DYNAMIC CORE STABILITY IN CHILDREN ... - …caduceushandouts.com/csm/2016/handouts/pedAPTA-2227202.pdf · inner core. 3. Identify the connection between breathing pattern, inner core

15-‐11-‐30

2015 Shelley Mannell, PT and Julie Wiebe, PT. All rights reserved. DuplicaCon, transfer and/or transmission of these materials is prohibited. 1

DYNAMIC CORE STABILITY IN CHILDREN WITH CEREBRAL PALSY

Shelley Mannell PT, Julie Wiebe PT

Conflict of Interest Statement

Both Shelley Mannell PT and Julie Wiebe PT provide continuing education courses, live and online, for various academic institutions, organizations, clinics and conferences.

Objectives:

Upon completion of this course, you will be able to: 1. Explain how the core functions in typical development and the development of children with CP, based on the current literature. 2. Identify the important role of alignment for activation of the inner core. 3. Identify the connection between breathing pattern, inner core muscle activation, and outer core muscle activation. 4. Demonstrate a basic understanding of the principles underlying an alternative clinical model for core stability used in children with CP.

15-‐11-‐30


Tug O’ War

=

Integration: TAP

Stability that is responsive to the demands of function (non-uniform response)

§  Teamwork §  Alignment §  Preparation

Integration: TAP


§  Teamwork

15-‐11-‐30


Gears in the Core Machine

Diaphragm

Transversus Abdominis

Pelvic Floor

Multifidus

Teamwork

•  Machine is optimized when all gears work together.

•  Gears must move or the machine will fail

•  Coordinated interaction will produce central stability

The Core Machine

Teamwork

Postural and Respiratory Functions of the PFM

Hodges, Sapsford, Pengel (2007) •  PFM followed respiratory cycle

(ant, not post) •  PFM expiratory activity more

associated with abs (low-level tonic activity w/bursts at mov’t frequency)

•  PISTON

15-‐11-‐30


Teamwork

Changes in IAP during Postural and Respiratory Activation of the

Human Diaphragm

Hodges et al (2000):

Teamwork

Teamwork

¨  Balanced interplay between the diaphragm, pelvic floor and abdominals preserves relative IAP throughout the respiratory cycle.

¨  A dynamic and coordinated model of core function

¨  5TH member of our team ¨  Intersection of multiple systems ¨  Breath gives us a new gateway

15-‐11-‐30


Teamwork

q  The Piston, driven by the action of the diaphragm, is a dynamic model for core function.

q  Accessing the deep core system through breath provides a gateway for our pediatric clients.

Graphic courtesy of Lee 2001, www.dianelee.ca

Integration: TAP



Alignment

The Core Machine

Machine works best if all the gears line up

15-‐11-‐30


Alignment

•  Muscles are strongest at the midpoint of available ROM •  Muscles are weakest when

long or short •  Neutral Pelvis and Ribcage alignment (ribcage over pelvis) puts the Core in midrange

positioning.

Alignment

Different Ways to Balance the Spine

Claus et al (2009): •  Flat, Long Lordosis, Short

Lordosis, Slump •  Short Lordosis best activity

for TA and Multifidus •  Flat-Least***

Alignment: Claus et al

Long Lordosis

15-‐11-‐30


Alignment: Claus et al

Short Lordosis

Alignment

Different Ways to Balance the Spine

Claus et al (2009): •  Flat, Long Lordosis, Short

Lordosis, Slump •  Short Lordosis best activity

for TA and Multifidus •  Flat-Least***

Alignment

Sitting Postures Affects PFM Activity in Parous Women

Sapsford et al (2006)

•  Slump, Upright Unsupported, and Very Tall Unsupported (thoracic)

•  Increased resting activation of PFM as alignment improved

15-‐11-‐30


Alignment: Sapsford et al

Slump Upright unsupported

Very Tall Unsupported

Alignment

Sitting Postures Affects PFM Activity in Parous Women

Sapsford et al (2006)

•  Slump, Upright Unsupported, and Very Tall Unsupported (thoracic)

•  Increased resting activation of PFM as alignment improved

Alignment

Neutral Rib Cage and Pelvis

§  Position of optimum Core recruitment (range)

§  Move toward neutral §  “Sweet Spot” : optimized

for your patient

15-‐11-‐30


Integration: TAP



Preparation

Neuromuscular Strategy: Preprogrammed motor control system, engaged through nervous system. The sensory system feeds information to create a graded response. Anticipatory + Reactive = Fxn Prepares for task + engaged based on demands of task = Function/movement

Preparation

Transverse Abdominis is not Influenced by the Direction of Arm

Movement

Hodges et al (1997)

•  TA EMG increased prior to deltoid regardless of UE direction

•  EMG of superficial abdominals varied with movement direction

15-‐11-‐30


Preparation

Contraction of the Human Diaphragm During Rapid Postural

Adjustments Hodges et al (1997):

•  Same result for the Diaphragm •  Anticipatory contraction occurred regardless of phase of respiration •  Same result for elbow motions,

not hand or digits

Preparation

Hodges et al (2007) •  Same result for the pelvic floor

•  Pelvic floor preceded the abdominals

Sjodhal et al (2009) •  PF precedes supine LE movement

Luginbuehl et al (2013) •  PF precedes heel strike in running

Integration

Build a clinical model that:

•  Teamwork: All gears moving •  Alignment: Optimized •  Preparation: Strategy

15-‐11-‐30


Core Redefined

CORE STRATEGY: NEUROMUSCULAR CORE EXERCISE:

MUSCULOSKELETAL

Core Strategy: Defined

Core Strategy is a system that harnesses the neuromuscular relationship that exists between the Anticipatory Core, Reactive Core, IAP Stability Cycle, Sensory System and the Brain. A cascade of force from the inside-out that provides both the stability and flexibility required to respond to the task at hand. #balance

Questions?

15-‐11-‐30


Pediatric Core Research

In contrast to the adult literature, very little pediatric research has specifically investigated the inner core musculature

Pediatric Research

What do we know about postural control in children with CP?

Pediatric Research

Altered Trunk Movements During Gait in Children with Diplegia:

Compensatory or Underlying Trunk Control Deficit?

Heyrman L et al. 2014 •  Looked at correlation between trunk

movement and LE movement •  Provided support for a primary trunk

control deficit NOT just as a result of LE impairment

15-‐11-‐30



Differences in Respiratory and Pulmonary Function Among

Children with Spastic Diplegia and Hemiplegia Cerebral Palsy in

Comparison with Normal Controls.

Kwon YH, Lee HY 2015 •  Children with spastic diplegic and

hemiplegia generate decreased respiratory pressure

Pediatric Research

Development of Postural Responses During Standing in Healthy Children and Children with Spastic Diplegia

Woollacott et al. 1998 •  Group of typical children standing in

alignment of child with spastic diplegia, showed similar disordered recruitment pattern during postural adjustments


Anticipatory and Compensatory Postural Adjustments in Sitting in

Children with Cerebral Palsy Bigongiari et al 2011

•  Tested in sitting •  Main postural control strategy is

compensatory •  Increased levels of co-activation in

outer core muscles (& others)

15-‐11-‐30



Anticipatory Postural Adjustments in Children with

Hemiplegia and Diplegia

Girolami G et al 2011 •  Tested in standing •  Higher levels of co-

activation reported in outer core muscles (& others)

Pediatric Research

Effect of Seat Surface Inclination on Postural Stability and Forward Reaching

Efficiency in Children with Spastic CP

Cherng et al. 2009

•  Studied effects of seat angle on postural stability and forward reach

•  Forward incline (=anterior inclination) more beneficial for both stability and reach for typical children and those with CP

Pediatric Research

Seat Surface Inclination May Affect Postural Stability During Bocci Ball Throwing in Children

with CP

Tsai et al 2014

•  GMFCS levels I, II and III •  Anterior inclination associated

with better postural stability and improved amplitude of elbow movement

15-‐11-‐30


Pediatric Research

Effects of Seat Surface Inclination on Respiration and Speech

Production in Children with Spastic Cerebral Palsy

Shin et al 2015

•  FVC was significantly improved with anterior inclination

The Role of Core Function in Typical Development

Examining details of typical development allows us to infer more about the development of the Core musculature

Typical Development

15-‐11-‐30


Typical Development

•  At birth, there is relatively low

tone in the Core musculature (Hulme J, 2005)

Implications for Core Activity

•  Resting tone of Core gradually increases during the first 2 – 3 years

(Hulme J, 2005)

Implications for Core Activity

•  This occurs as motor tracts form increased number and strength of connections with neurons in spinal cord during early movement

(Kasumacic N 2010, Martin JH 2005, Petersen TH 2012, Shumway Cook A, 2007)

• 

15-‐11-‐30


Typical Development: Newborn

Physiological Flexion •  High, triangular-shaped

rib cage •  Ribs close together

Implications for Anticipatory Core Activity

•  Alignment of rib cage allows for inferior excursion of diaphragm only

•  Little activity of the PF or TA

Typical Development: Newborn Milestones

Motor Function: •  Belly breathing •  Feeding •  Sleeping •  Uncontrolled elimination

15-‐11-‐30


Typical Development: 0-3 Months

Asymmetry •  Expansion of anterior chest

with activity of UEs in supine and prone

•  Decreased hip flexion with LE activity


•  Some increased excursion of diaphragm contributes to increased activity in PF

•  Increased excursion of diaphragm, activity of PF and LEs contributes to activation of TA; the team is developing

Implications for Reactive Core Activity

•  Pushing against surface in prone begins to activate reactive core Posterior oblique synergist (POS = contralateral latissiumus dorsi and glute max)

(Lee D, 1999)

15-‐11-‐30



•  Activation of reactive core Anterior oblique synergist (AOS = abdominal oblique and contralateral adductor) follows

(Lee D, 1999) •  Creates balance of extension and

flexion activity

Typical Development: 0-3 Milestones

Motor Function: •  Prone: head lifting •  Supported sitting: head

bobbing •  Begins to swipe at objects •  Voiced sounds with

movement


Symmetry •  With increased muscle

activation and independent movement, general increase in space between ribs occurs

15-‐11-‐30



Increased space between ribs supports change in rib cage shape allowing: ü  Deeper excursion of diaphragm ü  Improved activity of intercostals ü  Increased activity of PF and TA


•  Increased rotation activity around hip joints contributes to activation of PF


•  As hip flexion decreases, the POS becomes increasingly active, gains strength within the available range and contributes to anti-gravity function

15-‐11-‐30



Motor Function: •  Supine: bridges, rolling •  Prone: propping on extended

arms, superman, rolling •  Sitting with hands propped •  Beginning to reach forward

(humeral flexion) •  Transfers hand to hand •  Deeper breaths, longer sounds


Rotation •  Shape of rib cage is

elongating, changing alignment of shoulder girdle

•  Transitional movement creates functional linkage between the shoulder girdle and pelvic girdle


•  Increased hip ROM and capacity to maintain midline hip rotation ramps up activation of PF

•  Increased differentiation of control of diaphragm for postural stability, air flow and sound for speech

(Alexander R, 1991)

15-‐11-‐30



•  POS contributes hip extension for active base of support (anti-gravity extension)

•  AOS contributes to increased active rotation (protective reactions and transitional movement)


•  Crawling and ½ kneeling positions reflect activity in reactive core Lateral synergist (LS = Contralateral Glute Med/Min and Adductors) Lee D, 1999

•  and Rotational Synergist (Ipsilateral Hip Lateral Rotators and Adductors) Wiebe J 2013


Motor Function: •  Pushing up into sitting,

creeping/crawling, kneeling, pulling to stand, cruising

•  UEs for play, maturing grasp pattern

•  Produces sound independent of movement

15-‐11-‐30



Gross Motor Independence •  Rib cage becoming more

rectangular in shape •  Movement begins in all

planes against gravity


•  Trunk movement in all planes increases activation of diaphragm

•  Increased demand on mid-range hip control in standing contributes to activation of PF


•  Diaphragm, pelvic floor and TA partnership provides increased stabilization of lumbar spine and pelvis allowing initiation of movement from pelvis rather than upper trunk

15-‐11-‐30



•  Increased activity in all postural synergists in tandem with anticipatory core team


Motor Function: •  Climbing stairs, taking first steps •  Manipulates and combine fine

motor in play, dressing and feeding

•  Increased air intake, decreased respiratory rate

•  Abdominal-thoracic breathing pattern begins


I Can Do It Myself

•  effective Core muscle activation now in place for maintenance of stable trunk with simultaneous movement of the body in all planes

15-‐11-‐30



Motor Function: •  continued refinement in all areas of development

Effective Core Strategy

Core Strategy

=

stable head mobile trunk stable pelvis

=

dynamic postural control within

function

Q and A

15-‐11-‐30


What Happens to Core Function When Development is Atypical?

Atypical Development

•  Motor development can be impacted by difficulties in either the motor or the sensory systems


•  Ultimately, lack of physiological flexion at birth fundamentally impacts alignment

•  This negatively impacts the development of Core Strategy

15-‐11-‐30



Movement patterns develop to compensate for this inefficient postural control: ü  Breath holding ü  Head/neck extension ü  Stabilization by using end

ranges

Atypical Development: Breath holding

Task: Stabilize body against gravity

Compensation:

Breath holding


•  Rib cage remains high and compact

•  Decreased activation of respiratory diaphragm

15-‐11-‐30


Atypical Development: Breath holding

Functional Consequences: •  Poor midline head control •  Dislikes prone, unable to push

off surface with UEs •  Compromised movement –

moving for as long as breath holding

•  Decreased sounds •  Monocular fixation retained

Atypical Development: Neck Hyperextension

Task: Stabilize head to provide stable base for eyes

Compensation:

Neck hyperextension possibly combined with active tongue retraction


•  Rib cage remains high and compact secondary to shoulder elevation •  Decreased activation of respiratory diaphragm

15-‐11-‐30


Atypical Development: Neck Hyperextension Functional Consequences:

•  Poor midline head control •  Dislikes prone •  Decreased ability to pair UE function

or movement with vision •  Belly breathing •  ?voiced sounds with movement •  Monocular fixation retained

Atypical Development: Dynamic Holding

Task: Stabilizing the trunk against gravity Compensation: Active holding with rectus abdominus, iliopsoas and diaphragm


•  Muscles used isometrically for stabilizing during movement and against gravity •  Substituting phasic muscle activity for postural muscle activity •  Anticipatory core offline

15-‐11-‐30



Functional Consequences:

•  Supine preferred •  Sitting with posterior pelvic tilt •  Humerus remains internally

rotated w/elbow, wrist and hand flexed

•  Breath holding with movement •  Difficulty with development of

binocular vision


Muscle Tone

Neurological

(spasticity or hypotonia)

Mechanical

(stiffness)

Dynamic Holding


•  Changing alignment and muscle activation alters dynamic holding

•  can improve postural control

Muscle Tone

Neurological (spasticity, hypotonia)

Mechanical (stiffness)

Dynamic Holding

15-‐11-‐30


An Evidence-Based Pediatric Model for Dynamic Core Stability

Pop Quiz

Name that alignment?

K Pre-Botox

15-‐11-‐30


K 8 Weeks Post-Botox

Alignment: Function follows Form

Ribcage position dictates: ¨  Excursion and contribution of the

diaphragm to physiologic priorities, postural control and movement support

¨  Impacts the capacity of the diaphragm to set up the IAP pressure system

Alignment

How Do Anterior/Posterior Translations of the Thoracic Cage Affect Lumbar

Spine, Pelvic Tilt, and Thoracic Kyphosis Harrison et al (2002):

Posterior Thoracic Cage Translation •  Decrease lumbar lordosis (7.4) •  S-curve L-S (T-12-L2 flex) *apex* •  Increase pelvic posterior tilt (15.9) •  Sacral base posterior tilt (13.1), closer to horizontal

15-‐11-‐30


Posterior Ribcage Translation

Position of the ribcage relative to the pelvis q  Part 1: Military

Posterior Ribcage Translation

Position of the ribcage relative to the pelvis q  Part 2: Slouch

Rib Cage Tip

Lower Ribcage: Anterior/Superior (Top of the RibCage behind pelvis)

Lower Ribcage: Post/Inf (Bottom of the Ribcage behind pelvis)

15-‐11-‐30


Dixie Cup on a Stick

Lower Ribcage: Anterior/Superior Named by lower rib cage

Dixie Cup on a Stick

Lower Ribcage: Posterior/Inferior Named by lower rib cage

Let’s play

Seated Lab

15-‐11-‐30


Seated Lab

Make your rib cage tip Ant/Sup Named by lower ribcage

Seated Lab

Make your rib cage tip Post/Inf Named by lower rib cage

Defining Neutral Alignment

Neutral Ribcage/Pelvis •  Position of optimum recruitment

of the Diaphragm/Pelvic Floor Piston

•  Balance of flexors and extensors •  “Sweet Spot” within neutral

range; balancing their structure, muscular forces, and pressure

15-‐11-‐30


Breathing and Rib Cage Position

Diaphragm: Dysfunction

Breath Holding:

•  Valsalva: large loads •  Substitution for the Core in

postural control, movement strategies, transitions and prepping for small exertions

•  Repeated high intra-thoracic (ITP) and IAP can contribute to incontinence and constipation

Diaphragm: Dysfunction

Chest and Belly Breathers: •  Lateral component dysfunction

(lower 6 ribs) •  Keeps ribs high and flared or

fixed •  Core disconnected/IAP potential

is reduced •  Both use breath holding as a

stability strategy

15-‐11-‐30


Diaphragm: Intervention

Umbrella Inhale Close the Umbrella Around the Handle

Umbrella Breathing

Shelley’s Cues for Umbrella Breathing

•  Alignment is the key! •  Teach using an actual umbrella •  Use visual of diaphragm action

15-‐11-‐30


Shelley’s Cues for Umbrella Breathing

•  Place your hands around ribs 8-10 and provide gentle resistance throughout breath:

“Breathe into my hands” “Make my hands move out”

•  Use Theraband around ribs 8-10 and provide resistance (home program)

•  Emphasize gentle breath in •  Breathe out “through a straw”; some children may need a straw to

work with •  Some children may have increased difficulty with lip pursing

(orbicularis oris = flexion activity)

Alignment is the key!

15-‐11-‐30


Let’s Play

Standing Lab

Pelvic Floor

Anatomy 101: Action •  Anticipatory contraction to stabilize

lumbo-sacral, SI, pelvic-hip, and PS joints

•  Force couple with multifidus to control the sacrum

•  Synergist with TA (1˚ Anterior) •  Ebbs and flows with the Diaphragm

(1-7 mm) •  Supports pelvic viscera •  Pelvic floor (slow twitch) and

urogenital diaphragm (fast twitch) •  S2,3 nerve roots for PF and foot

intrinsics

Graphic courtesy of Lee 2001, www.discoverphysio.ca

Pelvic Floor: Function

Function: •  Needs to be integrated into Core

recruitment, and functional patterns •  Anticipatory, balanced contraction

between: •  anterior/posterior •  Right (R)/Left (L)

•  Spine length remains the same; No pelvic movement

•  Concentric/Eccentric •  Creating a motor program,

strategy, and resting tone


15-‐11-‐30


Pelvic Floor: Dysfunction

Dysfunction: •  Bum gripping

•  No link to the rest of Core o  No TA

o  Breath holding

•  Movement

o  Hollowing

o  Pelvic rocking o  Ribcage elevation/depression

o  Teeth gritting


Pelvic Floor: Tricks

Tricks: •  Ski Jump

•  Pursed lips/open mouth

•  Turn feet in/out

•  Lift your arches

Pelvic Floor and Kids

Primarily look at PF in function - pelvic stability in: •  Crawling •  Standing •  Moving from bilateral to

unilateral stance •  Unilateral stance

15-‐11-‐30


15-‐11-‐30


Palpation

•  Generally don’t palpate for motor function – observation!

•  Dealing with continence, always palpate

Permission

•  Ask permission of child and/or adult

•  Explain why •  “I need to put my hand here

(demonstrate on yourself) to feel what your PF is doing. Is that OK with you?”

•  Document, have another person present, use TA

Pelvic Floor Cues

•  Alignment is key! •  Gently “stop a toot” Break sequence down: •  Practice PF •  Inhale, extend the exhale •  Blow before you go •  Then practice movement •  “Beans” for teens

15-‐11-‐30


Case Presentation

Clinical Practice

Client Scenario: CP Hemiplegia

•  MD born at 25 weeks, 971 grams

•  Dx R hemiplegia CP


At 12 years old: •  Decreased range and

strength •  Difficulties with visual

scanning, attention •  Altered sitting and

standing posture •  Altered gait pattern

15-‐11-‐30



Functional limitations: •  Sit to stand transition with

UE support •  Decreased sitting

tolerance •  Decreased standing

balance


Anticipatory Core Deficit: •  Breath holding for transitional

movement or challenging tasks

•  Indicated poor diaphragm function


Anticipatory Core Deficit: •  Inability to hold midrange

posture in any position, stabilizing in end range

•  Indicated deficit in all four anticipatory core elements

15-‐11-‐30



Anticipatory Core Deficit: •  Pelvic retraction and poor

hip control in midstance gait •  Indicated poor pelvic floor

integration to stabilize pelvis and anchor hip during gait


Anticipatory and Reactive Core Integration: •  Poor anticipatory postural

control in sitting, standing and gait

•  Indicated poor timing of recruitment of both anticipatory and reactive core components


Pre-Treatment Sitting Pre-Treatment Standing

15-‐11-‐30



First Intervention Block: •  Ability to maintain bench sitting for 20 minutes to meet

demands of classroom organization and transitions. •  Increase dynamic postural control as demonstrated by

transitioning from sit-stand without the use of arms in order to carry school materials while moving and no loss of balance when stance is achieved.


First Intervention Block: 1 hr/week x 8 weeks •  Taught neutral alignment

of rib cage and pelvis in supine

•  Taught full utilization of diaphragm in supine “umbrella breathing”

•  Progressed to sitting with postural supports (wedge) and standing


•  Taught proper diaphragm engagement before transitional movement

•  ”Blow before you go”

15-‐11-‐30


In supine and sitting: •  Paired optimized alignment with

breathing with movement exercises for inside-out recruitment pattern

•  Variety of exercises and movement patterns targeted prioritized postural synergists



Pre-Treatment Post-Treatment (first block) Post-Treatment w/ wedge


Second Intervention Block: •  Increase trunk muscle coordination, strength and stability in

a more demanding position against gravity as demonstrated by standing in a more neutral alignment with ribs over pelvis and reduced reliance on extreme anterior tilt.

•  Increase standing balance as demonstrated by maintaining standing in the same place for 30 seconds to facilitate safety in standing and social interaction.

15-‐11-‐30


Second intervention block: In sitting and standing: •  Paired optimized alignment with

breathing with movement exercises for inside-out recruitment pattern

•  Increased awareness of alignment in standing

•  Variety of exercises and movement patterns targeted prioritized postural synergists



Pre-Treatment 2009 Post-Treatment 2010 2013


15-‐11-‐30



Treatment in Different Populations •  Cerebral Palsy •  Developmental Coordination Disorder •  Autism Spectrum Disorder •  Down Syndrome •  Varied Chromosomal Anomalies •  Organ Transplant •  Sensory Processing Disorder •  Anxiety Disorder •  Pediatric and Adolescent Stroke

Q and A

15-‐11-‐30


Julie Wiebe BSC, MPT www.juliewiebept.com Twi8er @JulieWiebePT Facebook.com/JulieWiebePT [email protected]

Connect

Shelley Mannell BSc, BHScPT www.heartspacept.com Twi8er @heartspacept Facebook.com/HeartSpacePT [email protected]

References

1.  Bigongiari A, de Andrade e Souza F, Franciulli PM, El Razi Neto S et al. Anticipatory and compensatory postural adjustments in sitting in children with cerebral palsy. Hum Mov Sci. 2011;30:648-657.

2.  Bordoni B, Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidisciplinary Healthcare. 2013;6:281-291.

3.  Brogren E, Hadders-Algra M, Forssberg H. Postural control in children with spastic diplegia: muscle activation during perturbations in sitting. Dev Med Child Neurol. 1996;38:379-388.

4.  Cherng RJ, Lin HC, Ju YH, Ho CS. Effect of seat surface inclination on postural stability and forward reaching efficiency in children with spastic cerebral palsy. Res Dev Disabil. 2009;30:1420-1427.

5.  Claus AP, Hides JA, Moseley GL, Hodges PW. Different ways to balance the spine: subtle changes in sagittal spinal curves affect regional muscle activity. Spine. 2009;34(6):E208-214.

6.  Dodd ME, Langham, H. Urinary incontinence in cystic fibrosis. J Soc Med. 2005:98 (suppl 45):28-36

7.  Girolami, G, Shiratori T, Aruin AS. Anticipatory postural adjustments in children with hemiplegia and diplegia. J Electromyogr Kinesiol. 2011;21:988-997.

15-‐11-‐30


References

8.  Heyrman L, Feys H, Molenaers G, Jaspers E et al. Altered trunk movements during gait in children with diplegia: Compensatory or underlying trunk control deficit? Res Devel Disabil. 2014; 35: 2044-52.

9.  Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997;505 (2):539–548.

10.  Hodges PW, Richardson CA. Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res. 1997;114(2):362-370.

11.  Hodges PW, Gandevia SC. Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. J Applied Physiol. 2000;89:967-976.

12.  Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurouro Urodyn. 2007;26(3):362-371.

13.  Holmes J. Bladder and Bowel Issues for Kids. Missoula, MT: Phoenix Publishing; 2003. 14.  Kasumacic N, Glover JC, Perreault MC. Segmental patterns of vestibular- mediated synaptic

inputs to axial and limb motorneurons in the neontatal mouse assessed by optical recording. J Physiol. 2010; 588(Pt 24): 4905-25.

References

15.  Kolar P, Sulc J, Kyncl M, Sanda J, Ondrej C, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without low back pain. J Orthop Sports Phys Ther. 2012;42(4):352-362

16.  Kwon YH, Lee HY. Differences in respiratory and pulmonary function among children with spastic diplegia and hemiplegia cerebral palsy in comparison with normal controls. J Phys Ther Sci. 2015; 27: 401-03.

17.  Lee, D. The Pelvic Girdle: An Approach to the Examination and Treatment of the Lumbo-Pelvic-Hip Region. Edinburgh: Churchill Livingstone; 1999.

18.  Luginbuehl H, Greter C, Gruenenfelder D, Baeyens JP, Kuhn A, Radlinger L. Intra-session test-retest reliability of pelvic floor muscle electromyography during running. Int Urogynecol J. 2013; 24: 1515-1522.

19.  Martin JH. The corticopinal system: from development to motor control. Neuroscientist. 2005; 11(2): 161–73. doi: 10.1177/1073858404270843

20.  Massery M, Hagins M. Stafford R, Moerchen V , Hodges PW. Effect of airway control by glottal structures on postural stability. J Appl Physiol. 2013;115:483-490

21.  Petersen TH, Farmer SF, Kliim-Due M, Nielson JB. Failure of normal development of central drive to ankle dorsiflexion relates to gait deficits in children with Cerebral Palsy. J Neurophysiol 2012; 109: 623-39.

References

22.  Sjodhal J, Kvist J, Gutke A, Oberg B. The Postural Response of the Pelvic Floor Muscles During Limb Movements: A Methodological Electromyography Study in Parous Women Without Lumbopelvic Pain. Clinical Biomechanics. 2009; (24): 183-189.

23.  Sapsford RR, Richardson CA, Stanton WR. 2006. Sitting posture affects pelvic floor muscle activity in parous women: an observational study. Aust J Physiotherapy. 2006;52(3):219-222.

24.  Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 2008;89(9):1741-1747

25.  van der Heide JC, Fock JM, Otten E, Stremmelaar E, van Eykern LA, Hadders-Aldra M. Postural control in during reaching in preterm children with cerebral palsy. Dev Med Child Neurol. 2004;46:253-266.

26.  Shin HK, Byeon EJ, Kim SH. Effects of seat surface inclination on respiration and speech production in children with spastic cerebral palsy. J Physiol Anthropol. 2015; 34: 17. doi 10.1186%2Fs40101-015-0057-3.

27.  Shumway-Cook A, Woollacott MH. Motor Control: Translating Research into Clinical Practice. Philadelphia, PA: Lippincott, Williams and Wilkins; 2007.

15-‐11-‐30


References 28.  Smith MD, Coppieters MW , Hodges PW . Postural response of the pelvic floor and abdominal

muscles in women with and without incontinence. Neurourol Urodyn. 2007;26(3): 377-385. 29.  Takas H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel

movement of diaphragm and pelvic floor during breathing and coughing – a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011;22(1):61-68.

30.  Tsai YS, Yu YC, Huang PC, Cheng HYK. Seat surface inclination may affect postural stability during boccia ball throwing in children with cerebral palsy. Res Devel Disabil. 2014; 35: 3568-73.

31.  Woollacott MH, Burtner P, Jensen J, Jasiewicz J, Roncesvalles N, Sveistruip H. Development of postural responses during standing in healthy children and children with spastic diplegia. Neurosci Biobehav Rev. 1998;22:583-589

Documents

DYNAMIC CORE STABILITY IN CHILDREN ... - …caduceushandouts.com/csm/2016/handouts/pedAPTA-2227202.pdf · inner core. 3. Identify the connection between breathing pattern, inner core