY TO CLEAR THE TONGUE FOR SWALLOWING AND BREATHING, but this protrusion is forceful and extreme in range. Hence, tongue protrusion is not the original problem, but a solution to moving the strongly retracted tongue. So, therapeutically we must deal with the problem of tongue retraction TO TREAT THE PROBLEM OF TONGUE PROTRACTION. Tongue retraction with Head asymmetrically positioned)

30. Athetoid CP: Typical Posture and Movement Strategies Tongue Retraction- Therapy This child forcefully protrudes her tongue. She has only sagittal plane movements available for tongue movements, just as she has sagittal plane movements available for the rest of her body. To facilitate more mid-range movements of the tongue, we must help her initially position her tongue out of retraction and then assist active movements.

31. Athetoid CP: Typical Posture and Movement Strategies Some children with Athetosis uses FORCEFUL CERVICAL FLEXION to hold head up or to counterbalance the tendency for strong extension . This cervical flexion is done by the LARGE CERVICAL FLEXORS , causing mass flexion without mid-range control of the head on the neck. CERVICAL FLEXION is primary way for a child with Athetosis to hold head, or some children develop it as compensatory strategy for certain posture or movements i.e. attempt to move prone or W-sitting- to stabilize vision, to speak and to stand. Lumbar Extension FUNCTIONAL LIMITATIONS: arise from Severe Head Asymmetry, Forceful Extension to Control Head, and the accompanying Tongue, Jaw and Eye Movements to assist that extension.

32. Athetoid CP: Thoracic Spine, Ribcage and Upper Extremities Children with Athetosis completely and often bypass any weight bearing into the surface with their UE. This could be due to multiple reasons; Strong cervical and lumbar extension may lift children in prone, or push them into the surface in supine, that substitutes for pushing with arms. Additionally arms are often placed in extremes of shoulder extension and internal rotation where the joint is biomechanically stable. Since Athetosis causes unpredictable force generation at unpredictable times, the child does not learn to rely on the arms for supporting antigravity postures. The shoulder complex may assist head control with strong elevation and shoulder IR.

33. Athetoid CP: Changes in BMD Bone 71 (2015) 89 – 93

34. Total Hip Joint BMD:- Non-Ambulatory & Ambulatory: Spastic CP Vs Dyskinetic CP Findings: Hyperkinetic and D ynamic movement patterns coupled with sufficient joint ROM have ANABOLIC EFFECT ON BONE BY REPETITIVE LOADING , hence higher BMD than Spastic CP.

35. Athetosis: Therapy Strategies Understand the Key Problems Differences between SPASTICITY Poverty of Movements and Richness in Muscle Tightness ATHETOSIS Richness of Movement and Limitations in Joint Stability PHASIC & TONIC MUSCLES functions as TONIC Causing Generalized Stiffness/Tightness/Contractures in Muscles/ Joints TONIC MUSCLES functions as PHASIC and Phasic Muscles Functions as TONIC Giving Outer Range of Movements at Proximal Joints without Joint Stability and Distal joint muscles reacts by Fisting or Mass Extension. Don’t Develop Tightness in Muscles

36. Should we do Passive Movements in Dystonia? Whenever the limb is passively moved in Dyskinetic disorders, the limb shows, involuntary resistance, increased EMG responses of the antagonist muscles, and delayed muscle relaxation. These responses reduces ROM when movements are voluntary.

37. Athetoid CP: Intervention Strategies 30 to 45 minute therapy sessions/ 2 times per day/ 5 sessions a week. Closed Chain/ postural stabilization activities (Weight-Bearing Exercises): allows limbs to be fixed and stabilized, and provide way to strengthen specific muscle groups. Initially focused more on proximal stabilizing muscle groups and then more distal musculature (with improvements ). In Supine: Bridging to wall squats for strengthening of hip musculature. In Prone : Maintaining weight-bearing position initially on elbows to quadruped ( Extended Elbow with Open Palm position). Pediatr Phys Ther 2014;26:85–93

38. Athetoid CP: Intervention Strategies Closed Chain/ postural stabilization activities (Weight-Bearing Exercises) Quadruped position: support and maximize weight bearing and facilitate weight shifting through lower extremities , trunk , and weighted upper extremity . Maintain each position until complained of fatigue or fatigue is evident (requiring increased assistance or unable to balance further) . Repeat position 2 to 3 times/ session, based on the time to tolerate the position . Pediatr Phys Ther 2014;26:85–93

39. Athetoid CP: Intervention Strategies O pen Chain Exercises and activities Open chain exercise and activities: increased the amount of non-purposeful movement and made it difficult to focus on specific muscle groups effectively. With improvements in selective motor control , therapy progressed to more open chain exercises and movement activities , e.g. Crawling and eventually ambulating . Note: Verbal and tactile cues- to perform movement at a decreased speed with small ROM- – facilitated by environmental adaptation i.e. small pieces of carpet placed close together on floor- to step only on carpet square, forcing child to take small, controlled steps. Pediatr Phys Ther 2014;26:85–93

40. Athetoid CP: Progression with Therapy Strategy Use Barriers during functional tasks , i.e. crawling through small tunnel to limit space and therefore the ROM. During reaching tasks : keep objects initially close to the child , and with progression place it further away- gradually increasing the ROM needed to accomplish the task . With progression, apply manual resistance during functional activities to limit speed of movement and ROM. Use COUNTING: as verbal cue for desired speed/duration to perform a tasks . Pediatr Phys Ther 2014;26:85–93

41. Athetoid CP : Important Points for effective Therapy Strategy Doing task at slower speed and within smaller movement amplitude – facilitates to completed functional tasks successfully, increases motivation and provides strategy to decrease Athetoid effect during movement. As SELECTIVE MOVEMENTS improves , progressed to activities requiring greater ROM at increased speed . ALWAYS control non-purposeful movement by weighting the extremities during open chain activities . E.g. Use ankle cuff weights during initial ambulation trials , and weighted pencil for writing activities (to reduce intensity, velocity, and degree of non-purposeful movements). Pediatr Phys Ther 2014;26:85–93 Note: Weighting limbs during fine and gross motor tasks- not effective in diminishing excessive movements and not considered as an appropriate intervention strategy for Athetoid children.

42. Athetoid CP : Important Points for effective Therapy Strategy Minimal assistance- child performing 75% of the task , Moderate assistance- child performing 25% to 75 % of the task , and maximal assistance- child performing 25% of the task Pediatr Phys Ther 2014;26:85–93

43. Athetoid CP: Variations in resulting impairments after successful Physical Therapy Interventions Many ATHETOID children initially presents with HYPERTONICITY After TREATMENT of HYPERTONICITY , we see more SUBTLE IMPAIRMENTS (that was masked by the strong influence of HYPERTONICITY) c alled EMERGING components of ATHETOID CP [ Alternating FLEXION & EXTENSION of FINGERS, Asymmetrical Posturing, Large-range Sagittal Plane Movements of TOUNGUE (Protrusion/Retraction) and Postures with more END-RANGE Positions].

44. Athetoid CP: Variations in resulting impairments after successful Physical Therapy Interventions Few ATHETOID CP (severely involved ones), were initially HYPOTONIC for many Years (with Postures associated with HYPOTONICITY) Begins to show impairments once they achieve any degree of movement against GRAVITY Thus, during treatment we need to be wise to continually OBSERVE and ASSESS . NOTE: Due to this, SPASTICITY Mx by SURGERY or Medications needs careful rethink.

45. Athetoid CP : Hydrotherapy use Pediatr Phys Ther 2014;26:85–93