dystonic cp

hello friends i have 3-1/2 year boy,who's mixed cp with more dystonia.he was premature with her twin sister at the 6 months.his sister is also right sided hemiplegic.right now he can roll and able to sit with sopport.i m attaching some of his photos..what i found that his tightness is dynamic.only comes when he attemps movement.he sits with thorasic lordosis.what can i do to improve his sitting?how can i achieve transitios.as usual therapy not giving satiseactory results..his iq level is normal.

What is his "usual" therapy based on? I would see about getting advice from a Bobath Pädiatric qualified physio. There is a center in India: The Indian Institute of Cerebral Palsy (IICP) Home Page.
Additional Comment I forgot:
may have clicked on the wrong link there, the cerebral palsy center may of course have all sorts of ways of treating CP and not only Bobath! I took a look at it again!:o

Thanx judith for u r kind rply.but the centre u mention is very far for me.i m aware of bobath techniques.but main problem with the child id of axial dystonia hamperring his trunk control.he isn't able to sit without support.can roll on groung.goes to prone on elbows.it will be beter if u can share u r experience with dystonia specially axial 1.one of the ndt specialist suggest me to do eccentric abdominal exs but not showed how!so pls help me...ask me if u want further information.

can any1 put more light on treatment of dystonic child and role of botox therapy for it?

Hi,
after watching pic, the child can be categorized as follow: severe to moderate spasticity in four limbs, pattern of posture is hyperflexion, symmetry in pattern of posture, one side being used for fixation (L) to balance himself, tends to do small movts within the base of support.

on the basis of above observations, treatment must be based on these lines:
reduce spasticity in upper limbs to start wid the session by taking it in tone influencing pattern of external rotation, abd and retraction of shoulder. child would need mobilization of shoulder and scapula, both, in side lying position first as a preparation for this tone influencing pattern. keeping his upper limbs in this position in supine would reduce spasticity in legs and would be easy to apart his legs. once spaticity is reduced try to do big shld movements in supine lying in abduction. avoid doing activity like gripping something or grasp rather involve him in activities with open hands like hitting something.

introduce assymmetry by taking him in side sitting on right side keeping shld in TIP. introduce rotations in trunk by moving him from side sitting to prone over elbow or palms over the roll or cushion, and then get him back again in side sitting position or may be in long sitting if child can tolerate it. also introduce tunk rot in long sitting bearing weight on one arm bringing another arm diagnolly crossing the mid line.

introduce balancing exercises in prone lying and supine lying on balance board and then in sitting on ball in small amplitude to teach weight shifting on pelvis.

start using bench for him for sitting in stride sitting and sitting on one side. integrate assymmetry by keeping one foot high on small foot rest. and then try again big shld movements wid same activities as in lying and trunk rot activities using arms diagnolly by crossing the midline.

avoid using lot of standing at this point rather we can proceed to halfkneelig later on. as this will give assymetry and tip at legs together.

dont forget to keep this child moving in and out of the position during therapy rather than stucking him in one position for long times. and pay special attention to develop balancing reactions in supine, prone, and sitting.

hope this will be helpful.
thnx. regards

thanx humera for u r detailed rply.the child is as i said more dynamic dystonic and i want to control that.his right side is better than left one.hw to improve transition as no stable base in suppine..kindly add more ndt points if u can...

Hi, I am sorry but I am bit confused with the term you are using Dystonic. If I am not mistaken, dystonia goes more with getting stucked with one posture as children with athetoid. however your child as he looks, goes more with dynamic spasticity. he seems to have moderate spasticity at rest as sitting with support, which increases to severe with movement. I would lebell this child moderate spastic diplegic, lowerlimb involved> upper limb, left side involved > right side. I would describe therapy plan of one session how we can progress during the session.

take him in supine on wedge. start from shld take one L in TIP i.e depression, abd, ext rot at shoulder, elbow straight and wrist and fingers open, taking shld as key point of controll. try to get this position gradually as child allows you. after moments when you feel arm is relaxed, mobilize the shld more in ext rotation. now keep that arm at side and do the same with R shld. now bring the two legs apart and in ext rotation with knees straight as much as possible. mobilize hips in external rot. now fix the legs at knees by sitting over the knees, make the child to do trunk rot at pelvis by picking any big object with L hand from same side and dropping on R side of body. do the same on R side. after this u will feel decreased spasticity in legs.

progress from here to long sitting, by pulling child to sit. make the child to to side lying on L side using R shld as KPC and help him to come up to sitting taking wt on L arm. come behind the child supporting his back from your body and keep his legs straight using your legs coming over his knees. now bring one arm in abd at 90 degrees keeping elbow straight and palms open. sup him from shld and wrist and make the child to hit small balls with open hands in different directions to get big and rapid movts at shoulder. this will also help to dev weight shifting at pelvis thus reducing spasticity in legs. repeat the same with other arm. now bring tilting/ balance board on L side. make child to transfer on balance board and take him in supine. come behind the child at his head side. bring both arms in abd at 90 degrees keeping elbows straight as much as possible. now move balance board side to side slowly to shift body weight to one side and wait till child comes in middle to keep his body straight. from here bring him again in long sitting as you did before in lying on floor. adapt the same long sitting position by sitting behind the child on balance board and engage him in play with both hands. keep moving board side to side with your body weight to make the child to adjust with weight shifting and balancing himself. from here you can take child in cross sitting on board and come in front to play with him keeping the board moving side to side.

Dear Colleague,
I would suggest to everyone treating children that you need to learn the GMFM. You can order the test manual /book including 3 DVD's on CanChild Centre for Childhood Disability Research
Reading and learning it ( proferably with others) it not only gives you the possibility to learn the test, it also gives you the possibility to think up new treatment goals.
We now realize that one of the biggest problem many children with neurological problems face is muscle weakness.

One of the new ways of treating children in a functional way is to give them the oppertunity to find their own solution to a problem. You only help make this easier. So if a child cannot sit alone, try teaching them to lower themselves from sit to supine or prone slowly (excentric), use 4point gate to slowly lower to sit. But most importantly, give the child the time to allow the movement, don't help. The suggestions made before are not bad but I personally miss the action. You cannot only passively move children. The child has to experience the weight change by doing it themselves.

Hope this helps a bit.

kind regards

esther

Dear Estherderu,
I totally agree with you to learn and use GMFM in our pediatric practice as it really help to set treatment goals in more realistic way. also it gives the idea that which part of gross motor needs to get more work done.

the suggestions I made regarding dystonic child, I neverth meant to move child passively rather I wanted to say to facilitate the child. as we say facilitation in NDT/ Bobath approach, it is a proecess in which we try to give the child more active control gradually throughout the activity through our handling till the child can take over completely. I never meant to move child passively. It would be the problem with my writing abilities that I couldnt express the things properly. I am sorry for that.

the suggestions you made regarding eccentric work, I agree with you that it is vey helpful. we always try to facilitate activities not only in forward chaining but in the backward chaining at the same time and it gives child more active control to reach to the final activity in the single session.

Thnx once again for taking the time out to read my reply to the thread. your suggestions are always very helpful.

thnx.

thanx humera for u r detailed reply.i too agree with esterduru that child shoould be facilitated.and yes humera couldn't we term that child as dynamic dystonic rather than dynamic spastic as spasticitiy is present in antigravitiy muscles and many factors lead it to increased.u initially define dystonia in u r rply is static one as child stuck in fixed posture and couldn't move out of it while dynamic dystonia comes with movement.the child i have mention when does reach out with right hand his left hand goes in aduution,internal rotation from shulder flexed from wrist and elbow as well adduction of thumb and also his mouth opens.it's more like assosiated reactions.the main problem i m facing in child is of transition is very poor.he has learned to roll nothing alse in transition his trunk is so flaby specially abdominals that he can't even assume keel standing position with support.and yes humera as u fing difficulty in description better that u include images here...thanx again for u r kind rplies.tc

Dear Spandanphysio,
I too agree with you, the pattern you described seems more like associated reaction. You described the pattern of upper limb, is the child having any abnormal reactions in lower limbs too. As far as associated reactions are concerned, they occur due to the effort made by less effected part during activity. In NDT approach, associated reactions can be reduced by grading the activity to reduce the effort. Weight bearing specifically mobile weight bearing can be done on effected limb, positioning it in TIP. Working on movement components required to achieve task also reduces the associated reaction.
As you said child's trunk is very low tone, this is something goes with history of premature birth having low tone proximally and abnormal high tone distally. Developing tone in trunk and increasing proximal stability might help to reduce effort and thus abnormal patterns in this child. Rolling ( the only thing child can do independently), facilitated through upper limbs keeping them fully extended above the shoulder could give the child experience of mobile weight bearing on shoulder while shoulder in TIP, and increase tone in trunk. I try approximation/ compressions on proximal joints (shoulder and hips) to get trunk and pelvic floor muscles active in some children with similar condition depending on how child is reacting.
In transitions, has child learnt to come up on all fours from side lying position . I try with my patients, facing difficulty to come up to kneeling, to assume four point kneeling against wedge. They are encouraged to get down on wedge while leaning upper trunk forward with slope so that they are resting on their elbows and than come back again to bear weight on palms on wedge. From there, they can extend less effected arm to pick object above the shoulder, keeping effected arm on wedge first and gradually taking that arm off the wedge to assume high kneeling gradually.
In sitting to reach out for an object can be made easier by working on balancing reactions in supine, prone, sitting on ball first. This will enable child to learn weight shifting on pelvis and trunk extension, required to use hands freely in sitting. Reaching out could be made graded by, sitting on lap/ bench with feet supported, reaching in midline first below the shoulder and gradually increase the level of object higher and side ways to reach out of the base of support. Child can learn to lean forward and come back to sit up, helpful to increase truncal tone. Mobile weight bearing on effected arm can be used together keeping arm in pattern of TIP, while child is moving forward to reach for an object.
I tried to share my experiences with you. I will be happy if we could stay in touch regarding this case and share some more experiences together. Regards.

hello humera.the child has a more spasticitiy in legs.especiialy addutors and calf.m activating abdutors in lying with guuter splint of knee .can u put more light on activating dorsiflexors and controling planterflexor overtone.his knee goes in hyper extension due to that.i has added u r recoomended exs on wedges.he is able to come on prone on elbow but not on palm on prone.also finding difficulty in learning him creeping and improve his transation by that.eccentric control of movt. is very poor and m concentrating on that.any idea for that?i m confused with world TIP,what's that?is it abbrevation?

Hi Spandanphysio,
Yes TIP is the abbreviation for "Tone influencing pattern". I still believe that getting more normal tone in upper limbs and trunk would be helpful to decrease/ normalize tone in legs. What about to take child in supine on ball to start the session, bringing his both arms in full extension above head gradually, with shoulders in abd and external rotation and elbows in extension, controlling shoulder around axilla. His legs must be hanging down the ball. then moving the ball in small amplitudes ant-post and sideways would help to get good stretching of all tight flexors.

Try activating hip abductors in side lying position. But before that , hip flexors and internal rotators would need stretching in side lying. Turning fron side lying to supine, initiating movement from legs would be helpful to activate hip abductors, ext. rotators and extensors.

Can you plz add more detail, in what position you want to activate dorsiflexors and control planterflexors.

if the child is feeling difficulty in coming up on palms in prone, it would be due to lack of extensors activity in lower trunk. Plz try bridging with legs abd and ext rotated and knees extended, supporting the legs at ankles, bit higher in your lap. This will increase extensor activity in lower trunk and legs, required for full trunk extension in prone. Also we can add taking one arm forward to reach for an object, while child is on elbows in prone.

I would suggest you not to work on creeping as it may increase flexor spasticity in the whole body which is childs original pattern and child need to inhibit this pattern.once good trunk extension in prone is achieved, this could be used to get child in all fours position and then on kneeling and half kneeling. These positions then can be use for transitions later on.

In which position you are working to get eccentric muscle control. You can try going in prone with head on floor from prone on elbows as an eccentric work as the child is able to control these positions.

Thanx once again humera for u r valuable suugestion.i have started act to u r suggestions but getting difficulty in activating abdutors in side lying.the child is not sincere in exs. but thanx god having good intrlligance level that follows commonds.how u deal with smaal childs and who doesn't follow commond in n.d.t?how u think abt prognosis of this child?will he able to walk independantly as he is already 5 years.i m dealing with another dystonic child came from interior parts at the age of 9 years.he has improved spontaneously after the age of 7 year.right now already walks with support!another child i m dealing is also axiaal dystonic ,1 and 1\2 yera old+he is blind.so lots of difficulties r there without vision.the child i have attached pics also having significint oromotor assosiated reactions.mouths gets open in every moderate effort.hw can v control that?and yes ,i m working here in interior parts of india and only qualified one in my region.so not geting frequet chance for exposer to N.D.T.hat's off for u r kind response...

and yes humera i want to deacese tone of palnterflexor in standing,that's y asking abt activating dorsiflexors..

Hi Spandanphysio,
Sorry for late reply, as schedule is bit busy and altered in month of fasting. Good to know that some of my advices helped you out.
Activating abductors in side lying would be difficult, if you are trying it as an exercise to pull up leg straight in side lying. I suggested you before to try rolling initiated from legs. This would bring some activity in abductors. Sitting on phsio ball with legs abducted, make child to do arm activity side ways to reach for an object keeping shoulder in abduction and external rotation with elbows in extension would be helpful. Sitting on bench, legs apart, trunk rotations would also activate hip abductors. You can advice parents to use bench for sitting at home with legs apart to inhibit wrong patterns and get more weight bearing on feet.

With small children, we usually try to get interaction first and get to know their interests. Than those activities of their interest could be used to facilitate the right and desired patterns.

I think this child would be able to walk with support, but might need surgical interventions to reduce spasticity. You can check with Orthopedic surgeon for further suggestions.

Childs oro-motor reactions would be due to keeping head and neck in extension to balance himself. Keeping child more in flexion and introducing jaw control within and outside meal time would be helpful.

If child is standing on toes, it doesn’t mean that he has only tight plantarflexors. Plz go through the whole pattern of legs in standing. Activating dorsiflexors is not the solution. Rather try to normalize the tone in legs by keeping them in TIP first. You can progress from sitting on bench with legs apart. after upper limb activities in abduction as suggested earlier, when you feel his abductors are relaxed and feet are well supported on floor in neutral position, you can facilitate pull to stand by making child lean forward on a small table in front, bearing weight on open hands. Let the child to keep standing, keeping the trunk leaned forward (perch st.). keep his legs abducted and ext. rot at hips and knees extended. Once you feel less tone in his legs, ask him to come up extending his trunk. Then again make him to lean forward on table and sit down. This would help to decrease tone in plantarflexors.

There is a book preview "Neurologic intervention for PT", has good pic for manual handling and facilitation. This would be helpful. Scribd.

hi humera,haapy id to u.the child is progresing well as his sitting is improved.also able to go to knel standing but still main problem is hypotonic lower trunk..

Hi Spandanphysio,

glad to know that your child is progressing satisfactorily. as he has started sitting well, i think go more for balancing reactions in sitting within different situations. now you can start thinking of functional activities in sitting e.g. dressing n undressing, eating n drinking, using both hands in midline for play etc. as you said still low tone in lower trunk is problem, can you plz describe more how and when it is causing trouble.

can any1 put more light on treatment of dystonic child and role of botox therapy for it?

hiii humera.the low tone lower trunk doesn't allow him to sit erect.he sits with lower trunk flexed.he frequenlty falls sideways not backwards as he was very earlier.we r plaaning adductor release as he has groved rapidly has developed significant spasticitiy.should v go for calf release simultaneously?y he couldn't sit from supine.he can lift head very well in supine.but can't extend arm from elbow also both legs goes in air with hip flexion and adduction with knee hyperextended.

Hi Spandanphysio,
As you say child has low trunk tone, I am bit not sure that is it truncal hypotonicity or hypertonicity. What I understand, legs position and arms position you described here are in supine position. if yes, than in my opinion that goes more with trunk hyperactivity. In attached pic also ( I reviewed), child looks more with truncal hypertonicity. With low tone trunk, I feel child cannot keep legs up in air with knees hyperextended and locked, rather legs might be fl. at hip but remain on floor and knees remain flexed and apart. you said before child has difficulty in coming up in kneeling from prone kneeling. It may be because of increased flexed pattern in upper trunk causing difficulty in extending upper trunk to come up to kneeling. His lower trunk remains flexed in sitting for add and fl spasticity in legs. He falls sideways bcz of same spasticity as it is causing narrow base of support. This leads to loose balance as soon as child attempts any hand movement out of base of support. High flexion tone in upper trunk and upper limbs doesn’t allow him to extend arm outside to protect himself.
I usually facilitate sequence in this way in such children: supine lying- side lying- pull up to side sit from side lying using arm on that side for wt bearing , kneeling from side sitting by bearing weight on both arms in front on support at chest level e.g stool/ bench and half kneeling either with trunk leaned forward on support or erect trunk as child can tolerate. Sequence from prone to prone kneeling and kneeling would not suitable with children with flexed pattern.
Make child to sit in stride positions on bench and facilitate balance reactions in sitting on ball.
in Pakistan, mostly these children get hamstrings release, adductor release and gastroecenemius lengthening together. Children with moderate spasticity mostly do well with these surgeries and able to walk with walker indoors under supervision within a year of surgery..

thanx humera for u r kind rply.the chld has improved a lot in siiting.he sits well in stride sitting and cross leg sitting with weight on knees.also can sit independently able to correct in any direction.right now main pblm is flexed upper limbs specially left one which usuually stucks to chest with arm flexed internally rotated ,elbow and wrist flexed.i think he will come from supine to sit wich i s my nearrest goal. also will come prone on hands and also improve in independant sittind once he is able to entend elbow and take wight on it.i neeed u r valuable suggestions for that.

Hi Spandan,
Nice to know that child is doing very well. Children having 3 limbs hypertonicity always give hard time. With these children main problem is trunk hypertonicity. Try to improve functions at shoulder first. Try to take arm in tone inhibiting pattern at shoulder. Scapular mobilization is always helpful to start with to bring shoulder in abd and ext. rot. Take the child in sitting on bench, using the shoulder as KPC in abd and ext rot, encourage the child to touch or pat the objects by actively extending the elbow and wrist as much as he can do it easily. Use weight bearing on hand at sides or at back keeping shoulder in abd, ext rot and extension, elbow straight, and wrist extended. As the tone decreases and arm gets active, encourage the child to do bilateral activity in front rather than emphasizing to do much activity with only affected hand. I usually ask parents to mobilize the scapula, keep arm in TIP and than encourage the child to hold the arm in front with abduction while putting on sleeves during dressing. You can use hand painting using affected hand keeping the worksheet in front on board/ wall so child has to stabilize shoulder in flexion and abduction.
Plz let me know if anything you cant understand because of my writing. These days my centre is closed for winter vacations. But will try to post some pic showing some excs once centre is reopen. Let me know if you want anything in particular.

hi humera the child is improving well as he has gained good balance in siting with rare falls.i want to activate his abdominal oblique muscles and want u r suggestion for that he is not able to shift weight to lower extrimities in standing and kneel standing..i will atach his new pics soon.