Post on 25-Aug-2018
8212016
1
Mark J Romness MDAssociate Professor of Orthopaedic Surgery
uvaorthocom
University of Virginia Orthopaedic Surgery
bull Anatomicndash Diplegia
ndash Quadriplegia
ndash Hemiplegia
ndash Other bull Asymmetric Diplegia
bull Monoplegia
bull Double Hemiplegia
bull Physiologicndash Spastic - velocity induced resistance to movement
ndash Extrapyramidal - dystonia athetosis ballismuschorea ataxia
ndash Mixed Tone
Classifications of Cerebral Palsy
University of Virginia Orthopaedic Surgery
bull Hypertonia
ndash Spasticity
ndash Dystonia
ndash Rigidity
bull Negative Motor Signs
ndash Weakness
ndash Poor control
Tone Patterns
bull Hyperkinetic
ndash Dystonia
ndash Chorea
ndash Athetosis
ndash Monoclonus
ndash Tremor
ndash Tics
ndash Stereotypies
Sanger TD et al Mov Disord 2010 Aug 1525(11)1538-49Taskforce on Childhood Motor Disorders
University of Virginia Orthopaedic Surgery
bull Weakness
ndash Inability to generate normal voluntary force
bull Poor Control
ndash Reduced selective motor control
ndash Ataxia Incorrect patterns for movement
ndash Apraxia Impaired patterns for a task
ndash Dyspraxia Lack of age-appropriate motor actions
Negative Signs
Sanger TD et al Pediatrics 2006 Nov118(5) Definition and Classification of Negative Motor Signs in Childhood Taskforce on Childhood Motor Disorders
University of Virginia Orthopaedic Surgery
bull Hypotonia not well defined
bull Was not included in the Sanger Task Force
bull Difficult to distinguish from
ndash Weakness
ndash Diffuse laxity
bull Personally I would say ldquoinappropriately low resistance to passive stretch manifested by reduced reflex response to unexpected perturbationsrdquo
Definition
Sanger TD ndash Personal Communication
University of Virginia Orthopaedic Surgery
8212016
2
University of Virginia Orthopaedic Surgery
bull Decreased strength
bull Decreased activity tolerance
bull Delayed motor skills development
bull Rounded shoulder posture with leaning onto supports
bull Hypermobile jointsincreased flexibility
bull Poor attention and motivation
bull Martin K et al Pediatr Phys Ther 2005 Winter17(4)275-82
Characteristics of Hypotonia
University of Virginia Orthopaedic Surgery
bull Hypotonia v Laxity
bull Central v Peripheral
bull History amp Exam
bull Tests
Diagnosis
University of Virginia Orthopaedic Surgery
bull Beighton score
Laxity
hypermobilityorg
University of Virginia Orthopaedic Surgery
bull Central nervous system
bull Peripheral nervous system
bull Neuromuscular junction
bull Muscle diseases
in order of prevalence
Hypotonia Etiology
Harris SR Dev Med Child Neurol 2008 Dec50(12)889-92
University of Virginia Orthopaedic Surgery
bull Central disorders
ndash Neonatal seizures
ndash Hypoxic-ischemic events
ndash Neonatal encephalopathy
bull Peripheral disorders
ndash Diminished reflexes
ndash Decreased anti-gravity limb movements
Central v Peripheral
University of Virginia Orthopaedic Surgery
bull Transient Hypotonia
ndash Preterm infants
ndash Perinatal drug exposure
ndash Acute infectious state
8212016
3
University of Virginia Orthopaedic Surgery
bull Family Historybull Prenatal History
ndash Prenatal fetal movementndash Poly or Oligohydramniosndash Maternal health during pregnancy
bull Drugsalcohol infections illness
bull Perinatalndash Apgar scoresndash Respiratory problemsndash Feeding difficulties
bull Infantsndash Motor milestones
History
University of Virginia Orthopaedic Surgery
bull Head circumference
bull Reflexesbull Primitive
bull DTRs
bull Muscle tone
bull Standardized Testsbull Neurological Assessment of the Preterm and Full-term Newborn Infant
bull Test of Infant Motor Performance ndashTIMPndash 34 weeks postconceptional age to 4 months post-term
bull Harris Infant Neuromotor Test ndash HINTndash 25 to 125 months
httpthetimpcom
Examination
University of Virginia Orthopaedic Surgery
bull Musclenerve biopsy
bull EMGndash denervation in the muscle
ndash muscle irritability
bull CTMRI
bull Ultrasound sheer wave elastography Joline E Brandenburg MD
ndash Quantifies the elasticity of tissue
ndash Used to show increased passive muscle stiffness in children with CP
ndash Hypotonia pending
Interventional Assessment
University of Virginia Orthopaedic Surgery
Hypotonia
Ginny Paleg PT DScPT
ginnypalegcom
I measure hypotonia using a scale of 6 items
suggested by Dr Andrew Morgan from Peoria
Illinois (Morgan-Paleg Hypotonia Scale)
1 Head Control
2 Vertical Suspension
3 Sitting
4 Hip Abduction
5 Ankle Dorsiflexion
6 Standing
8212016
4
Score each item 0 1 or 2 points
1 = normal
2 = eh
3 = oy vey
Add score divide by 6
Thatrsquos the total score
Recommend services 2xmo
Hip Helper
compression
shorts $15
Seating Device
Stander
Supported Stepping andor treadmill training
Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)
Orthotics
Theo at 9
months
Gericke 2006
Paleg 2013
Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years
Itrsquos not done yet
Treadmill will be green light ldquoGOrdquo
Orthotics ldquomightrdquo be Green Light
8212016
5
Exercise and Physical Therapy came out well (but no one type)
Whole Body Vibration came out well but fell out when we went to younger children
Video taken at Dr
Rainer Blankrsquos
clinic in Germany
Compression GarmentsLycra Suits
Bicycle
Massage
Kinesiotaping
Power Toy Car and Power Chair
VestibularSensory Training including Wii
Already adapted
Comes with wireless remote
Lil Rover
$70 from toysruscom
Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children
Damiano said this intervention should be standard of care for children with Down syndrome
Hi intensity is better than low intensity
If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age
R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam
8212016
6
Start at 9 months if child is not yet sitting independently to play
Start at 12-15 months if child is not yet pulling to stand and cruising
Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V
(Martinsson 2011 Macias 2015 aampb)
Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)
Wear 50 of waking time
No orthotics = handplay
w orthotics = postural play
(Martin and Looper CSM 2015)
No evidence
Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo
Children without head control may benefit supportive seating at 3-6 months of age
Try dynamic setaing
We need a definition
Is it CP
We need a valid reliable measurement tool
We need outcome measures
Once we have these we can better evaluate interventions
Email Ginny for handouts Ginnypalegcom
8212016
2
University of Virginia Orthopaedic Surgery
bull Decreased strength
bull Decreased activity tolerance
bull Delayed motor skills development
bull Rounded shoulder posture with leaning onto supports
bull Hypermobile jointsincreased flexibility
bull Poor attention and motivation
bull Martin K et al Pediatr Phys Ther 2005 Winter17(4)275-82
Characteristics of Hypotonia
University of Virginia Orthopaedic Surgery
bull Hypotonia v Laxity
bull Central v Peripheral
bull History amp Exam
bull Tests
Diagnosis
University of Virginia Orthopaedic Surgery
bull Beighton score
Laxity
hypermobilityorg
University of Virginia Orthopaedic Surgery
bull Central nervous system
bull Peripheral nervous system
bull Neuromuscular junction
bull Muscle diseases
in order of prevalence
Hypotonia Etiology
Harris SR Dev Med Child Neurol 2008 Dec50(12)889-92
University of Virginia Orthopaedic Surgery
bull Central disorders
ndash Neonatal seizures
ndash Hypoxic-ischemic events
ndash Neonatal encephalopathy
bull Peripheral disorders
ndash Diminished reflexes
ndash Decreased anti-gravity limb movements
Central v Peripheral
University of Virginia Orthopaedic Surgery
bull Transient Hypotonia
ndash Preterm infants
ndash Perinatal drug exposure
ndash Acute infectious state
8212016
3
University of Virginia Orthopaedic Surgery
bull Family Historybull Prenatal History
ndash Prenatal fetal movementndash Poly or Oligohydramniosndash Maternal health during pregnancy
bull Drugsalcohol infections illness
bull Perinatalndash Apgar scoresndash Respiratory problemsndash Feeding difficulties
bull Infantsndash Motor milestones
History
University of Virginia Orthopaedic Surgery
bull Head circumference
bull Reflexesbull Primitive
bull DTRs
bull Muscle tone
bull Standardized Testsbull Neurological Assessment of the Preterm and Full-term Newborn Infant
bull Test of Infant Motor Performance ndashTIMPndash 34 weeks postconceptional age to 4 months post-term
bull Harris Infant Neuromotor Test ndash HINTndash 25 to 125 months
httpthetimpcom
Examination
University of Virginia Orthopaedic Surgery
bull Musclenerve biopsy
bull EMGndash denervation in the muscle
ndash muscle irritability
bull CTMRI
bull Ultrasound sheer wave elastography Joline E Brandenburg MD
ndash Quantifies the elasticity of tissue
ndash Used to show increased passive muscle stiffness in children with CP
ndash Hypotonia pending
Interventional Assessment
University of Virginia Orthopaedic Surgery
Hypotonia
Ginny Paleg PT DScPT
ginnypalegcom
I measure hypotonia using a scale of 6 items
suggested by Dr Andrew Morgan from Peoria
Illinois (Morgan-Paleg Hypotonia Scale)
1 Head Control
2 Vertical Suspension
3 Sitting
4 Hip Abduction
5 Ankle Dorsiflexion
6 Standing
8212016
4
Score each item 0 1 or 2 points
1 = normal
2 = eh
3 = oy vey
Add score divide by 6
Thatrsquos the total score
Recommend services 2xmo
Hip Helper
compression
shorts $15
Seating Device
Stander
Supported Stepping andor treadmill training
Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)
Orthotics
Theo at 9
months
Gericke 2006
Paleg 2013
Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years
Itrsquos not done yet
Treadmill will be green light ldquoGOrdquo
Orthotics ldquomightrdquo be Green Light
8212016
5
Exercise and Physical Therapy came out well (but no one type)
Whole Body Vibration came out well but fell out when we went to younger children
Video taken at Dr
Rainer Blankrsquos
clinic in Germany
Compression GarmentsLycra Suits
Bicycle
Massage
Kinesiotaping
Power Toy Car and Power Chair
VestibularSensory Training including Wii
Already adapted
Comes with wireless remote
Lil Rover
$70 from toysruscom
Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children
Damiano said this intervention should be standard of care for children with Down syndrome
Hi intensity is better than low intensity
If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age
R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam
8212016
6
Start at 9 months if child is not yet sitting independently to play
Start at 12-15 months if child is not yet pulling to stand and cruising
Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V
(Martinsson 2011 Macias 2015 aampb)
Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)
Wear 50 of waking time
No orthotics = handplay
w orthotics = postural play
(Martin and Looper CSM 2015)
No evidence
Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo
Children without head control may benefit supportive seating at 3-6 months of age
Try dynamic setaing
We need a definition
Is it CP
We need a valid reliable measurement tool
We need outcome measures
Once we have these we can better evaluate interventions
Email Ginny for handouts Ginnypalegcom
8212016
3
University of Virginia Orthopaedic Surgery
bull Family Historybull Prenatal History
ndash Prenatal fetal movementndash Poly or Oligohydramniosndash Maternal health during pregnancy
bull Drugsalcohol infections illness
bull Perinatalndash Apgar scoresndash Respiratory problemsndash Feeding difficulties
bull Infantsndash Motor milestones
History
University of Virginia Orthopaedic Surgery
bull Head circumference
bull Reflexesbull Primitive
bull DTRs
bull Muscle tone
bull Standardized Testsbull Neurological Assessment of the Preterm and Full-term Newborn Infant
bull Test of Infant Motor Performance ndashTIMPndash 34 weeks postconceptional age to 4 months post-term
bull Harris Infant Neuromotor Test ndash HINTndash 25 to 125 months
httpthetimpcom
Examination
University of Virginia Orthopaedic Surgery
bull Musclenerve biopsy
bull EMGndash denervation in the muscle
ndash muscle irritability
bull CTMRI
bull Ultrasound sheer wave elastography Joline E Brandenburg MD
ndash Quantifies the elasticity of tissue
ndash Used to show increased passive muscle stiffness in children with CP
ndash Hypotonia pending
Interventional Assessment
University of Virginia Orthopaedic Surgery
Hypotonia
Ginny Paleg PT DScPT
ginnypalegcom
I measure hypotonia using a scale of 6 items
suggested by Dr Andrew Morgan from Peoria
Illinois (Morgan-Paleg Hypotonia Scale)
1 Head Control
2 Vertical Suspension
3 Sitting
4 Hip Abduction
5 Ankle Dorsiflexion
6 Standing
8212016
4
Score each item 0 1 or 2 points
1 = normal
2 = eh
3 = oy vey
Add score divide by 6
Thatrsquos the total score
Recommend services 2xmo
Hip Helper
compression
shorts $15
Seating Device
Stander
Supported Stepping andor treadmill training
Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)
Orthotics
Theo at 9
months
Gericke 2006
Paleg 2013
Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years
Itrsquos not done yet
Treadmill will be green light ldquoGOrdquo
Orthotics ldquomightrdquo be Green Light
8212016
5
Exercise and Physical Therapy came out well (but no one type)
Whole Body Vibration came out well but fell out when we went to younger children
Video taken at Dr
Rainer Blankrsquos
clinic in Germany
Compression GarmentsLycra Suits
Bicycle
Massage
Kinesiotaping
Power Toy Car and Power Chair
VestibularSensory Training including Wii
Already adapted
Comes with wireless remote
Lil Rover
$70 from toysruscom
Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children
Damiano said this intervention should be standard of care for children with Down syndrome
Hi intensity is better than low intensity
If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age
R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam
8212016
6
Start at 9 months if child is not yet sitting independently to play
Start at 12-15 months if child is not yet pulling to stand and cruising
Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V
(Martinsson 2011 Macias 2015 aampb)
Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)
Wear 50 of waking time
No orthotics = handplay
w orthotics = postural play
(Martin and Looper CSM 2015)
No evidence
Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo
Children without head control may benefit supportive seating at 3-6 months of age
Try dynamic setaing
We need a definition
Is it CP
We need a valid reliable measurement tool
We need outcome measures
Once we have these we can better evaluate interventions
Email Ginny for handouts Ginnypalegcom
8212016
4
Score each item 0 1 or 2 points
1 = normal
2 = eh
3 = oy vey
Add score divide by 6
Thatrsquos the total score
Recommend services 2xmo
Hip Helper
compression
shorts $15
Seating Device
Stander
Supported Stepping andor treadmill training
Compression Garment (Neoprene thigh wrap Benik SPIO Theratogs DMO etc)
Orthotics
Theo at 9
months
Gericke 2006
Paleg 2013
Systematic Review of over 70 articles (Paleg Romness and Livingstone in progress) age 0-6 years
Itrsquos not done yet
Treadmill will be green light ldquoGOrdquo
Orthotics ldquomightrdquo be Green Light
8212016
5
Exercise and Physical Therapy came out well (but no one type)
Whole Body Vibration came out well but fell out when we went to younger children
Video taken at Dr
Rainer Blankrsquos
clinic in Germany
Compression GarmentsLycra Suits
Bicycle
Massage
Kinesiotaping
Power Toy Car and Power Chair
VestibularSensory Training including Wii
Already adapted
Comes with wireless remote
Lil Rover
$70 from toysruscom
Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children
Damiano said this intervention should be standard of care for children with Down syndrome
Hi intensity is better than low intensity
If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age
R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam
8212016
6
Start at 9 months if child is not yet sitting independently to play
Start at 12-15 months if child is not yet pulling to stand and cruising
Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V
(Martinsson 2011 Macias 2015 aampb)
Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)
Wear 50 of waking time
No orthotics = handplay
w orthotics = postural play
(Martin and Looper CSM 2015)
No evidence
Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo
Children without head control may benefit supportive seating at 3-6 months of age
Try dynamic setaing
We need a definition
Is it CP
We need a valid reliable measurement tool
We need outcome measures
Once we have these we can better evaluate interventions
Email Ginny for handouts Ginnypalegcom
8212016
5
Exercise and Physical Therapy came out well (but no one type)
Whole Body Vibration came out well but fell out when we went to younger children
Video taken at Dr
Rainer Blankrsquos
clinic in Germany
Compression GarmentsLycra Suits
Bicycle
Massage
Kinesiotaping
Power Toy Car and Power Chair
VestibularSensory Training including Wii
Already adapted
Comes with wireless remote
Lil Rover
$70 from toysruscom
Treadmills will be strongest recommendation at 8 min 5xwk for pre-walkers to 20-30 min 2-5xwk for older children
Damiano said this intervention should be standard of care for children with Down syndrome
Hi intensity is better than low intensity
If you donrsquot have access to a treadmill andor prefer natural environment try a gait trainerStart at 9-12 months adjusted age
R82Convaid (formally known as Snug Seat) Rifton and Prime Engineering all offer devices that go as small at 6 inch inseam
8212016
6
Start at 9 months if child is not yet sitting independently to play
Start at 12-15 months if child is not yet pulling to stand and cruising
Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V
(Martinsson 2011 Macias 2015 aampb)
Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)
Wear 50 of waking time
No orthotics = handplay
w orthotics = postural play
(Martin and Looper CSM 2015)
No evidence
Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo
Children without head control may benefit supportive seating at 3-6 months of age
Try dynamic setaing
We need a definition
Is it CP
We need a valid reliable measurement tool
We need outcome measures
Once we have these we can better evaluate interventions
Email Ginny for handouts Ginnypalegcom
8212016
6
Start at 9 months if child is not yet sitting independently to play
Start at 12-15 months if child is not yet pulling to stand and cruising
Consider abduction to protect hips is you suspect child will be at GMFCS Levels III IV or V
(Martinsson 2011 Macias 2015 aampb)
Get orthotics when child is pulling up to stand and cruising (very weak evidence for Sure Steps over Cascase Dafo 4)
Wear 50 of waking time
No orthotics = handplay
w orthotics = postural play
(Martin and Looper CSM 2015)
No evidence
Martin showed that most PTs thought that children with hypotonia ldquolean into supportsrdquo
Children without head control may benefit supportive seating at 3-6 months of age
Try dynamic setaing
We need a definition
Is it CP
We need a valid reliable measurement tool
We need outcome measures
Once we have these we can better evaluate interventions
Email Ginny for handouts Ginnypalegcom