Changing Function: An Intervention for Children with Hemiplegiacaduceushandouts.com/csm/2016/handouts/pedAPTA-2233600.pdf · Changing Function: An Intervention for Children with Hemiplegia

Changing Function: An Intervention for

Children with Hemiplegia

CSM 2016

11/30/2015

M. P. Haynes and H. Holly_Reprint with

permission only 1

Changing Function: An

Intervention for Children with

Hemiplegia

Margo Prim Haynes, PT, DPT, PCS, C/NDT

Holly Holland, OTR/L, ATP, C/NDT

Disclosure

Margo Prim Haynes, PT, DPT, PCS, C/NDT

and Holly Holland, OTR/L,ATP, C/NDT

declare no conflict of interest to report that

would bias this presentation. No relevant

financial relationship exists

Objectives

At the conclusion of this session the learner

will be able to:

1.Describe how CIMT / BIT / NDT are

combined for skill acquisition with children

diagnosed with hemiplegia and the

evidence that supports combining the

interventions

2.Demonstrate the process of cast fabrication

utilized in conjunction with CIMT



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Objectives

3. Discuss selected NDT-based therapeutic

handling strategies that guide symmetrical

postural alignment/symmetry to enhance

function in children with a diagnosis of

hemiplegia used in this clinical framework

4. Review application of combined

CIMT/BIT/NDT clinical practice models

Outline

• Clinical Presentation of Children with

Hemiplegia

• Pediatric Constraint Induced Movement

Therapy (P-CIMT) with Constraint Cast

• Bimanual Intensive Treatment /Training

(BIT)

• Neuro-Developmental Treatment (NDT)

• Clinical Practice Model

• Case Studies

Clinical Presentation:

Children with Hemiplegic Cerebral

Palsy (CP)



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Children with a Diagnosis of

Hemiplegic CP

Primary impairments:

• Impaired postural control (Arndt et al 2008, Westcott, Burtner 2004, Howle 2002)

• Movement coordination disorders (Richards, Malouin 2013, Shumway-Cook, Woollacott 2001)

• Sensation (Maitre 2013)

• Developmental Disregard (Bialoocerkowski2013, Zielinski et al 2014)

• Motor neglect

Postural

System

Movement

system

Body

Systems

Function

• BOS

• Alignment/Symmetry

•Balance

3 planes of movement

• Sagittal

• Frontal

• Transverse

• Musculoskeletal

• Cardiovascular

• Respiratory

• Gastro-intestinal

•Neuromuscular

•Auditory, Visual,

Vestibular

• Somatosensory

CIMT, BIT and NDT

are evidence based interventions

for

children with hemiplegic CP

Anttila,Autti-Ramo, Suoranta et al 2008

Sakzewski, Ziviani, Boyd 2009

Martin, Baker, Harvey 2010

Cope, Liu,Verbe, et al 2010

Franki, Desloovere, De Cat, et al 2012

Huseyinsinoglu BE, Ozdincler AR, Krespi 2012

Haynes, Phillips 2012



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Pediatric Constraint Induced

Movement Therapy

(P-CIMT)

P-CIMT Summary

Key Ingredients:

• Constraint of well functioning limb

• Intensive structured skills practice

DeLuca SC et al 2012

Eliasson A, et al 2013

Clinical / Research Questions

• Amount of Practice: 30-60 hours (Deluca et al 2012)

• Duration (hours / day): 1 hour – 6 hours (Eliasson et al 2005, 2011, Haynes, Phillips 2012, DeLuca et al 2006, 2012)

• Program length: 1 week – 2 months

• Location



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Types of Constraints for P-CIMT

Resting hand splint

(puppet over splint)

Sling

Cast

Constraint Cast

First Layer 2” terry cloth stockinette



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Second layer thumb spica stockinette

Secure cutting strip

Wrap distal to proximal



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Appropriate Positioning

Cast removal

Line the cast



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Secure the strap

Bimanual Intensive Treatment /

Training (BIT)

Bimanual Intensive Training / Treatment (BIT):

• HABIT (hand - arm bimanual intensive

training) program (Gordon, Charles, Wolf 2010,

Gelkop et al 2013 ,Greaves et al 2010 )

• Intensive Intervention Model

• Intensity versus treatment model (Arpino et al

2010)


• Amount of Practice: 60-90 hours (de Brito Brandao et al 2012, Facchin 2011)

• Duration (hours / day): 3 hour – 6 hours (de Brito Brandao et al 2012, Facchin et al 2011)

• Program length: 2 week – 10 weeks (Deppe et al 2013, Sakzewski et al 2012)

• Location



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CIMT and BIT

Equally Effective

• CIMT better at improving unimanual performance

• BIT better at improving

bimanual coordination and goal

achievement

Dong et al 2013

de Brito Brandao et al 2012

Summary of CIMT and BIT

Interventions

• Equally effective in improving

functional outcomes for children with

hemiplegic CP

• Research evidence is strong

• Improvements can last for one year

without further intervention

Friel et al 2013

Dong et al 2013

Sakzewski et al 2014

Summary of CIMT and BIT

Interventions

• Practice and intensity are key factors

in improving outcomes

• Cortical reorganization has been

shown

• Intervention can be performed by

trained volunteersFriel et al 2013

Dong et al 2013

Sakzewski et al 2014



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Neuro-Developmental Treatment

(NDT)

NDT Process…..

Trained in problem solving

strategies:

– Observe

– Analyze

– Consider the relationship

between the person, task,

environment

NDT Research- Postural System

• Postural System

– Alignment

– Symmetry

–Base of Support (BOS)

Evans-Rogers et al 2015

Arndt et al 2008

Girolami et al 1994, 2011



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NDT In Action


• Amount of Practice: 2-4 hours (Evans-Rogers et

al 2015), 15 hours (Arndt et al 2008)

• Program length: 1-2 weeks (Evans-Rogers et al

2015), 3 weeks (Arndt et al 2008)

• Location

Clinical Practice Model

Blending CIMT/BIT/CIMT



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NDT

CIMT

BIT

Clinical Practice Model

Clinical Practice Model includes…

• Functional Outcome Directed Practice

– Targeted unilateral and bilateral play (Geerdink et al 2015)

– Child specific

– Practice variation – with NDT (Haynes, Phillips

2012, Cope et al 2010)

– Multiple players



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Clinical Practice Model includes…

• Motor Learning ( Gordon 2005, Geerdink et al 2013)

– Practice, Practice, Practice

– Specificity of Training

• Functional Outcomes (age specific)

• Skill acquisition …. continues

Remember….. Postural System

• Alignment (symmetry)

– Ongoing midline orientation

• Feet part of the postural system

• Trunk rotation

Arndt et al 2008

Cope et al 2010

Haynes, Phillips 2012

Remember : Start with

Symmetry

39



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Putting it Together

Practice in Play

Case Studies

Summary

Clinical Practice Model for Children

with Hemiplegia

• Emphasize P-CIMT and NDT to acquire

new skills and use of involved extremities

– Constraint

– Intensity

– Functional Practice

• Integrates BIT and NDT for acquisition of

new functional bimanual skills

–



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Margo Haynes:

[email protected]

Holly Holland:

[email protected]

Appendix

Cerebral Palsy (CP)

• CP is a disorder of the development of

movement and posture, causing activity

limitations attributed to non-progressive

disturbances of the fetal or infant brain that

may also affect sensation, perception,

cognition, communication, and behavior.

Rosenbaum, 2006

Richards CI, Malourin F, 2013

mailto:[email protected]

mailto:[email protected]



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Constraint-Induced Movement

Therapy (CIMT)

• Less impaired upper extremity is

restrained

• More impaired upper extremity is

engaged in intensive and goal directed,

repetitive practice of functional tasks for

an extended period (Taub et al 2007)

Bilateral Intensive Training

Upper extremities are engaged in structured

bimanual goal directed, repetitive practice of

functional tasks for an extended period (Charles, Gordon 2006, Gordon, Charles, Wolfe 2010)

NDTA Treatment Definition

NDT is a holistic and interdisciplinary clinical

practice model informed by current and evolving

research that emphasizes individualized

therapeutic handling based on movement analysis

for habilitation and rehabilitation of individuals with

neurological pathophysiology. Using the ICF

model, the therapist applies a problem-solving

approach to assess activity and participation to

identify and prioritize relevant integrities and

impairments as a basis for the establishment of

achievable outcomes with clients and caregivers.



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NDTA Treatment Definition

An in-depth understanding of typical and atypical development, and expertise in analysis of postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activation of optimal sensorimotor processing, task performance, and skill acquisition for achievement of participation in meaningful activities.(Cayo et al 2015)

Recommended Casting Materials

• DELTA-CAST CONFORMABLE CAST TAPE

• TERRY-NET THUMB SPICA STOCKINETTE –SHORT/LONG

• DELTA TERRY NET STOCKINETTE 2”

• ADHESIVE FLEECE EDGER 1-1/4”

• STRETCH LOOP 1”

Casting Materials



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Outcome measures

• SHUE- Shriners Hospital upper extremity

assessment

• AHA - Assisting hand assessment

• Melbourne - Assessment of unilateral upper limb

function

• Quest - Quality of upper extremity skills test

• PROMIS- Patient reported outcomes

measurement

• Modified HOUSE - Orthopedic assessment of

upper extremity

• Revised VOAA-DDD

References

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Effectiveness for children with cerebral palsy: a systemic

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• Arndt SW , Sweeney JK, Sharkey MA, McElroy JJ. Effects

of a neurodevelopmental treatment-based trunk protocol

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• Arpino C, Vescio MF, DeLuca A, et al. Efficacy of

intensive versus nonintensive physiotherapy in children

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• Bialoocerkowski, A. Assessment of the upper limb in CP:

validity and reliability of the revised VOAA-DDD. Dev Med

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• DeLuca SC, Case-Smith J, Stefenson R, et al. Constraint-

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Documents

Changing Function: An Intervention for Children with Hemiplegiacaduceushandouts.com/csm/2016/handouts/pedAPTA-2233600.pdf · Changing Function: An Intervention for Children with Hemiplegia