386 Rehabilitation Techniques Table R22. Continued PROM: TENODESIS ON STRETCH: WITH FINGERS HELD IN EXTENSION, WHAT IS PASSIVE EXTENSION OF WRIST? R ____ L ____ ABILITY TO FOLLOW DIRECTIONS: (Circle) GOOD FAIR UNABLE COMMUNICATION EFFECTIVENESS: (Circle) CLEAR MILDLY UNCLEAR SPECIAL SYSTEM: __________________________________________________________________________ Comments _________________________________________________________________________________________________________________ STRENGTH OF GRASP and WRIST ANGLE: R ____ # ____ L ____ # ____ TIP PINCH: R ____ # ____ L ____ # ____ LATERAL PINCH: R ____ # ____ L ____ # ____ OPPOSITION: R: THUMB to Index Y/N, to 3 Y/N, to 4 Y/N, to 5 Y/N L: THUMB to Index Y/N, to 3 Y/N, to 4 Y/N, to 5 Y/N GRASP/RELEASE AND TENODESIS INFLUENCE (Indicate R or L): TIP PINCH: R ____ # ____ L ____ # ____ LATERAL PINCH: R ____ # ____ L ____ # ____ OPPOSITION: R: THUMB to Index Y/N, to 3 Y/N, to 4 Y/N, to 5 Y/N L: THUMB to Index Y/N, to 3 Y/N, to 4 Y/N, to 5 Y/N GRASP/RELEASE AND TENODESIS INFLUENCE (Indicate R or L): 0123 0 = UNABLE, NO RELEASE CUBE _____________________________ 1 = RELEASE C WRIST FLEXED >40 DEG PENCIL ___________________________ 2 = RELEASE C WRIST NEUTRAL SPOON/FORK _____________________ 3 = RELEASE C WRIST EXT. >20 DEG CUP _______________________________ CHEERIO PICK UP _________________ Uses mirroring of other hand (Synkinesis) Yes = Abnormal No = Normal CHEERIO TO MOUTH _____________ Y/N UNSCREW A 3″ LID ________________ Y/N JEBSEN HAND TEST (If possible): (Seconds) R ____ L ____ Standard Deviation ____ Comments _________________________________________________________________________________________________________________ Write 30 letter sentence ________________________________________________________________________________________________________ Turn over 5 cards _____________________________________________________________________________________________________________ Pick up 6 small objects _________________________________________________________________________________________________________ Use spoon—5 beans ___________________________________________________________________________________________________________ Stack 4 checkers_______________________________________________________________________________________________________________ Pick up 5 empty cans __________________________________________________________________________________________________________ Pick up 5 1# cans______________________________________________________________________________________________________________ (continued)
Rehabilitation Techniques 387 Table R22. Continued REFLEX OVERFLOW: (Circle) STARTLE - Y/N HOFFMAN’S (finger claw with index flick) - Y/N KLIPPEL+WEIL (quick flexed fingers are extended, thumb flexes and adducts) - Y/N SENSATION SCREEN: STEREOGNOSIS (Distinguish 1″ cube of foam from 1″ block of wood) - R=Y/N L=Y/N SHARP/DULL - R=Y/N L=Y/N 2PT DISCRIMIN (Thumb and index tips 1/4″) - R=Y/N L=Y/N FUNCTIONAL REPORT: (AIDHC) UE Functional Classification for CP (Circle) R/L Type 0 (No function) With dynamic contractures ____ With fixed contractures ____ No contractures ____ R/L Type I (Uses hand as paperweight or swipe only, poor or absent grasp and release, poor control) No contractures ____ With dynamic contractures ____ With fixed contractures ____ R/L Type II (Mass grasp, poor active control) With fixed contractures ____ No contractures ____ With dynamic contractures ____ R/L Type III (Can actively grasp/release slow and place object with some accuracy) No contractures ____ With dynamic contractures ____ With fixed contractures ____ R/L Type IV (Shows some fine pinch such as holding pen, some key pinch with thumb) No contractures ____ With dynamic contractures ____ With fixed contractures ____ R/L Type V (Normal to near normal function; fine opposition of thumb; can do buttons and tie shoes) No contractures ____ With dynamic contractures ____ With fixed contractures ____ PARENTAL REPORT: Limb interferes with dressing self (Circle) R=Y/N L=Y/N SPLINTS: PRIOR to surgery _____________________________________________________________________________________________________________ AFTER surgery _______________________________________________________________________________________________________________ NIGHT RESTING with hand at maximum tenodesis stretch _________________________________________________________________________ WRIST COCK-UP (For protection during ambulation)______________________________________________________________________________ SUPINATION ________________________________________________________________________________________________________________ OTHER _____________________________________________________________________________________________________________________ VIDEO/PHOTO OF HAND GRASPING OBJECT: (Circle) Start position Grasp block Pick up Cheerio Other________________________________________________________________________ TREATMENT RECOMMENDATIONS: _________________________________________________________________________________________ SURGERY EXPECTATIONS: (Review post-surgery home program and show types of splints) Therapist
388 Rehabilitation Techniques Occupational Therapy Treatment Goals Following Surgery Occupational therapy goals are to improve scar formation, avoid swelling, maintain normal position of the wrist, and prevent muscle transfers from be- ing avulsed. Gentle restoration of grasp is also a goal, but does not include resistive strengthening or passive stretching of wrist flexion for several months. Therapy goals are progressive and begin with improving the coor- dination of grasp (mass grasp, and then refined grasp if feasible). Next is coordination of grasp–release accuracy and grasp with supination/pronation. Focus is then directed at improving the tripod pinch accuracy. Finally, iso- lated finger control (if feasible) is improved, using many in-hand manipula- tion activities. Examples are sign language or hand gestures, rotation of two isospheres in the palm, performing peg activities with progressively finer pegs and using resistive tools to strengthen grasp while working with the pegs, and bilateral/bimanual hobbies such as hand sewing, leather lacing, cook- ing, working with dough/clay, and erector set assembly. Generally, use of the new arm and hand positions shows favorable re- sults of improving appearance (cosmesis) and advances one functional type (AIDCH orthopaedic score) or progresses one level of the Green’s scale in about 2 months; results are best at 6 months, and grip strength recovers in about 6 months. Photography: Position with Grasp/Release Effort Photographs obtained before and after surgery will assist documentation to help quantify the outcome. Typically the following activities are photo- graphed if the child can perform them: resting position of the limb (elbow, wrist, and fingers), also called the “attitude” of the limb, best opening of the hand (finger extension and thumb abduction) in combination with the wrist (flexion, ulnar deviation), supination/pronation, elbow flexion/extension, shoulder position (internal or external rotation), and functional grasp and release (thumb/wrist position), which includes the child’s attempts at grasp- ing a pen on table, releasing a 1-inch cube into a coffee can, and lifting and placing a 3-inch can (from the Jebsen test). Some grasp or pen-holding pat- terns have a high risk for developing fatigue or writer’s cramp if these postures are used over long periods of time (Figure R12). Informational/Instructional Handouts for Families and Home Therapist Families require written instructions and instructional handouts can be stan- dardized. Examples include information pertaining to splint care (completed for the family when the splints are made), and postsurgery guidelines for the family and home therapist (Tables R23 and R24). Prediction of Functional Outcomes The more abnormal the reflexes and sensory awareness, the less function even after surgery. A combination of more than one of these systems will de- crease use of the limb. Surgery will improve the position of the limb but not improve the sensory control of the limb. If influence of grasp–release skill is present before surgery, it should be better following surgery performed to improve wrist extension because the fingers and thumb will be in a better
Rehabilitation Techniques 389 A B C D Figure R12. Some grasp patterns that develop have a high risk of leading the writers cramp if the individual does a significant amount of writing. The adducted thumb posture (A) and combinations of digit hyperextension grasps (B–D) are at-risk positions.
390 Rehabilitation Techniques Table R23. Therapy services: splint care. Purpose of Splint: This splint was prescribed by your doctor for: ____ preventing deformity ____ proper positioning to correct deformity ____ increasing range of motion (gentle stretching) ____ permitting exercise of specific muscles ____ stabilizing for better use of involved limb ____ protecting weak muscles, bones and/or joints ____ permitting complete rest or healing of the limb, joints, or muscle transfers ____ preventing the child from removing tubes, bandages, or interfering with healing Wearing Instructions: First, build up the length of time using the splint by wearing it about an hour and then remove it, and examine the skin for red marks. If these marks disappear within one-half hour, then wear the splint for ____ hours. Usage: ____ Night use Build up the length of time wearing the splint by 1 hour until reaching 5 hours; then wear all night. ____ Day use Wear ____ hour(s) on, and ____ hour(s) off Instructions: If there is pain or redness that does not resolve in one hour, contact the therapist. If sweating occurs, try sprinkling powder (without talc), cornstarch, or placing thin absorbent cotton such as a sock or stockinette between the skin and splint. Dampening the splint, shaking baking soda on the splint and rising it off can eliminate odor from body perspiration. Be sure the splint straps are not so tight that circulation is cut off. One way to test this is to pinch the nails of the limb in the splint. The toe or finger should turn white, and then pink. If the toe or finger does NOT become pink again or develops a darker color, Recheck the fit of the splint and loosen the strap slightly. Care of Splint: The materials in the splint are affected by heat, so take care that it is not left near heat producing areas such as the television and radiator, or left in an enclosed car, or on a sunlit windowsill. Store the splint in a safe area away from pets and where dogs cannot get them; dogs will chew them! The splint should be washed in lukewarm water and mild soap or alcohol. Acetone (fingernail polish remover) and other chemicals should not be used near the splint. Follow-Up: Therapists prefer to periodically examine the splint to ensure proper fit if it is used to progressively correct deformity. Please obtain your insurance referral and then call for an appointment if you are not regularly in therapy. Material Used: ________________________________________________________________________________________________________________ ______________________________________________ _______________________ Therapist Constructing Splint Phone Number ______________________________________________ Date Constructed Splint Care Home Program AIDHC/MK, 1989 AIDHC 2001 Home Therapy Program biomechanical position to grasp items on a table. If skill with influence of sensation is diminished, the use of the limb in dynamic, quick situations will be diminished. Automatic or spontaneous use of the limb will also be re- duced. Influence of primitive reflexes will hinder good control or speed of control. These changes may cause a child to avoid the use of the limb.
Rehabilitation Techniques 391 Table R24. CP surgery: FCU to ECRB and other surgeries. Guidelines for Family & Occupational Therapist The main goals of surgery for the arm of a child with cerebral palsy or spasticity of the flexors are: (Check applicable) ____ less skin maceration from tight position (thumb, wrist, elbow creases, even axilla) ____ easier cleaning of these creases ____ a better appearance of the limb at rest ____ a better position of the wrist to permit easier dressing, for care-giver or individual improved ability to see what is in the hand or pinch ____ to improve a cylindrical helping-grasp ____ to improve the grasp-release but not with the expectation of a faster, normal fine ____ pincer grasp or controlled release combined with supination (enhanced dexterity) The most common surgery is the FCU>ECRL/B which is to transfer the muscle that causes the wrist to flex and ulnarly deviate (the flexor carpi ulnaris or FCU) and transfer it to the insertion of the wrist extensor tendon (the extensor carpi radialis longus and brevis also called ECRL+B or extensor digitorum communis EDC). Associated surgeries usually performed at the same time include biceps release or lengthening, thumb abductor augmentation or thumb adductor release, pronator teres release or rerouting. Following the surgery, the arm is casted for 1 month in a position that stretches the muscles out of the deforming posture. This cast position is typically with the elbow held at 60 degrees of flexion, forearm supinated (palm toward face), and wrist extended (hand away from palm) to about 50 degrees. ROM during cast wear should occur to the shoulder and fingers several times daily to prevent stiffness. About 1 month after surgery, the surgical dressing/cast is removed and a wrist cock-up splint for protection during ambulation or at school is made the same day as the cast removal. This splint permits grasp but prevents wrist flexion, protecting the transfer while it heals and is to be worn continuously for a period of one to two months. A night resting splint with the wrist, fingers and thumb in full extension is frequently ordered to stretch the tenodesis so that grasp-release is more effective during the day. A supination splint or elbow extension splint may also be ordered. Home exercises include stretching the joints that were released. Elbow extension, wrist extension and thumb abduction should be done. There should be no active or passive wrist flexion for two months. Early therapy includes gentle scar massage after the scabs are gone, monitoring swelling, monitoring scar maturation (absorbable sutures), and general wound management. Stretching should be done for the thumb into abduction and extension, the wrist into extension only, the forearm into supination and the elbow into extension. These should be done two to three times per day. The wrist splint should be worn continuously and only removed during the day for therapy or for bathing once the patient is transferred into the tub. The splint is worn all night for the next six weeks, and possibly up to six months. If the child is walking, the splint must be worn to protect the wrist from forceful flexion, which could tear the FCU transfer to the ECRB during the two to three month healing period. For the therapist at home or school: There is a need to clarify confusion between typical hand therapy for peripheral injuries versus therapy following hand surgery for CNS involvement and spasticity such as CP. These outcome expectations differ greatly. For children with CP who have muscle transfers to balance the power of wrist flexors, the wrist cock-up splint is not intended to create a thumb post, which could cause rubbing due to spasticity, would not permit passive stretching out of the thumb-in-palm tendencies, would limit the thumb to only a pincer thumb post and would interfere with healing of palmar incisions. Instead the use of the wrist cock-up splint is to afford protection for the tendon transfers during healing by preventing fast forceful wrist flexion. The surgery together with the cock-up splint allows some mass cylindrical grasp and pinch early. If the child has a pincer grasp, it is encouraged. A pincer grasp can be assisted with a soft stretchy neoprene strap attached to the wrist cock-up splint to hold the thumb in the necessary abduction and extension and may be removed when walking, holding crutches, doing thumb stretches, etc. A firm functional thumb-post splint is only provided later if there is functional ability to pinch and use the pinch, and if the child has the ability to follow directions for that pinch. If there is some grasp and release, the family can gather a bowl of 1-inch to 3-inch sized items to pick up and move as part of games (hard, soft, fuzzy, rough, i.e., dice, cans, cubes/blocks, Legos, bristle blocks, etc.). Start with picking up and putting down of items. If successful and not frustrating, have the child pick up and put the items into slots, stack, or place on a target like a checkerboard, Tic-Tac-Toe, etc. If the child has better grasp control, try picking up coins, paperclips, buttons, playing cards, etc. Combining grasp with turning the wrist can be tried next, for example buttoning clothes, wind-up toys etc., but these are not usually possible for children with CP. If there are further questions, please call your therapist at ________________________ . 11. Intrathecal Baclofen Pumps Maura McManus, MD, FAAPMR, FAAP Neurosurgical interventions have been brought into wide use during the past 10 to 15 years. The first is that of dorsal root rhizotomies, which has met with mixed reviews. Recent meta-analysis of affected patients demonstrates that if there is any benefit it is only in a few points of improvement and not dramatic functional improvements. Use of intrathecal baclofen in the pedi- atric patient having CP has yielded as good a reduction in tone as dorsal rhi- zotomy and does not represent an ablative procedure. This is important be- cause, unlike rhizotomies, it is entirely reversible.
Rehabilitation Techniques 391 Table R24. CP surgery: FCU to ECRB and other surgeries. Guidelines for Family & Occupational Therapist The main goals of surgery for the arm of a child with cerebral palsy or spasticity of the flexors are: (Check applicable) ____ less skin maceration from tight position (thumb, wrist, elbow creases, even axilla) ____ easier cleaning of these creases ____ a better appearance of the limb at rest ____ a better position of the wrist to permit easier dressing, for care-giver or individual improved ability to see what is in the hand or pinch ____ to improve a cylindrical helping-grasp ____ to improve the grasp-release but not with the expectation of a faster, normal fine ____ pincer grasp or controlled release combined with supination (enhanced dexterity) The most common surgery is the FCU>ECRL/B which is to transfer the muscle that causes the wrist to flex and ulnarly deviate (the flexor carpi ulnaris or FCU) and transfer it to the insertion of the wrist extensor tendon (the extensor carpi radialis longus and brevis also called ECRL+B or extensor digitorum communis EDC). Associated surgeries usually performed at the same time include biceps release or lengthening, thumb abductor augmentation or thumb adductor release, pronator teres release or rerouting. Following the surgery, the arm is casted for 1 month in a position that stretches the muscles out of the deforming posture. This cast position is typically with the elbow held at 60 degrees of flexion, forearm supinated (palm toward face), and wrist extended (hand away from palm) to about 50 degrees. ROM during cast wear should occur to the shoulder and fingers several times daily to prevent stiffness. About 1 month after surgery, the surgical dressing/cast is removed and a wrist cock-up splint for protection during ambulation or at school is made the same day as the cast removal. This splint permits grasp but prevents wrist flexion, protecting the transfer while it heals and is to be worn continuously for a period of one to two months. A night resting splint with the wrist, fingers and thumb in full extension is frequently ordered to stretch the tenodesis so that grasp-release is more effective during the day. A supination splint or elbow extension splint may also be ordered. Home exercises include stretching the joints that were released. Elbow extension, wrist extension and thumb abduction should be done. There should be no active or passive wrist flexion for two months. Early therapy includes gentle scar massage after the scabs are gone, monitoring swelling, monitoring scar maturation (absorbable sutures), and general wound management. Stretching should be done for the thumb into abduction and extension, the wrist into extension only, the forearm into supination and the elbow into extension. These should be done two to three times per day. The wrist splint should be worn continuously and only removed during the day for therapy or for bathing once the patient is transferred into the tub. The splint is worn all night for the next six weeks, and possibly up to six months. If the child is walking, the splint must be worn to protect the wrist from forceful flexion, which could tear the FCU transfer to the ECRB during the two to three month healing period. For the therapist at home or school: There is a need to clarify confusion between typical hand therapy for peripheral injuries versus therapy following hand surgery for CNS involvement and spasticity such as CP. These outcome expectations differ greatly. For children with CP who have muscle transfers to balance the power of wrist flexors, the wrist cock-up splint is not intended to create a thumb post, which could cause rubbing due to spasticity, would not permit passive stretching out of the thumb-in-palm tendencies, would limit the thumb to only a pincer thumb post and would interfere with healing of palmar incisions. Instead the use of the wrist cock-up splint is to afford protection for the tendon transfers during healing by preventing fast forceful wrist flexion. The surgery together with the cock-up splint allows some mass cylindrical grasp and pinch early. If the child has a pincer grasp, it is encouraged. A pincer grasp can be assisted with a soft stretchy neoprene strap attached to the wrist cock-up splint to hold the thumb in the necessary abduction and extension and may be removed when walking, holding crutches, doing thumb stretches, etc. A firm functional thumb-post splint is only provided later if there is functional ability to pinch and use the pinch, and if the child has the ability to follow directions for that pinch. If there is some grasp and release, the family can gather a bowl of 1-inch to 3-inch sized items to pick up and move as part of games (hard, soft, fuzzy, rough, i.e., dice, cans, cubes/blocks, Legos, bristle blocks, etc.). Start with picking up and putting down of items. If successful and not frustrating, have the child pick up and put the items into slots, stack, or place on a target like a checkerboard, Tic-Tac-Toe, etc. If the child has better grasp control, try picking up coins, paperclips, buttons, playing cards, etc. Combining grasp with turning the wrist can be tried next, for example buttoning clothes, wind-up toys etc., but these are not usually possible for children with CP. If there are further questions, please call your therapist at ________________________ . 11. Intrathecal Baclofen Pumps Maura McManus, MD, FAAPMR, FAAP Neurosurgical interventions have been brought into wide use during the past 10 to 15 years. The first is that of dorsal root rhizotomies, which has met with mixed reviews. Recent meta-analysis of affected patients demonstrates that if there is any benefit it is only in a few points of improvement and not dramatic functional improvements. Use of intrathecal baclofen in the pedi- atric patient having CP has yielded as good a reduction in tone as dorsal rhi- zotomy and does not represent an ablative procedure. This is important be- cause, unlike rhizotomies, it is entirely reversible.
392 Rehabilitation Techniques Table R25. Evaluation sources. Crawford Small Parts from Psychological Corp, 1-800-872-1726 DeMatteo C, Law M, Russell D, Pollock N, Rosenbaum P, Walter S. The reliability and validity of the Quality of Upper Extremity Skills Test (QUEST). Phys Occup Ther Pediatr 1993;13(2):1–18. Bruinink RH. “Bruinink-Oseretsky Test of Motor Proficiency.” Circle Pines MN: American Guidance Service, 1978. Jebsen RH. An objective and standardized test of hand function. Arch Phys Med Rehab 1969; 50:311, 1969. (Unilateral hand dexterity test made from household objects) Mathiowitz V, Rogers SL, Dowe-Keval M, Donohoe L, Rennells C. The Purdue Pegboard: norms for 14- to 19-year olds. Am J Occup Ther 1986;40(3):174–179. Minnesota Rate of Manipulation Test. Published by American Guidance Service, Inc., Publishers Building, Circle Pines, MN 55014 Peabody Developmental Motor Scales (PDMS-2) by M. Rhonda Folio, Rebecca R. Fewell, Austin, TX: Pro-ed. Order Number 9281 from Pro-ed, 8700 Shoal Creek Boulevard, Austin TX, 78757-6897, 1-800-897-3202 Physical Capacities Evaluation of Hand Skill (PCE). In: Bell E, Jurek K, Wilson T. Hand skill: a gauge for treatment. Am J Occup Ther 1976;30(2):80–86. Schmidt R, Toews J. Grip strength as a measured by Jaymar dynamometer. Arch Phys Med Rehab 1970; 51:321. Shriners Hospital, Greenville, SC. “SHUE” Evaluation. Contact the Occupational Therapy Dept. at 864-240-6277. Taylor N, Sand PL, Jebsen RH. Evaluation of hand function in children. Arch Phys Med Rehab Mar 1973;54:129–135 (Jebsen Hand Test: Pediatric Norms). Tiffin J, Asher E. Purdue Pegboard: norms and studies of reliability and validity. J Appl Psychol 1948;32:234. (Purdue Pegboard is available from Lafayette Instrument, 1-800-428-7545.) Spasticity is the most common motor disorder in CP and is seen in ap- proximately two thirds of the population.45,56,84 It is a component of the upper motor neuron syndrome and is described as a velocity-dependent in- crease in resistance to passive stretch associated with increased deep tendon reflexes (DTR). Spasticity is probably due to an imbalance between inhibitory and excitatory impulses that terminate on or near the alpha motor neurons in the spinal cord.56,63,64 In CP, there is believed to be a deficiency of de- scending impulses that typically stimulate the release of the inhibitory neuro- transmitter gamma-aminobutyric acid (GABA). GABA acts presynaptically to inhibit the release of excitatory neurotransmitters such as glutamate and aspartate, resulting in relative excess of excitatory impulses and resultant hypertonia.45,59,64 Although some spasticity may be necessary for function in children with neurologic impairment, it is often a problem that can be difficult to treat. Spasticity may cause pain, limit sleep, lead to joint deformity, and interfere with function. It may also interfere with care including transfers, toileting, bathing, and dressing.59,68,71 Multiple approaches are available for treatment of spasticity in patients with CP. These include physical and occupational therapy for stretching, positioning, and bracing. Oral medications have been used as well as local treatments such as Botox injections and phenol motor point block injec- tions.56,59,68 Orthopaedic surgery may be necessary, and this may include soft-tissue releases and/or osteotomies.84 Neurosurgical procedures such as selective dorsal rhizotomy are also available.44,79 The goals for treatment should be realistic and individualized and they need to be agreed upon by patient, family/caregiver, and medical team. Ideally, a multidisciplinary team should be involved in the decision making. Such a team may include physi-
Rehabilitation Techniques 393 cal and occupational therapists, nurse, physiatrist, neurologist, orthopaedist, neurosurgeon, patient, and family. Several oral medications have been used to reduce tone, including di- azepam, baclofen, dantrolene, tizanidine, and clonidine. Although they can decrease spasticity, their sedating side effects are not well tolerated in children.59,68,90 Baclofen has been noted to be moderately helpful when taken orally for spasticity of spinal origin in adults. It has been relatively unhelpful in treat- ing spasticity of cerebral origin, especially in children with CP. It is lipophilic and crosses the blood–brain barrier poorly. Intrathecal baclofen has been shown to reduce spasticity with fewer side effects.68 Pharmacology of Baclofen Baclofen (lioresal) is an analogue of GABA, which is the main inhibitory neu- rotransmitter in the central nervous system (CNS). Intrathecal baclofen dif- fuses into the superficial layers of the dorsal gray matter of the spinal cord (layers II–III) where GABAB receptors are believed to be located.70,82 These receptors have been noted in the brainstem as well. Muller et al. noted the concentration of baclofen in the cerebrospinal fluid (CSF) is 10 times higher then levels achieved by oral administration.76 Also, there is a concentration gradient from the lumbar to cervical region of 4 to 1.70 History In 1984 Penn and Kroin pioneered the use of intrathecal baclofen for spas- ticity in patients with multiple sclerosis and spinal cord injury.70 Albright et al. did their first study in 1991 and a follow-up study in 1993 noting successful decrease in spasticity in patients with spasticity of cerebral ori- gin.45,46 In 1992 the Federal Drug Administration (FDA) approved the use of intrathecal baclofen in the form of the Medtronic SyncroMed im- plantable infusion system for treatment of spasticity of spinal origin. This same treatment was approved by the FDA for treatment of spasticity of cere- bral origin in adults in 1992, but it was not approved for use in children until 1997.46 Criteria For the success of intrathecal baclofen, careful patient selection is critical. Patients with moderately severe spasticity of spinal and cerebral origin (i.e., CP, traumatic or anoxic brain injury) have been successfully treated with intrathecal baclofen.46,73,88 Patients with dystonia have also responded to this treatment, often at higher doses.47 Patients with athetosis, ataxia, and myoclonus have not noted improvement. Spasticity is considered severe with Ashworth scores of greater than 3.51 Spasticity and dystonia are believed to be problematic when they are generalized and significantly interfere with movement, positioning, or care. Patients may also experience spasticity- related pain during the day and at night, and this sometimes limits sleep. Many patients are at risk of severe joint deformity.84 Other important issues to consider include the following62: the patient must have significant body mass to maintain the pump, the patient and family need to understand and accept the cosmesis of the pump, the entire team must agree upon appropri- ate goals, and the patient and family must be motivated to achieve these goals
394 Rehabilitation Techniques and be committed to the follow-up required to maintain the pump’s function. Ideally, the previous assessments should be made with a multidisciplinary team in a spasticity management clinic where families can have access to adequate information. Gait analysis should be part of the evaluation in am- bulatory patients.74 The following are additional clinical considerations, not contraindica- tions, for intrathecal baclofen pump implantation.62 A trial of oral baclofen is not a prerequisite for patients with spasticity of cerebral origin. Patients who have had a spinal fusion cannot undergo a trial, but this not a contra- indication for pump implantation. A history of seizures is not a contraindi- cation to intrathecal baclofen therapy. The presence of a ventriculoperitoneal (VP) shunt is not a contraindication. Patients with VP shunts may require less baclofen. Prior soft-tissue lengthenings, tendon releases, and selective dorsal rhizotomy are not contraindications. For patients with cervical or trunk weakness, the benefits of baclofen in reducing extremity spasticity must be weighed against the potential for loss of the patient’s function if trunk and cervical tone is reduced. Some patients and families may be reluctant to undergo the destructive invasive procedure. The reversible nature of intra- thecal baclofen may be especially important. Screening Trial and Pump Implantation Once a patient is felt to be a potential candidate, a screening trial is sched- uled. Because of the risk of respiratory depression during the trial, it is prob- ably most appropriately performed in a hospital on a general nursing floor.83 Early on the day of the trial, a baseline physical exam is completed, and a lumbar puncture is performed. The test dose of either 50, 75, or 100 µg is injected into the intrathecal space. If conscious sedation is used, a short- acting sedative such as midazolam may be used in conjunction.65 After the lumbar puncture is performed and intrathecal baclofen is injected, patients should remain flat for at least 1 hour to avoid spinal headache. Spasticity scores/Ashworth or modified Ashworth scores are recorded preinjection and at 2-hour intervals postinjection as patients are followed for 6 to 8 hours. It takes 1 to 2 hours for the baclofen to penetrate the spinal cord to produce clinical effect. Peak effect is believed to be at 4 hours.75 Aside from noting Ashworth scores, it is important to assess patients out of bed in their seat- ing/wheelchair system.52 It is often difficult to obtain a functional assessment during the screening trial. Evaluation of mobility in an ambulator may be challenging as underlying weakness may limit function during the trial. Such a patient may still be a candidate for the pump because a lower dose of intra- thecal baclofen can be programmed through the pump than can be achieved during the trial.58 Although bolus injections are preferred for screening trial, continuous infusion trials using an externally placed catheter can be per- formed; this is important in patients in whom dystonia is being evaluated.47,53 If the patient had a clinically significant response to intrathecal baclofen (i.e., Ashworth or modified Ashworth scores decreasing by 1 or more), the pump implantation is scheduled. The intrathecal baclofen delivery system consists of a programmable sub- cutaneously implanted pump with a reservoir attached to an intraspinal catheter (Medtronics, Inc., Minnapolis, MN). The adult-sized pump with an 18-ml reservoir is 7.5 cm by 2.8 cm (similar to the size of a hockey puck). A pediatric-sized pump with a 10-ml reservoir is available. It is one third thin- ner, but has the same diameter as the adult-sized pump.62 Because they are close in size, it might be difficult to justify using the pediatric-sized pump, which will need to be refilled much more frequently.
Rehabilitation Techniques 395 Figure R13. Baclofen pumps may be very prominent in thin children. Implanting the pump under the fascia makes it less prom- inent, and it is very important to implant the pump so the scar is not overlying the im- plant, as this has a higher risk of breaking down than normal skin The pump is inserted under general anesthesia into a lateral abdominal subcutaneous location or under the external oblique and rectus fascia (Fig- ure R13). A catheter is tunneled subcutaneously and connected to an intra- thecal catheter. The catheter enters the subarachnoid space of the spinal canal at the lumbar spinal level.46,62 The catheter can be placed at various heights depending on whether upper extremity relaxation is also a goal. To increase the effect of intrathecal baclofen on the upper extremities, the catheter can be placed at midthoracic level (T6–T7) rather than T11–T12.60 The mean dosing may also be lower. The pump is programmed to deliver a continuous infusion, which assists with diffusion of baclofen into the spinal cord. Postoperatively the patient remains supine for 48 hours to limit spinal leak and headache. For nonambulators, postoperative dose adjustments can be made daily even during bed rest. For ambulators, it may be necessary to wait until they are cleared to be out of bed to ambulate before adjusting the dose.60,65 Adjustments should be made once daily while in the hospital post- operatively. The first follow-up visit should be at 7 to 10 days and then monthly for the first 6 months. It may take 6 to 9 months to gradually titrate the dose to the desired clinical response. In some cases, the dose may need adjustment for the first 2 years after implantation.46,73 Typically, the dose of intrathecal baclofen is not related to age or weight. As noted above, pa- tients with VP shunt may require a lower dose. The pump reservoir is refilled by percutaneous puncture through a sep- tum in the pump at intervals of 1 to 3 months. Dosage adjustments are made via an external computer/programmer and transmitted to the pump by a hand- held radiofrequency wand. The pump can be programmed to deliver the baclofen in several modes including simple continuous infusion, complex continuous infusion (i.e., rate changes at set times during the day), and bolus infusion mode.62 Complications Complications seen with the intrathecal baclofen infusion system may be related to the medication, the pump, the catheter, or the surgical procedure.
396 Rehabilitation Techniques Complications related to the medication may be seen during the trial, im- mediately postoperatively, or during maintenance therapy especially at the time of dose adjustments. Common adverse affects of the medication include somnolence, headache, nausea, vomiting, hypotonia, dizziness, and increased constipation. Transient urinary retention/hesitation has been noted after dose adjustment, and this appears to respond to decreasing the dose.66,77 The most serious side effects of medication overdose include respiratory de- pression and loss of consciousness progressing to coma. There is no specific antidote for treating overdose, but reports suggest that intravenous (IV) physostigmine may reverse the central effects, most notably drowsiness and respiratory depression.76 Pediatric dosage of physostigmine is 0.02 mg/kg IV, with no more than 0.5 mg/min. This dose may be repeated at 5- to 10-minute intervals if necessary, with a maximum dose of 2 mg.62 Complications of intrathecal baclofen withdrawal have been well docu- mented in the literature; they include rapid increase in spasticity, irritability, hallucinations, seizures, and pruritus without rash. Muscle rigidity, rhab- domyolysis, multiorgan system failure, and death have been reported but are quite rare.87 Other complications are more easily divided into immediate postopera- tive and late complications. Immediate postoperative complications include infection at pump or catheter site, meningitis, wound dehiscence, seroma, or cerebrospinal fluid (CSF) leak.46,72,73 Infections have lead to pump removal, but the overall number of postoperative infections has decreased with use of prophylactic antibiotics. CSF leak may be suspected if postoperative spinal headache persists. Fluid collection and/or leakage at the catheter site in the lumbar region may also present as a CSF leak. Such a leak usually seals off within 1 to 2 days but may take as long as 2 to 3 weeks. If the spinal leak persists, a blood patch may be considered.65 Late complications can involve pump and catheter problems and skin breakdown, as well as human error. Skin breakdown over the pump site has been seen under braces or seatbelts. Close monitoring of pump site and ad- justments to wheelchairs and braces can limit this problem. Human error can lead to programming errors, improper filling of the reservoir, and errors in dosing concentration. The highest probability of seeing these problems is within 48 hours after refill.83 Pump problems may include positional and mechanical problems. Pumps have been reported to flip over, especially in obese patients, and more secure suturing may limit this. Mechanical problems include battery failure and rotor lock problems. Low battery level can be detected by interrogating the pump. Current batteries, placed since 1999, have a longer lifespan of 7 years, rather than 4 years as observed in the original pumps. With a low reservoir volume, less than 2 ml, the pump will slow the rate automatically, and this can lead to an underinfusion of programmed dose. If a rotor lock problem develops, this may also present with the patient receiving less medication than was programmed. This can be evaluated by obtaining an X-ray of the pump to identify the roller and repeat X-ray in 24 hours should reveal roller- changing position.62 Catheter problems can include a kink, fracture, blockage, migration, and disconnection. Patients can present with signs of limited clinical response or even clinical withdrawal. After interrogating the pump, a radiologic exami- nation with anteroposterior and lateral views of the pump and catheter sys- tem should be obtained. If an X-ray provides minimal information, a check of the catheter patency to the site of delivery with either contrast media or radiolabeled indium is indicated.62 Follow-up X-rays are reviewed after radio-
Rehabilitation Techniques 397 paque solution is injected. After radiolabeled indium is used, serial nuclear medicine scans over 12 to 24 hours are reviewed.85 After the cause of intra- thecal baclofen interruption is determined, either surgical repair, revision, or replacement of system components is carried out. Catheter problems over- all have been reduced since catheters have been made more flexible and since the one-catheter system has replaced the two-catheter system. Outcomes The benefits of intrathecal baclofen have been published in the spinal cord injury literature and more recently in the CP literature.46,49,50,81 Functional improvements and improved quality of life have been reported in the treat- ment of both spasticity and dystonia. These benefits include increased com- fort and ease of positioning, with increased seating tolerance and decreased caregiver burden; this has been reported in areas of bathing, toileting, and dressing. Decreased pain and improved sleep have also been noted.46,50,52 Many families have reported increased smiling, engaging, and socializing at home and at school. Functional improvement has been noted in upper ex- tremities as well as lower extremities.48 Although the benefits of intrathecal baclofen in the spastic quadriplegic population are well documented, the role of intrathecal baclofen in ambula- tory patients is not as clear.50,72,73 One study by Albright et al. investigated functional improvement in ambulators, marginal ambulators, and non- ambulators. Of 24 patients, clinicians noted functional improvement in 9, no change in 12, and worsening function in 3. Subjectively, 20 of 24 of these families felt gait had improved.58 This is a promising study even without for- mal gait analysis. Pre- and postintrathecal baclofen gait analysis will likely add significant information.74 Intrathecal baclofen treatment in CP may re- duce the need for subsequent orthopaedic surgery related to spasticity and may decrease the need for multiple orthopaedic procedures.57 Some challenges to outcome include the fact that there is more effect from intrathecal baclofen on lower extremities then upper extremities. If patients and families feel strongly about optimizing upper extremity function, they need to be aware that standing, transfers, and ambulation may be lost. One great advantage of intrathecal baclofen compared to selective dorsal rhizotomy is that the dose of intrathecal baclofen can be titrated to carefully reduce tone while not completely eliminating it.48 This has been demonstrated to be very helpful in children who have significant spasticity with lower ex- tremity weakness who inherently use some of the spasticity in their lower extremities to ambulate. Another advantage is if patients and families are not completely satisfied with the intrathecal baclofen therapy, the system may be removed. Summary Intrathecal baclofen treatment has been shown to successfully decrease gen- eralized spasticity in patients with CP. The benefits in spastic quadraplegic patients have been demonstrated. While there does seem to be a functional benefit in ambulatory patients, the role of intrathecal baclofen in this group is not as clear. This continues to need further study, particularly with gait analysis. Success of the intrathecal baclofen therapy does seem to be related to appropriate patient selection, setting of achievable goals, patient and family motivation and compliance, and dedicated multidisciplinary team.
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Index A occupational therapy clinic evaluation custom-molded, 146, 147–149f Abduction wedges, for wheelchairs, worksheet, 385–387f flexible leaf-spring, as hemiplegic 173–174, 174f Alcohol injections, as spasticity gait pattern type 1 treatment, Ablative surgery, as athetosis treatment, treatment, 74, 78 300 ground reaction (GRAFO), 138, 89 Alcohol use, as neurologic defect cause, 38 149–150, 150f Accidents, as cerebral palsy cause, 11 Alpers syndrome, 37t articulated, 150, 151f Achilles’ tendon Alpha-2-adrenergic receptor blockers, 66 half-height, 151 Alternative medicine, 16, 132–133 hinged, 146, 149 incompetent, as ankle dorsiflexion Amblyopia (“lazy eye”), 30–31 contraindications to, 148–149 contracture cause, 277–278 molded (MAFO), 138 eye patch treatment of, 114 motor control effects of, 79 Achilles’ tendon lengthening Amino acid metabolism disorders, 35t with plantar flexion-limiting ankle as ankle dorsiflexion treatment, 315 Ankle hinge, 150f as hemiplegic gait type 2 treatment, for preambulatory children, 148, 301 in gait abnormalities, 275–278 150f in normal gait, 249–251, 250f for quadriplegic patients, 327 Acidosis, lactic, 37t solid, 146, 149 Aciduria power output function of, 275–276, modifications of, 154f 276f terminology related to, 146 argininosuccinic, 36t twister cable use with, 144 glutaric, 35t “shock absorber” function of, 275, as unstable foot treatment, 267 276f wraparound, 151–152 type 1, 38 Ankle jerk reflex, 60 4-hydroxybutyric, 36t plantar flexion prepositioning of, Ankle orthoses. See also Ankle-foot Activities of daily living (ADLs) 276 orthoses (AFOs) effect of spasticity on, 64 as ankle plantar flexion prepositioning functional, evaluation of, 380 Ankle dorsiflexion treatment, 276 Acupressure, 131 in diplegia, 315 for hypotonia management, 83 Acupuncture, 131 in normal gait, 250 as spasticity treatment, 79 Adaptive devices. See also Assistive during swing phase, 277–278 Ankle procedures. See Foot and ankle as balance deficit cause, 95 procedures devices contractures associated with, 278f Ankle reflex, 62 definition of, 125 treatment of Ankle restraints, lateral, 327 prescriptions for, 126 with gastrocnemius neurectomy, 74 Anticholinergic drugs, as dystonia ADELI suit, 132 with orthopedic shoes, 138 treatment, 85 Adolescent growth spurt with orthotics, 138, 146, 278 Anti-inflammatory drugs. See also balance development during, 93 Nonsteroidal anti-inflammatory Adolescents Ankle-foot orthoses (AFO), 138, drugs back-kneeing in, 326 146–153, 147–148f, 149f, 150f, Antispasticity medications. See also crouched gait in, 318–327 151f, 154f specific antispasticity medications intrathecal administration of, 66–70, treatment of, 319–326 as ankle dorsiflexion treatment, 278 67f, 69f foot deformities in, 268, 269–270f treatment of oral administration of, 65–66, 65t occupational therapy for, 121 as ankle plantar flexion prepositioning physical therapy for, 118 quadriplegic ambulation in, 328–329 treatment, 276 Adrenoleukodystrophy, 37t anterior ankle strap, 152–153, 154f X-linked, 37t articulated A.I. du Pont Hospital for Children ground reaction, 150, 151f (AIDHC) as hemiplegic gait pattern type 2 Clinic Scale, 374, 375t treatment, 301 comparison with tone-reducing casts, 114
404 Index Aquatic therapy, 351–356, 353f. See also B Beta-galactosidase deficiency, 34t Hydrotherapy; Swimming Babinski’s pronation sign, 379t Bidabe, Linda, 369 Back-kneeing “Birthday syndrome,” 22–23, Bad Ragaz Ring Method of, 355–356 contraindications to, 354t, 355 in adolescents or young adults, 326 298–299 Halliwick Method of, 355 diplegia-related, 312f, 317–318 Bladder dysfunction multidisciplinary approach in, 356, 358 in midstance phase, 279, 281 pool design/accessibility in, 356, 356t, Back pain. See also Low back pain dorsal rhizotomy-related, 72 Baclofen Blindness, as posterior walker contra 357f contraindication as athetosis precautions in, 354t indication, 191 Watsu, 355 treatment, 89 Blix Curve (muscle length-tension Arginase deficiency, 36t intrathecal pump administration of, Arthritis. See also Rheumatoid arthritis relationship), 213–215, 215f Arthrogryposis patients, power 66–70, 67f, 69f, 391–397 Blood loss. See also Hemorrhage after dorsal rhizotomy, 73 Blood pressure. See also Hypertension; wheelchairs for, 166 baclofen overdose in, 396 Ashworth Scale, 60–61, 61f, 61t complications of, 68–69, 70, 395–397 Hypotension criteria for, 393–394 Bobath, Berta, 345, 356 comparison with Barry Albright versus dorsal rhizotomy, 391, 397 Bobath, Karl, 345, 356 Dystonia scale, 85 as dystonia treatment, 85, 87, 88 Bobath technique. See as hemiplegia type 4-related in gait analysis, 231, 231t Neurodevelopmental Therapy in hypotonia measurement, 82 spasticity treatment, 308 (NDT) in occupational therapy evaluations, outcomes in, 397 Bones pump and catheter malfunction in, effect of hypotonia on, 82 378, 379 effect of spasticity on, 64 in upper-extremity evaluations, 344 98–99f, 396–397 Botox. See Botulinum toxin injections Aspartylglycoaminuria, 35t pump implantation procedure in, Botulinum toxin injections Asphyxia, near, 38 as dystonia treatment, 85–86, 88 Assistive devices, 358–361. See also 394–395, 395f as hemiplegic gait pattern type 2 screening trial in, 394 treatment, 301 Durable medical equipment as spasticity treatment, 81 as quadriplegic gait treatment, Asymmetric tonic neck reflex (ATNR), oral administration of, 65–66, 65t, 68, 327–328 as spasticity treatment, 74, 76–78, 76f, 41, 42, 42f, 44, 378 70, 393 77f, 80–81, 392 Ataxia, 93–95 pharmacology of, 393 Bowel dysfunction, dorsal rhizotomy- as spasticity treatment, 65–66, 65t related, 72 closed head injury-related, 33 Bad Ragaz Ring Method, of aquatic Bracing, 138 definition of, 46, 93 of trunk, weaning from, 353 hypotonia associated with, 93 therapy, 355–356 Brain inappropriate synaptic remodeling- Balance central program generator (CPG) of, 56, 59, 262–263 related, 31 assessment of, 94 embryonic development of, 29f, primary, 94 definition of, 46 53 spasticity associated with, 93 development of, 93, 261, 348 defects in, as cerebral palsy cause, treatment of, 94–95 Balance deficits, 46, 46f, 93–96 28, 30–31, 30f ankle-foot orthoses-based role in motor control, 52, 53f orthoses, 96 synapse formation and remodeling in, physical therapy, 94–95 improvement of, 146 30–31 surgical, 95 as gait abnormalities cause, 260–261 Brain imaging studies, for cerebral palsy Athetosis, 88–92 Balance exercises, 95 diagnosis, 47, 48f definition of, 45, 88 Balance interventions, 348–349 Brain injury development of, 262 Ballismus developmental aspects of, 41 differentiated from dystonia, 89 definition of, 45, 92 Bronchospasms, dorsal rhizotomy- dystonia associated with, 262 treatment of, 92, 93 related, 72 gait abnormalities associated with, Barry Albright Dystonia (BAD) scale, 85 Bruininks-Osterestky Test of Motor Basal ganglia, role in motor control, 52, Proficiency, 349 262, 263, 329–330 Bunions, 64 physical therapy for, 91–92, 93 53f Buoyancy, 352–353 powered wheelchair use in, 161 Basal ganglion lesioning, as dystonia prevalence of, 39 C sensory motor effects associated with, treatment, 85 Calorimetry, indirect, 238 Basal ganglion lesions, athetosis-related, Canes, 193–195, 196f, 360–361 88–89 Ativan. See Lorazepam 88 contraindication in ataxia, 95 Augmentative communication, 122, 197 Bath chairs, 187, 189f Cannabis, as spasticity treatment, 66 Augmentative communication devices, on Batten disease, 35t Bean bags, as positioning devices, 188 wheelchairs, 178 Bechterew’s sign, 379t Augmentative communication Benzedrine. See Amphetamine Benzodiazepines evaluations, 108 Autism, 31 as dystonia treatment, 85 Ayers technique, 111
Index 405 Capsulotomy evolutionary pathology of, 41–43f, of fascia latae, 286 knee posterior 41–44 of fingers, 345f orthoses use following, 145–146 forearm pronation, 139 misdiagnosis of, 27 of gastrocnemius Carbamazepine prevalence of, 39 as dystonia treatment, 85 prognosis of, 11 effect on gait, 275, 276 terminology of, 39–40 of hamstrings Carboxylase deficiency, 36t treatment goals in, 22–25 Cardiovascular conditioning, 264 Cerebral palsy clinics, 6 in athetosis patients, 89 Care-providing community, 5–6 Cerebrospinal fluid leaks hemiplegia gait type 3-related, Carnitine deficiency, 37t intrathecal baclofen-related, 69, 396 Car seats, 184, 185f Cervical instability, 34t 303–306, 304, 304f Casts Chaddock’s wrist sign, 379t as kyphosis cause, 183, 183f Chaos theory, 57–58, 57f nighttime splinting treatment of, 146 inhibition, 24 Chaotic attractors, 57–58, 57f as quadriplegic gait cause, 328–329 tone-reducing, 79, 114 in early childhood physical therapy, wheelchair seating management of, Cats synaptic formation experiment in, 30 117 184 as Toxoplasma gondii host, 38 Cherry red spot myoclonus syndrome, of hip abductors, 288 Central nervous system. See also Brain development of, 53 34t abduction bracing-related, 144 role in motor function control, 52, 53f Child abuse and neglect external rotation, 139 of hip adductors, 287 feedback control mechanism in, as brain injury cause, 32–33, 33f hip flexion, 285 54–155, 55f Chlorazepate, as spasticity treatment, 65t diplegia-related, 316 Chorea hip internal rotation-related, 144–145, feed-forward control mechanism in, 54–155, 55f definition of, 45, 92 289–290, 291, 291f treatment of, 92, 93 of knee, 64 open-loop control mechanism in, 55 Choriomeningitis, lymphocytic, 38 knee extension, 64 Central nervous system surgery Circumferential wraps, as forearm knee flexion as athetosis treatment, 89 pronation deformity treatment, in athetosis patients, 89, 90 as dystonia treatment, 85 139, 140f hemiplegia gait type 3-associated, Central program generator (CPG), 56, Citrullinemia, 36t Clasp-knife stiffness, 47 303 59, 262–263 Clonazepam knee-ankle-foot orthoses treatment Ceramide trihexoside deficiency, 34t as spasticity treatment, 65t Cerebellum, role in motor function Clonidine, as spasticity treatment, 65t, of, 145–146, 145f 66, 393 wheelchair seating management of, control, 52, 53f Clostridium botulinum, 76 Cerebral cortex, gyri formation in, 30, 30f Clubfoot deformities. See also Equinus 184 Cerebral cortex, role in motor function Cognitive integration, evaluation of, 378 of rectus muscles, 286 Cognitive skills, relationship with motor of shoulder, 64 control, 52, 53f function, 51 of soleus muscle Cerebral hemispheres, embryonic Computed tomography (CT) for cerebral palsy diagnosis, 48f effect on gait, 275, 276 development of, 29f in gait impairment diagnosis, 241–242 upper-extremity “Cerebral palsies,” 27 Conductive education, 113 Cerebral Palsies, The (Miller and Congenital cerebellar malformations, as splinting of, 372–374 ataxia cause, 93 of wrist, 64 Clarke), 28 Congenital developmental deformities, as wrist flexion, 138 Cerebral palsy. See also Diplegia; cerebral palsy cause, 28–31, 29f, 30f orthoses treatment of, 138–140 Hemiplegia; Quadriplegia Congenital limb deficiency patients, Copper metabolism disorders, 37t classification of, 39–40 power wheelchairs for, 166 Cornelia-DeLang syndrome, 371 Connective tissue laxity, Down Coronal plane deformity, of the hip, by anatomic pattern, 39, 40–41 syndrome-related, 82 definition of, 3, 27 Contractures, 63 287–289 diagnosis of, 47 in athetosis patients, 89 Craniosacral therapy, 132–133 closed head injury-related, 33 Crawford Small Parts, 380 “blame” for, 8, 9, 11 of elbow, 64 Crouched gait delayed, 9, 11 splinting of, 373t failure to provide parents with, elbow flexion during adolescence and young orthoses treatment of, 138 adulthood, 318–327 11–12 equinus-related, 278f physician-parent communication treatment of, 319–326 definition of, 318–319 regarding, 11–12 diplegia-related, 316–317 as dual diagnosis, 27–28 foot deformity-related, 265 epidemiology of, 39 foot moment arm in, 273–274 etiology of, 27, 28–38 as hinged ankle-foot orthoses congenital etiologies, 28–31, 29f, contraindication, 148–149 30f during middle childhood, 316–317 midstance knee extension in, 279, neonatal etiologies, 31–32, 32f postnatal etiologies, 32–38, 33f, 280–281, 280–281f 34–37t
406 Index Crouched gait (continued) Down syndrome, 31 Ectoderm, 29f muscle-strengthening exercise connective tissue laxity associated Education, of children with disabilities, treatment of, 114 with, 82 hypotonia associated with, 82 124–125 Crutches, 191, 193–195, 196f, 360–361 sensory integration treatment in, 111 least restrictive environment in, 127 for ataxia patients, 95 Educational system, as care support Drooling, athetosis-related, 89 Crutch holders, on wheelchairs, 178 Duchenne’s muscular dystrophy, 27–28 provider, 5, 5f, 6 Cutaneous reflexes, 41 Durable medical equipment. See also Education for All Handicapped Children Cyclobenzapine, as spasticity treatment, Orthotics; Wheelchairs Act, 124 65t definition of, 137 Elastic wraps, 145 Cyproheptadine, as spasticity treatment, floor positioning devices, 188–191, Elbow 66 190f splinting of, 373–374, 373f Cystathionine beta-synthase deficiency, parapodiums, 189, 191 Elbow contractures, 64 prone standers, 189, 359, 359f 36t standers, 188–189, 190f flexion contractures, 371 Cysts, porencephalic, 32 supine standers, 83, 189, 190f orthoses treatment of, 138, 139 Cytomegalovirus infections, 38 lifts, 196–197 prescriptions for, 137 splinting of, 373t D tax deductions for, 197 Elbow orthoses, 139, 140f Dance, as therapy, 131 walking aids, 191–195 Electrical stimulation therapy, 113–114, Dantrolene, as spasticity treatment, 65t, for ataxia patients, 95 canes, 195, 360–361 349–350 75–76, 393 for crouched gait patients, 319, for athetosis, 89 Darvaset, 88 neuromuscular electrical stimulation Data reduction algorithms, in kinematic 320–322, 320–322f crutches, 191, 193–195, 196f, (NES), 113, 349–350 evaluations, 233–235, 234f as spasticity treatment, 73–74 Denervation, therapeutic. See also 360–361 transcutaneous electrical nerve gait trainers, 193, 194–195f, 196f, Neurectomy stimulation (TENS), 113–114, botulinum toxin-related, 77 360 349 as dystonia treatment, 75, 75f walkers, 191–192, 191f, 192f, 193f Electromyography (EMG) Development, normal, deviation from, Dynamic Systems Theory, 56–58, 57f, in gait analysis, 237, 238t for spasticity evaluation, 61 44–47, 45t, 46f 59, 345 Emula cream, 77 Developmental milestones, 44, 45t applied to early childhood physical Encephalocele, anterior or posterior, 28 Encephalomalacia, multicystic, 32 abnormalities in, 44, 45t, 47 therapy, 117 Encephalopathy Dexedrine. See D-Amphetamine in Neurodevelopmental Therapy, 345 hypoxic-ischemic, 31–32 Diapers, 197 Dynamometers, 380 metabolic, 32, 33 Dystonia, 83–88 Endoderm, 29f as athetosis treatment, 89 athetosis-related, 262 Enforced-use therapy, 114–115 as spasticity treatment, 65–66, 65t, 81, closed head injury-related, 33 Equilibrium reactions, 46f definition of, 45, 83–84 Equinovarus 393 differentiated from foot orthoses treatment of, 153 Diphenhydramine, as dystonia treatment, hemiplegic gait-related, 302–303 athetosis, 89 Equinus 85 spasticity, 45, 60, 84–85 contractures associated with Diplegia, 344 etiology of, 32 shortened gastrocsoleus associated as foot deformity cause, 86–87 with, 278f definition of, 40 gait disorders associated with, 330 hemiplegic gait-related, 301–302 diagnosis of, 27–28 generalized, 83–84, 85, 87–88 treatment of, as external foot rotation Duchenne’s muscular dystrophy- localized, 83–84, 85, 88 cause, 274, 274f secondary effects of, 84–85 Erectile dysfunction, baclofen-related, 70 related, 27–28 spasticity associated with, 84 Euler angles, 233–234, 234f gait abnormalities associated with, treatment of, 85–88 Excitogenic injury, as synaptic with botulinum toxin injections, remodeling cause, 31 308, 310–327 Eye, neurologic development of, 109 crouched gait, 316–327 85–86, 88 knee recurvatum, 317–318 with upper-extremity surgical F during middle childhood, 316–318 Fabry’s disease, 34t toe walking, 308, 310–316, 313f, denervation, 75, 75f Falls volitionally-controlled, 84 314f in ataxia patients, 95, 96 hemiplegia associated with, 40 E protective response to, 94–95, 260 prevalence of, 39 Early childhood Family, of cerebral palsy patients. See Disability, definition and classification of, occupational therapy during, 121 Parents, of cerebral palsy patients 39, 40, 40t physical therapy during, 116–117 Diseases of the Nervous System in Childhood (Aicardi), 33 Doman-Delacato technique, 112 Dopamine receptor-blocking drugs, as dystonia treatment, 85 Double bump pelvic motion, 296, 297
Index 407 Fascia latae prescriptions for, 201–203f normal, 244–259 contractures of, 286 supramalleolar, 154, 156f ankle in, 249–251, 250f Foot placement response, 42–43, 43f cycle functions in, 258–259 Fazano technique, of laminectomy, 71, Foot progression angle foot segment in, 251 71f malrotation of, 267–274 gait cycle of, 244–245, 246–247f Foot surgery. See Foot and ankle HAT body segments in, 246–249, Feeding. See also Nutrition 248f, 249f, 251, 258, 259 Feeding clinics, occupational therapists’ procedures hip in, 252, 255f, 257, 258–259 Foot varus, 265 joint functions in, 256–257 role in, 122 Force plate, 235–236, 235f, 238 knee in, 251–252, 252f, 253f, 257, Feeding seats, 186, 186f Forearm 258–259 Feldenkrais, Moshi, 133 locomotor body segments in, 246, Feldenkrais therapy, 132, 133 pronation contractures of, 139 247–248 Femoral anterersion, 64. See also Coxa Fragile X syndrome, 31 pelvis in, 254–256, 257, 257f Fucosidosis, 35t stance phase of, 245–246, 247f vara Functional ability, scoring scales of, swing phase of, 246, 247f torsional malalignment associated 374–376, 375t, 376t Gait abnormalities with, 267 Functional electrical stimulation (FES), ankle in, 275–278 Femoral rotation, with hip extension, ataxia-related, 95 113 athetosis-related, 262, 263, 329–330 measurement of, 267 Functional mobility, M.O.V.E.(TM) balance deficiencies-related, 260–261 Femur complications of treatment of, 330–334 (Mobility Opportunities Via gait analysis-related, 331 internal torsion of. See Femoral Education) curriculum in, multiple procedures-related, 76–333 anteversion 368–371, 370f rehabilitation-related, 333 contraindications to, 369 surgery planning-related, 331–332 torsional malalignment of, 64 Fuzzy logic, 56 surgical execution-related, 333 Fingers. See also Thumb diplegia-related, 308, 310–327 G crouched gait, 316–317 deformities of, surgical treatment of, Gait, 207–342 knee recurvatum, 317–318 373t during middle childhood, 316–318 basic science of, 207–208 toe walking, 308, 310–316, 313f, tight flexion of, 371 biomechanics of, 208–209, 209f 314f Flexor carpi ulnaris transfer, to extensor bone mechanics of, 222 foot in, 265–274 feedback control of, 46f hemiplegia-related, 299–308 carpi radialis brevis (Green feed-forward control of, 46f tendon lengthening treatment of, transfer), 371–372, 384 global body mechanics of, 225–241 301–303 Floor positioning devices, 188–191. See type 1 gait pattern, 300, 300f also Standers balance subsystem, 226 type 2 gait pattern, 301 Folate acid, as neural tube defect cognitive subsystem, 225–226 type 3 gait pattern, 303–306, 304, prophylaxis, 28 energy production, 226–227 304f Folate metabolism defect, 36t motor control, 227 type gait pattern 4, 306–307 Foot. See also Ankle; Forefoot; Hindfoot; structural stability, 227–228 knee in, 278–285, 294t, 306 Midfoot; Toe deformities joint mechanics of, 222–225 as stiff gait, 282–284, 306 deformities of, 64 joint motor mechanics, 223–224, motor control deficiencies-related, dystonic, 86–87, 88 261–263 secondary adaptations to, 265 223f motor power deficiencies-related, wheelchair seating management of, in multiple-joint muscles, 224–225 263–264 184 in single-joint muscles, 224 movement-disordered gait, 329–330, effect of torsional malalignment on, muscle anatomy of, 213, 214f 330 267, 270, 271–273, 271–273f muscle length-tension relationship neurologic basis of, 45 external rotation of, planovalgus quadriplegia-related, 327–329 deformity-associated, 270, 273 (Blix Curve) in, 213–215, 215f spasticity-related, 64, 81 in gait abnormalities, 265–274, muscle mechanics of, 210–213 treatment of 275–278, 294f algorithm for, 335–338t moment arm at, 267 alterations in, 215–222 “birthday syndrome” approach in, in crouched gait, 273–274 connective tissue mechanics, 298–299 effect of torsional malalignment on, energy use measurement evaluation 267, 270, 271–273, 271–273f 219–220, 220f of, 334 in knee flexion, 278–279 energy production, 210–212, 210f, monitoring the outcome of, 333–334 in normal gait as moment arm for ground reaction 211f force, 267, 270 force production, 212, 212f primary function of, 265 increasing excursion, 218–219 as stable, stiff segment, 265 muscle control alterations, 215–216 unstable, 265 muscle excursion, 217–218 treatment of, 267 muscle fiber types in, 213 Foot orthoses, 153–156, 155–157f muscle force-generating capacity, for hypotonic management, 83 intramalleolar, 154, 156f 216–217 muscle-tendon unit growth, 220–222
408 Index Gait analysis as premature gastrocnemius Hand grasp/release, photographic applications of, 243–244 contraction treatment, 275, 276 evaluation of, 388 in ataxia, 94 complications of, 331 Gastrostomy tube feedings, Hand grip reflex, 41f electromyography in, 237, 238t thoracolumbar sacral orthosis use Handicaps, definition and classification gait impairment diagnosis in, 241–243 and, 142–143 kinematic evaluations in, 232–235 of, 39, 40, 40t accuracy of, 235 Gaucher’s disease, 34t Hand orthoses, 139 data reduction algorithms in, Gillette Functional Assessment 233–235, 234f resting splints, 140–141, 141f optical measurements in, 232–233, Questionnaire, 334 swan neck splints, 141–142, 142f 233f Global Motor Function Measure thumb splints, 141, 142f kinetic evaluations in, 235–237, 235f, HAT body segments 236f (GMFM), 230t definition of, 246–247 measurement techniques in, 228 Glycine, as spasticity treatment, 66 in hip lurch, 297, 297f oxygen consumption measurement in, Glycoprotein metabolism deficiency, 34t in normal gait, 248–249, 248f, 249f, 238–241, 240f GM1 gangliosidosis, 34t patient history in, 228, 229t, 242 Gordon’s finger sign, 379t 251, 254, 255, 257, 258, 259, pedobarograph use in, 238, 239f Grasp reflexes, 41, 41f. See also Hand 298, 298f physical examination in, 228–231, 241 Head trauma. See also Brain injury global function measures in, grasp; Toe grasp reflex; Toe grip ataxia-related, 95 228–229, 230t Green’s Scale, 374 as cerebral palsy cause, 32–33, 33f motor control assessment in, 229, Green transfer, 371–372, 384 Heel whip, 291 230t Grood-Suntay technique, of kinematic Hemiplegia muscle strength assessment in, 231 definition of, 40, 299 muscle tone assessment in, 231, 231t evaluation, 234 diplegia associated with, 40 passive range-of-motion assessment Gross Motor Function Measure double, 40 in, 231 enforced-use therapy for, 114–115 videotaping in, 232, 232f, 242 (GMFM), 94, 229, 334, 348, 349 gait abnormalities associated with Ground reaction force tendon lengthening treatment of, Gait Analysis, Normal and Pathological 301–303 Function (Perry), 244 foot as moment arm for, 267, 270 in type 1 hemiplegia, 300, 300f, 311f measurement of, 235–236, 235f, 236f in type 2 hemiplegia, 301, 311f Gait analysis laboratories, as physical Guardianship, 127–129 in type 3 hemiplegia, 303–306, 304, therapy setting, 120 304f, 311f H in type 4 hemiplegia, 306–307, 311f Gait trainers, 193, 194–195f, 196f, 360 Halliwick Method, of aquatic therapy, prevalence of, 39 for quadriplegic patients, 327 thumb abduction associated with, 141 in M.O.V.E. (TM) (Mobility 355 toe walking associated with, 265, Opportunities Via Education) Hamstring contractures, 287 266–267f curriculum, 370, 371f Hemorrhage in athetosis patients, 89 cerebral Gait training, with pool walking, 353f hamstring lengthening treatment of as cerebral palsy cause, 31 β-Galactocerebrosidase deficiency, 34t germinal matrix, 31, 32f Galactosialdosis, 35t complications of, 296, 296f intraventricular, 28, 31, 32f β-Galactosidase deficiency, 34t hemiplegia gait type 3-related, periventricular-intraventricular, 31, Gamma-aminobutyric acid, 392 32f Gamma-aminobutyric acid receptor 303–306, 304, 304f in premature infants, 28 as kyphosis cause, 183, 183f Herpes simplex infections, neonatal, 38 blockers, 65 night splinting treatment of, 146 Hip Gangliosidoses, 34t as quadriplegic gait cause, 328–329 dystonia at, 87 Gastrocnemius wheelchair seating management of, in gait abnormalities, 285–291, 294t coronal plane deformity, 287–289 contractures of 184 sagittal plane in, 285–287 effect on gait, 275, 276 Hamstring lengthening transverse plane deformity, 289–291, 291f, 303, 306, 307 neurectomy of, as ankle equinus in athetosis patients, 89 spastic treatment, 74 as diminished knee extension computer modeling studies of, 26f Hip abduction, 64 in normal gait, 250–251 treatment, 283–284 in gait abnormalities, 287, 288–289 premature contraction of, 275, 276 as hyperlordosis cause, 296, 296f Hip abduction orthoses, 144 spastic, botulinum toxin injection knee extension orthotic use after, 146 Hip abductor contractures, 288 Hamstrings abduction bracing-related, 144 treatment of, 77, 77f effect on knee flexion and extension, external rotation, 139 Gastrocnemius lengthening 282f, 283–284 as ankle dorsiflexion treatment, 315 spasticity of, as kyphosis cause, 183f in ataxia patients, 95 Hand. See also Fingers; Thumb as hemiplegic gait type 2 treatment, functional evaluation of, 374–376 Hand and wrist orthoses, 139–140, 140f 301, 302, 302f Hand grasp developmental stages of, 376, 377f efficient, 381f evaluation of, 380, 381–384f forced, 379t inefficient, 382–384f
Index 409 Hip adduction, 64, 287–288 Hypertonia Kearns-Sayre syndrome, 37t asymmetric pelvic rotation-associated, aquatic therapy for, 351–352 Kernicturus, athetosis associated with, 88 295–296 spasticity-related, 63 Ketazolam, as spasticity treatment, 65t as scissoring gait cause, 290f Kidney obstruction, as pain cause, 71, 71f Hypotonia. See also Hip, hypotonic Kinematic evaluations Hip adductor lengthening anatomic mixed tone pattern of, 82 hip abduction orthosis use prior to, Ashworth scale measurement of, 82 accuracy of, 235 144 ataxia associated with, 93 data reduction algorithms in, 233–235, definition of, 47, 60, 82 Hip dislocations, 64 hyperreflexia associated with, 82 234f Hip extension local mixed tone pattern of, 82 optical measurements in, 232–233, secondary effects of, 82 deficiency of, 286 treatment of, 82–83 233f Hip extensors, weakness in, 285, 286f spasticity-related, 63 Kinesthesia, evaluation of, 378 Hip flexion contractures, 285 of the trunk, athetosis-related, 89 Kinetic evaluations, in gait analysis, diplegia-related, 316 Hypoxia 235–237, 235f, 236f Hip flexors, weakness in, 286–287 neonatal, 31–23 Kinetics, definition of, 236f Hip guides, as walker attachments, 192 Kleist’s hooking sign, 379t Hip lurch, 297, 297f I Klippel and Weil thumb sign, 379, 379t Hip orthoses, 144, 145f Ibuprofen Klonopin. See Clonazepam Hip pain Ileus, dorsal rhizotomy-related, 72 Knee. See also Menisci; Patella Hippotherapy (horseback riding), Iliopsoas lengthening contractures of, 64 79–80, 129–130, 350–351, 351t, as diplegic hip flexion contracture crossing over of, 290f 352f treatment, 316 dystonia at, 87 Hip rotation in gait abnormalities, 278–285, 294t, definition of, 289 Impairments external rotation deformity, 290, definition and classification of, 39–40, 306. See also Knee, stiffness in 292–293f 40t in normal gait, 251–252, 252f, 253f, internal rotation contractures, functional, 39–40 289–290, 291, 291f 257, 258–259 elastic wrap-based control of, 145 Incompetency, determination of, stiffness in, 282–284, 306 as twister cable contraindication, 128–129 144–145 rectus transfer treatment of, 282, major role of, 285 Individual education programs (IEPs), 284, 284f in normal gait, 252, 254, 255f, 257, 124, 126 258–259 Knee-ankle-foot orthoses (KAFO), Hoffmann’s sign, 379, 379t Individuals with Disabilities Education 145–146, 145f Home-based physical therapy, 119 Act, 124 Home modifications, 197 Knee blocks, anterior, on wheelchairs, Homeobox gene defects, 28 Infants, physical therapy with, 116, 117t 183, 183f Home social environment, 280–281 Infant stimulation programs, 107, 116 Homocystinuria, 36t Infection Knee extension Horseback riding, 79–80, 129–130, at foot contact, 278, 283–284, 285f 350–351, 351t, 352f as microencephaly cause, 28 during terminal swing phase, 283 H-reflex, 54, 54f, 62 as neurologic disorder cause, 38 H-response, 61 postnatal, as cerebral palsy cause, 32 Knee extension contractures, 64 Human immunodeficiency virus (HIV) Inpatient rehabilitation setting, for Knee flexion infection, 38 Hunter’s syndrome, 34t physical therapy, 119–120 in diplegia, 315 Hurler’s syndrome, 34t Intermedullary metabolism disorders, 33, at foot contact, 278–279, 278–283 Hydrocephalus, 28, 30 in gait abnormalities, 278–284, 284f Hydrotherapy, 130. See also Swimming 38 Knee flexion contractures Hyperbaric oxygen therapy, 132 Intrathecal pump administration, of in athetosis patients, 89, 90 Hyperbilirubinemia, athetosis associated hemiplegia gait type 3-associated, 303 with, 88 antispasticity medication. See knee-ankle-foot orthotics treatment of, Hyperextension reflex, 44 Baclofen, intrathecal pump Hyperglycemia, nonketotic, 36t administration of 145–146, 145f Hyperkinetic pattern, 88 Intravenous pump holders, on wheelchair seating management of, Hyperlordosis wheelchairs, 178 Hyperphenylalaninemia, 35t Isokinetic exercise programs, 347, 348, 184 Hyperreflexia 348t Knee flexors hypotonia-related, 82 Isotonic exercise programs, 347, 347t, Knee immobilizers, 146, 146f spasticity-related, 47, 62 348 Knee jerk reflex, 60 Knee orthoses, 145–146, 145f J Knee recurvatum, 317–318 Jebson hand test, 380 Knupfer exercises, in aquatic therapy, John G. Leach School, 371 355–356 K Krabbe’s disease, 34t Kano, Jigaro, 133 Kufs’ disease, 35t Kyphosis dorsal rhizotomy-related, 72 hamstring contracture-related, 183, 183f
410 Index Kyphosis (continued) Mannosidosis, 35t Motor activity, neurologic control of, hamstring spasticity-related, 183f Maple syrup urine disease, 35t 51–106 lumbar, seating-related pressure in, Marijuana, as spasticity treatment, 66 173f Maroteaux-Lamy’s syndrome, 34t Motor development treatment of Martial arts, 131 hierarchical theory of, 108–109, 110, with spinal orthoses, 143, 143f Massage therapy, 131–132 111 wheelchair seating in, 183, 183f impairment of, developmental aspects in Votja therapy, 112 of, 44–47, 45t, 46f L Mathematical modeling, in kinetic recapitulation theory of, 111 Labyrinthine reflex, 41, 42f subsystems theory of, 109 Laminectomy measurement, 236–237 Maturation theory, of motor control, 56, Motor function, importance of, 51 with dorsal rhizotomy, 71, 71f Motor function control Fazano technique in, 71, 71f 59 Lamotrigine Mayer’s sign, 379t assessment of, in gait analysis, 229, as spasticity treatment, 66 Meckel’s syndrome, 28 230t “Lazy eye” (ambylopia), 30–31 Medicaid, 163 eye patch treatment of, 114 Medical equipment. See also Durable central motor program generator Least restrictive environment, for concept of, 45 medical equipment education, 127 definition of, 125 development of, 262 Leg drop test, 59, 61 Medical system, relationship with special Motor function control disorders Leg length discrepancy, 307–308, 309, education system, 124–125 as gait abnormalities cause, 261–263 309f Megaloencephaly, 28, 30 treatment of, 92–93 Leigh syndrome, 37t Meningitis, bacterial, 38 Motor function control system Leri’s sign, 379t Meningomyelocele, 6, 28 center of gravity positioning by, 298, Lesch-Nyhan syndrome, 37t Mental retardation Lesioning procedures. See also 298f inappropriate synaptic remodeling- neurologic control of, 51–52 Neurectomy related, 31 as dystonia treatment, 85 automatic, 52 Leukodystrophy sensory integration treatment in, chaotic attractors in, 57–58, 57f globoid cell (Krabbe’s disease), 34t 111 dynamic systems model of, 56–58, metachromatic, 34t Lever arm disease, 270, 273–274 Mesoderm, 29f 57f, 59, 63–64, 345 Levodopa, as dystonia treatment, 85 Metabolic neurologic disorders feedback control mechanism of, Lifts, 196–197 for gait trainers, 195f classification of, 33, 34–37t 54–56, 55f Limb deficiencies, congenital, power intermedullary metabolism disorders, feed-forward control mechanism of, wheelchair use in, 166 33, 38 55–56, 55f Lioresal. See Baclofen metallic metabolism disorders, 33 fuzzy logic model of, 56 Lissencephaly, 27, 30, 30f, 82 storage disorders, 33, 38 maturation theory of, 56, 59 Lordosis. See also Hyperlordosis Metachromatic leukodystrophy, 34t open-loop control mechanism of, 55 Metallic metabolism disorders, 33 unified theory of, 58–59 dorsal rhizotomy-related, 72, 72f Metatarsal phalangeal joints volitional, 52 wheelchair seating in, 183 fusion of as peripheral nervous system Low back pain, flexion lumbosacral Microencephaly, 28 Middle cerebral artery, occlusion of, in component, 52 orthosis treatment of, 144, 144f subsystems of, 59 Lower-extremity orthoses, 144–156 neonates, 27 Motor impairments Middle childhood diagnostic implications of, 27–28 ankle-foot orthoses (AFO), 146–152, durable medical equipment-based 147–148f, 149f, 150f, 151f, 154f occupational therapy during, 121 physical therapy during, 117–118 treatment of, 137–205 elastic wraps, 145 upper-extremity functional encephalocele-related, 28 foot orthoses, 153–156, 155–157f encephalopathy-related, 51 hip orthoses, 144, 145f development during, 347 Motor neurons, alpha, excitability of, 61 knee orthoses, 145–146, 145f Midfoot break, 265 Motor skills, maturation of, 53 twister cables, 144–145 Midfoot deformities. See also Subtalar Movement, evaluation of, 378 Lumbar flexion jacket, 144, 144f Movement disorders. See also Athetosis; and midfoot deformities M Minnesota Rate of Manipulation Ballismus; Chorea; Dystonia Macroencephaly, 28, 30 definition of, 45, 83 Magnetic resonance imaging (MRI) (MMRT) Test, 380 as gait disorders, 329–330 Mitochondrial cytopathy, 37t pathology of, 83 for cerebral palsy diagnosis, 47, 48f Mitochondrial fatty acid defects, 37t M.O.V.E. (TM) (Mobility Opportunities for gait impairment diagnosis, 241 Mitochondrial myopathy, 37t Malpractice lawsuits, 8 Mobility Opportunities Via Education Via Education) curriculum, 368–371, 370f (MOVE) Program, 120, 120f contraindications to, 369 MODEMS questionnaire, 334 Mucolipidosis, 34t Monoplegia, definition of, 41 Mucolipidosis IV, 34t Moro reflex, 42, 42f Mucopolysaccharidoses, 34t Morquio’s syndrome, 34t
Index 411 Multiple births, as cerebral palsy risk Neuromotor junction injections, as foot, 153–156, 155–157f, 155f factor, 39 spasticity treatment, 76–78, 77f as foot progression angle malrotation treatment, 274 Multiple carboxylase deficiency, 36t Neuromuscular electrical stimulation as hypotonia treatment, 83 Muscle lengthening. See also specific (NES), 349–350 intramalleolar, 154, 156f prescriptions for, 201–203f muscle lengthening procedures Niemann-Pick disease, 34t supramalleolar, 154, 156f dystonia as contraindication to, 85 North American Riding for the Muscle length-tension relationship (Blix hand and wrist, 139–140, 140f Handicapped Association resting splints, 140–141, 141f Curve), 213–215, 215f (NARHA), 350 swan neck splints, 141–142, 142f Muscles. See also specific muscles thumb splints, 141, 142f O effect of spasticity on, 62f, 63–64 Obturator nerve ablation, as spasticity hip, 144, 145f hypotonic, 82 hip abduction, 144 Muscle strength, 63 treatment, 74 knee, 145–146, 145f assessment of, in gait analysis, 231 Occupational therapist assistants (OTAs), knee-ankle-foot (KAFO), 145–146, Muscle-strengthening exercises, 114, 122 145f 346–348 Occupational therapy lower-extremity, 144–156 aquatic, 353–354 as plantar flexion treatment, 96 Muscle tone cerebral palsy scoring scales used in, problem-based understanding of, 153t abnormalities of, 47 374–378, 375t, 376t purpose of, 138 definition of, 59, 60 shoulder orthoses, 139 evaluation/measurement of, 60–61, extremity evaluations in, 371–391 as spasticity treatment, 79, 80–171 functional abilities evaluations in, spinal, 142–144, 143f, 144f 61t, 378 terminology of, 138 in gait analysis, 231 374–376, 375t, 376t twister cables, 144–145 in spasticity, 62 overall evaluations in, 376–378, upper-extremity, 138–142 viscoelastic dampening in, 59–60 dorsal rhizotomy-related, 72 Muscle transfers. See also specific muscle 377f Osteochondroma, 241 overlap with Osteogenesis imperfecta patients, power transfers dystonia as contraindication to, 85, 87 physical therapy, 107 wheelchairs for, 166 electromyography prior to, 348 speech therapy, 108 Osteopenia Muscle weakness, 63 postoperative goals in, 388 as gait abnormalities cause, 263–263 prescriptions for, 121–122 hypotonia-related, 82 Musculoskeletal surgery, as athetosis upper-extremity evaluations in Osteoporosis functional outcome prediction in, treatment, 89 hypotonia-associated, 82 Myelotomy, as spasticity treatment, 74 388, 390 tibial Myofascial lengthening informational/instructional handouts foot-to-thigh angle as indication for, of the biceps, 354, 354f in, 388, 390t, 391t 274 of the brachialis, 354, 354f postoperative, 384–391, 389f, Myofascial release therapy, 131 Outpatient setting, for physical therapy, 390–391t 119 N preoperative, 378–384, 381–384f National Center for Medical Opisthotonic patterning, 84 Oxygen consumption measurement, in Optical measurements, in kinematic gait analysis, 238–241, 240f Rehabilitation Research, 39–40 Near drowning, 38 evaluations, 232–233, 233f P Near hanging, 38 Oral motor dysfunction management, Pallidotomy Nemours Foundation, 128 Neonates, cerebral palsy in, 11 122 as dystonia treatment, 85 Nerve conduction velocity, age-related Oral motor reflex, 379t Palmo-mental reflex, 379t Orthopedist-educator relationship, 126 Parachute reflex, 42, 43f increase in, 54 Orthopedists Nerves, effect of spasticity on, 62–63 absence of, 44 Nervous system. See also Central nervous interaction with physical therapists, Paralysis, meningomyelocele-related, 28 122–123 Paraplegia, definition of, 41 system; Peripheral nervous system Parapodiums, 189, 191 anatomy of, 51–52 interaction with special educational Parents, of cerebral palsy patients Neural tube, 53 system, 124 Neural tube defects, 28, 29f care-providing community for, 5–6, 5f Neurectomy role in physical therapy, 122–123 divorce rate in, 4 anterior branch obturator, 74 therapy prescriptions from, 125–126 emotional response patterns of, 8–11 of gastrocnemius, as ankle equinus Orthoses, 137, 138–156 medical decision-making by, 15–20 ankle need to assign blame, 8, 9, 11, 15, 18, treatment, 74, 131 Neurodevelopmental Therapy (NDT), as ankle plantar flexion 19–20 prepositioning treatment, 276 stress experienced by, 4–5, 8 110, 345–346, 356 Passive stretching exercises, 80 Neurologic maturity, development of, 44 as hypotonia treatment, 83 as spasticity treatment, 79 ankle-foot (AFO), 138, 146–152, 147–148f, 149f, 150f, 151f, 154f as dystonia treatment, 88 elastic wraps, 145 elbow, 139, 140f
412 Index Patella Physical examination foot orthotic treatment of, 153 stress fractures of, 62 in gait analysis, 228–231, 241 hemiplegia-associated, 301–302 global function measures in, orthoses treatment of, 154, 156f Patterning therapy, 30–31, 112 228–229, 230t quadriplegia-associated, 328 Peabody Developmental Scales of motor control assessment in, 229, torsional malalignment in, 267 230t Plantar flexion Fine Motor Skills, 349, 375, of motor control function, 262 ataxia-related, orthotics treatment of, 380 muscle strength assessment in, 231 Pediatric Evaluation of Disability muscle tone assessment in, 231, 231t 96 Inventory (PEDI), 334 Plantar flexion-knee extension couple, Pediatric therapists, training programs Physical therapist assistants (PTAs), 122 for, 109 Physical therapists 273f Pedobarograph, 238, 239f, 265 Play chairs, 186, 187f Pelvic malalignment “grandmother” role of, 12–13 Pneumonia anterior pelvic tilt, 294t, 296 relationship with orthopedists, diplegia-related, 316 aspiration, dorsal rhizotomy-related, pelvic obliquity, 297, 297f 122–123 72 asymmetric, 294t Physical therapy, 107, 108–120 hip abduction-related, 287 Polymicrogyria, 30 in normal gait, 256, 257f for ataxia, 94–95 Pompe’s disease, 35t seating-related pressure in, for athetosis, 91–92, 93 Pool walking, 353f, 354 173f current approach in, 115–119 Popliteal angle wheelchair seating management evaluation of effectiveness of, 108 of, 184 goal setting in, 115–116 in diplegia, 315 pelvic rotation home-based, 119 Porencephaly, 32 asymmetric, 295–296 inpatient, 119–120 Premature infants, intraventricular excessive, 291, 294t orthopedist’s role in, 122–123 torsional malalignment in, 267 outpatient, 119 hemorrhage in, 28 Plantar flexion overlap with occupational therapy, 107 Prematurity, as cerebral palsy risk factor, posterior pelvic tilt, 296–297 school-based, 120 Pelvic obliquity. See Pelvic malalignment, settings for, 119–120 31 pelvic obliquity for spasticity, 79–80 Pressure mapping, 172, 173f Pelvis during specific age periods Pressure sores, 172 in gait abnormalities, 291, 294t, Primitive reflexes, 41–43f, 41–44 295–298 adolescence, 118 gait analysis of, 291 early childhood, 116–117 development of, 53 in normal gait, 247–248, 248f, 249f, infancy, 116 persistent, 43–44, 47 254–256, 257, 257f middle childhood, 117–118 preoperative evaluation of, 378 Pennsylvania Bi-Manual test, 380 young adulthood, 119 relationship with high-functioning Pentaplegia, 41 techniques in Perception, evaluation of, 378 conductive education (Peto cortical motor activities, 108–109 Peripheral nerve lesioning, as spasticity Prone standers, 189, 359, 359f treatment, 74 technique), 113 Proprioceptive neuromuscular facilitation Peripheral nervous system electrical stimulation, 113–114 development of, 154 enforced-use, 114–115 (PNF), in aquatic therapy, role in motor control, 52 muscle-strengthening exercises, 114 355–356 Peripheral nervous system surgery, as Neurodevelopmental Therapy Proprioceptive reflexes, 41–43 dystonia treatment, 86–87 Proximal interphalangeal joints Peroneal muscle (NDT), 110, 345–346 hyperextended, splint treatment of, varus deformity of, 87 patterning therapy (Doman-Delacato 141–142, 142f Peroxisomal disorders, 37t Psychosocial skills, evaluation of, 378 Personality characteristics, evaluation of, technique), 112 Public Law 010-476, 124 378 sensory integration approach (Ayers Public Law 94-98, 124 Peto, Andreas, 113 Purdue Pegboard, 380 Peto technique, 113 technique), 111 Pyruvate dehydrogenase deficiency, 37t Phenol injections, as spasticity treatment, sensory motor treatment approach 74, 75, 78 Q Phenylketonuria (PKU), 35t (Rood technique), 111 Quadriplegia Photography, use in occupational therapy tone-reducing casts, 114 evaluations, 388, 389f Votja therapy, 111–112, 131 bacterial meningitis-related, 38 Physical Capacities Evaluation (PCE), theoretical basis for, 101, 108–109, definition of, 40 380 gait abnormalities associated with, 111 therapeutic relationship in, 109 327–329 Physician-educator relationship, 126 prevalence of, 39 Physician-parent relationship, 12, 13–15 Quality of Upper Extremity Skills Test dysfunctional, 14–15 Pinch strength, 380 (QUEST), 374–375 Planovalgus, 64, 265, 268 external foot rotation-associated, 270, R Radiography 273 for gait impairment diagnosis, 241 Ragged red muscle fibers, 37t
Index 413 Range of motion, spasticity-related Rhizomelic chondrodysplasia punctata, Sensory system, effect of aquatic exercise decrease in, 62f 37t on, 353 Range-of-motion exercises, passive, 80 Rhizotomy, central, as spasticity Shaken baby syndrome, 32–33, 33f Range-of-motion measurement, upper- treatment, 71–72 Shiatsu, water-based version of, 355 Shoes, orthopedic, 138 extremity, 378–379 Rhizotomy, dorsal, 71–73 Shoulder Recapitulation of species theory, 112 complications of, 72–73, 72f Rectus femoris contractures, 286 contraindication in mild quadriplegia, dislocation Rectus muscle 327 treatment of, 373t versus intrathecal pump-administered as knee stiffness/stiff gait cause, 282, baclofen, 391, 397 excessive external rotation of, 371, 373t 284, 284f as knee recurvatum treatment, 318 dislocation with laminaplasty, 72, 72f splints for, 373t Rectus transfer with laminectomy, 71, 71f, 72 in dystonia, 87 outcome of, 72–73, 72f treatment of, 373t as stiff knee treatment, 282, 284, 284f Shoulder contractures, 64 Rhythmic activities, as spasticity therapy, Shoulder orthoses, 139 Reflexes 80 Shriners’ Hospital (South Carolina) preoperative evaluation of, 378 upper-extremity, evaluation of, 378, Riluzole, as spasticity treatment, 66 Upper Extremity Test (SHUE), 379t Rood, Margaret, 111 375–376 Rood technique, 111 Shriners’ Hospital System, 128 Reflexology, 131 Rooting reflex, 41 Shunts Refsum’s disease, 37t ventriculoperitoneal Rehabilitation inpatient programs, S implications for baclofen therapy, Salla disease, 35t 394 physical therapy component of, Sandhoff’s disease, 34t Sialidosis, 34t 119–120 Sanfilippo’s syndrome, 34t type 1, 34t Rehabilitation techniques, 343–401. See Scheie’s syndrome, 34t Skin breakdown also Occupational therapy; Schizoencephaly, 28 effect of wheelchair seating on, 162 Physical therapy School-based therapy, 120, 120f, Sleep disturbances aquatic therapy, 351–356, 353f spasticity-related, 81 Bad Ragaz Ring Method of, 125–126 Sly’s syndrome, 34t 355–356 Sciatic nerve palsy, 90 Soccer, as therapy, 131 contraindications to, 354t, 355 Scissoring gait, 287 Societal limitations, 40 Halliwick Method of, 355 Soleus muscle multidisciplinary approach n, 356, control of, 144, 145f contractures of 358 definition of, 290f effect on gait, 275, 276 pool design/accessibility in, 356, differentiated from hip internal Somatosensory system, role in balance 356t, 357f development, 348 precautions in, 354t rotation gait, 289 Souque’s sign, 379t Watsu, 355 quadriplegic gait-related, 328 Space suit therapy, 132 assistive devices, 358–361 Scoliosis, 64 Spasticity balance interventions, 348–349 floor positioning devices use in, 188 in adolescents, treatment of, 327 electrical stimulation techniques, adverse effects of, 392 349–350 with spinal orthotics, 142–143 assessment of, 61 horseback riding (hippotherapy), wheelchair seating in, 179–182, 180f, with Ashworth Scale, 60–61, 61f 79–80, 129–130, 350–351, 351t, ataxia associated with, 93 352f 181–182f athetosis associated with, 89–90 M.O.V.E. (TM) (Mobility Opportunities Scoring scales, for cerebral palsy benefits of, 64–65 Via Education) curriculum, as chaotic attractor, 61, 62, 63–64 368–371, 370f evaluation definition of, 47, 60, 392 contraindications to, 369 for functional ability evaluation, differentiated from dystonia, 45, 60, muscle-strengthening exercises, 84–85, 330 346–348, 347t, 348t 374–376, 375t, 376t dystonia associated with, 84 Neurodevelopmental Therapy (NDT), for overall evaluation, 376–378, 377f effect on bones, 64 345–346 Seat belts, for wheelchairs, 174 effect on muscle, 62f, 63–64, 65 Resistive exercises, aquatic, 353–354 Seating. See Wheelchairs, seating effect on nerves, 62–63 Respirators, wheelchairs supports for, Seating clinics, occupational therapists in, effect on tendons, 63–64 178 evaluation of, 97t, 378 Respiratory chain disorders, 37t 122 functional effects of, 61–62, 64, 84 Respiratory compromise, postoperative, Seating systems. See Wheelchairs gait disorders associated with, 81 81 Seat restraint laws, 184 global, 80, 81 Respiratory depression, Sebaceous nevus syndrome, 28, 30 idiopathic, 31 diazepam/morphine-induced, 88 Second opinions, 15 Rett syndrome, 27, 31 Sensory deficiencies, 46 Sensory integration, assessment of, 378 Sensory integration approach, in physical therapy, 111 Sensory motor treatment, in physical therapy, 111
414 Index Spasticity (continued) volar, 139–140 Swallowing studies, 122 local, 80–81 wrist, 139–140, 140f Swan neck deformity, 371 prevalence of, 392 wrist cock-up, 380, 384 severe, 393 Spondylolisthesis finger and wrist extension in, 378 treatments for, 64–81 dorsal rhizotomy-related, 72 Swan neck splints, 141–142, 142f alcohol injections, 78 lumbar Swimming aquatic therapy, 351–352 baclofen, 393–397 athetosis-related, 90–91 for physical conditioning, 264 botulinum toxin injections, 76–78, as low back pain cause, treatment as therapy, 130, 350–351, 351t, 352f 76f, 77f, 80–81, 392 Symmetric tonic neck reflex (ATNR), dantrolene sodium, 75–76 of, 144, 144f dorsal rhizotomy, 71–73, 71f Spondylolysis 41–42, 378 electrical stimulation, 73–74 Synapses, formation and remodeling of, evaluation for, 80 lumbar global approach in, 80–81 athetosis-related, 90–91 30–31 horseback riding therapy, 130 dorsal rhizotomy-related, 72 Synaptic plasticity, 30 intrathecal medication, 66–70, 69f as low back pain cause, 144, 144f local treatments, 80–81 Sports participation, 131 T muscle tendon lengthening, 78 Stair lifts, 197 Tay-Sachs disease, 34t myelotomy, 74, 75, 75f Standers, 188–189, 190f Tendon lengthening, 371 oral medication, 65–66, 65t for quadriplegic patients, 327 orthotics, 79 parapodiums, 189, 191 as hemiplegic gait treatment, phenol injections, 78 prone, 189, 359, 359f 301–303 physical therapy, 79–80 supine, 189, 190f, 359 surgery, 392–393 for hypotonic children, 83 as spasticity treatment, 78 in young adults, treatment of, 327 upright, 359–360 Tendons. See also specific tendons Stepping reflexes, 42–43, 43f Special education, 124–125, 127, 128 Step reflex, 42–43, 43f effect of spasticity on, 63–64 physician-educator relationship in, 126 Stereognosis, evaluation of, 378 Tetrahydrobiopterin deficiencies, 36t relationship with medical system, postoperative, 384 Tetrazepam, as spasticity treatment, 65t 124–125 Sterling’s sign, 379t Therapeutic relationship transitional planning in, 127–129 Stiff knee gait, 282–284, 306 rectus transfer treatment of, 282, 284, with physical therapists, 12–13 Speech impairment, athetosis-related, 89 with physicians, 13–15 Speech therapy, 107–108, 122 284f Sphingomyelinase deficiency, 34t Stomach ulcers. See Gastric ulcers dysfunctional, 14–15 Spielmeyer-Vogt-Sjogren disease, 35t Storage disorders, 33, 34t, 38 Therapist assistants, 122 Spina bifida, 6 Strabismus, eyepatch treatment of, 114 Therapy. See also Occupational therapy; Spinal cord, role in motor control, 52, 53f Strengthening exercises, for muscle Spinal cord-mediated activities, Physical therapy; Speech therapy weakness, 264 acupuncture, 131 relationship with primitive Stretchers alternative medicine, 132–133 reflexes, 108 for athetosis, 91–92 Spinal cord paralysis, as paraplegia, 41 reclined, 182, 182f hippotherapy (horseback riding), Spinal cord stimulators, 16 Stretch reflex, 60 Spinal fusion. See Spinal instrumentation Strokes, neonatal, 32 79–80, 129–130, 350–351, 351t, and fusion Strumpell’s pronation sign, 379t 352f Spinal orthoses, 142–144, 143f, 144f Subanterior superior iliac spine hydrotherapy (swimming), 130, 264, thoracolumbar sacral orthosis (TLSO) 350–351, 351t, 352f bivalved, 143, 143f (SUBASIS) bar, 174–175, 174f hyperbaric oxygen therapy, 132 lumbar flexion jacket, 144, 144f Subtalar and midfoot food deformities martial arts, 131 soft, 142–143, 143f massage and myofascial release weaning from, 353 equinovarus, 64 therapy, 131–132 Splints/splinting Subtalar joint prescriptions for, 125–126 Benik thumb abductor, 372–373, 374 space suit therapy, 132 dorsal wrist extension, 139–140 function of, 251 sports, 131 as elbow contracture treatment, 373t motion of, 251 Thoracolumbar sacral orthoses (TLSO) for hand, 140–142, 141f, 142f, 347 Succinylcholine, spasticity-related bivalved, 143, 143f upper-extremity, 372–374 lumbar flexion jacket, 144, 144f for contractures, 372–374 resistance to, 63 soft, 142–143, 143f dorsal wrist cock-up, 372, 373t Sucking reflex, 41, 41f weaning from, 353 following muscle transfer surgery, Thumb abduction 372 development of, 53 evaluation of, 380 Sulfite oxidase deficiency, 36t splint treatment of, 141, 142f Supine standers, 189, 190f, 359 Thumb adduction, 371 Thumb deformities for hypotonic patients, 83 splinting of, 372–373 Surgery surgical treatment of, 373t Thumb splints, 141, 142f complications of Tibia management plan for, 20 torsional malalignment of, 64 physician-family discussion of, 20, 21 recommendations for, 18, 20
Index 415 Tibialis anterior Twins, cerebral palsy prevalence rate in, with tibialis posterior and peroneal in hemiplegic gait pattern type 1, 300, 39 muscles, 87 300f in hemiplegic gait pattern type 2, 303 Twister cables, 144–145 treatment of Tyrosinemia, 36t with orthotics, 154 Tibialis posterior in hemiplegic gait type 2, 302, 303 U Vault, 276, 276f, 277f varus deformity of, 87 University of California Biomechanics Vestibular system Tibial osteotomy Laboratory (UCBL) orthotic, 154, effect of aquatic exercise on, 353 foot-to-thigh angle as indication for, 156f role in balance development, 348 274 Upper-extremity deformities Vests, weighted, 92 Tibial torsion surgical treatment of, 371–372, 373t Vibrators, 80 diplegia-related, 315 occupational therapy evaluations Videotaping, in gait analysis, 232, 232f, external, 272 following, 384–391, 389f, internal, 272 390–391f 242 measurement of, 267, 270 occupational therapy evaluations Viral infections. See also specific viral torsional malalignment in, 267 prior to, 378–384, 381–384f Upper-extremity denervation, as dystonia infections Tilt boards, 190f treatment, 75, 75f prenatal and neonatal, as neurologic Tizanidine, as spasticity treatment, 65t, Upper-extremity occupational therapy evaluations disorder cause, 38 66, 393 functional abilities evaluations, Viscoelastic dampening, in muscle tone, TLSO. See Thoracolumbar sacral 374–376, 375t, 376t functional evaluations, 374–376, 375t, 59–60 orthoses (TLSO) 376t Visual system, role in balance Toe dragging functional outcome prediction in, 388, 390 development, 348 inadequate ankle dorsiflexion-related, informational/instructional handouts Vitamin B12 metabolism defect, 36t 278 in, 388, 390t, 391t Vitamin metabolism disorders, 36t overall evaluations, 376–378, 377f Votja therapy, 111–112, 131 Toe grasp reflex, 53 postoperative, 384–391, 389f, Toe grip reflex, 41f 390–391t W Toe strike, as initial foot contact, 275 preoperative, 378–384, 381–384f Waking aids Toe walking Upper-extremity orthoses, 138–142 elbow orthoses, 139, 140f canes, 193–195, 196f, 360–361 ataxia-related, 95, 96 hand and wrist orthoses, 139–140, contraindication in ataxia, 95 mild, 308, 310 140f moderate, 310–311 shoulder orthoses, 139 Walkers, 191–192, 191f, 192f, 193f severe, 311–312 spinal orthoses, 142–144, 143f, front, 360 treatment of, 312–316, 313f, 314f 144f for hemiplegia type 4 patients, 308 Upper-extremity reflexes, evaluation of, initial evaluation for use of, 358–359 hemiplegia-related, 265, 266–267f, 378, 379t mechanical lift, 371f 301 Upper-extremity surgical procedures posterior, 360 preoperative evaluation for thigh and foot guide attachments on, Toilet seating, 186–187, 188f occupational therapy-based, 144, 145f Tonic neck reflexes, 378 378–384, 381–384f Top-Down Motor Milestone Test, 369 Upper motor neuron syndrome, 392 Walking. See also Gait Toxic agents, as neurologic deficit cause, Urea cycle disorders, 36t balance deficits during, 94 Urinary retention neurologic control of, 55–56 38 dorsal rhizotomy-related, 72 prognosis for, 43–44 Toxoplasma gondii, 38 intrathecal baclofen-related, 396 Toy cars, battery-powered, 167, 167f Walking aids, 191–195, 198t, 360 Transcutaneous electrical nerve V for ataxia patients, 95 Valgus canes, 195, 360–361 stimulation (TENS), 113–114, crouched gait patients’ use of, 319, 349 orthotic treatment of, 154, 156f 320–322, 320–322f Transitional planning, 127–129 pedobarograph measurement of, 239f crutches, 191, 193–195, 196f, Transverse plane deformities, of the hip, Valium. See Diazepam 360–361 289–291, 291f Varicella zoster infection, in utero, 38 for ataxia patients, 95 hemiplegic gait type 2-associated, 303 Varus gait trainers, 193, 194–195f, 196f, 360 hemiplegic gait type 3-associated, 306 of foot, 265 walkers, 191–192, 191f, 192f, 193f hemiplegic gait type 4-associated, 307 pedobarograph measurement of, 239f Trauma, as brain injury cause, 32–33, Walking speed, velocity attractors in, 57 33f Watsu, 355 Tremor, definition of, 45 Weight bearing Trendelenburg gait, 297, 297f Tricycles, therapeutic, 197, 197f in spasticity, 64 Trihexiphenidyl, as dystonia treatment, Weights, therapeutic use of, by athetosis 75, 85, 86, 86f, 87 Triplegia, 40 patients, 92 Tromner’s sign, 379t Wheelchair lifts, 185 Wheelchairs, 156–188, 361–368 abduction wedges on, 173–174, 174f abductors on, 362t
416 Index Wheelchairs (continued) for knee flexion contracture patients, shoulder harnesses on, 176–177, 362t anterior knee blocks on, 183, 183f 184 shoulder retractor pads on, 362t armrests on, 170, 170f shoulder straps on, 362t attachments on, 178 for kyphosis patients, 183, 183f special, 185–188 backrests on, 364t lap trays on, 161, 161f, 178, 366t summer/winter bracket hardware on, base of, 162, 172, 172f laterals, 361t standard, with large wheels, for lordosis patients, 183 361t 163–164, 163f Medicaid coverage for, 163 swing-away hardware on, 361t standard, with one-arm self- parental attitudes toward, 156–157 during transportation, 184–185, propelling feature, 165 for pelvic obliquity patients, 184 standard, with small wheels, 163 pelvis positioning straps on, 363t 185f stroller-base, 159–161, 159f, power, 165–169 trunk positioners on, 362t 162–163 for windblown disorder patients, for blind children, 166 battery-powered toy cars as, 167, children’s attitudes toward, 156, 157 167f 183–184, 183f for children who are dependent in all Wheelchair swings, 197, 197f transfers, 161–162 controller mechanisms of, 165–166, Wheelchair vans, 185 for children who are exercise 166f Wilson disease, 37t ambulators/transfer standers, Windblown hip deformity 160–161, 161f criteria for, 167t for children with some ambulatory use by athetosis patients, 91–92 wheelchair seating management of, ability, 159–160 wheel base of, 168–169, 168f 183–184, 183f cosmetic appearance of, 178–179 prescriptions for, 158–159, 179, cost of, 366f World Health Organization, crutch holders on, 178 199–200t “Classification of Impairments, cushions on, 365t for scoliosis patients, 179–182, 180f, Disabilities, and Handicaps” desks on, 187–188 report, 39, 40, 40t documentation of medical need for, 181–182f 363–364, 367–368 seatbelt rigidizers on, 363t Wound infections effect on cardiovascular endurance, seat belts and restraints on, 174–175, baclofen intrathecal pump-related, 263–264 68–69, 69f effect on walking ability, 156–157, 174f, 363t postoperative 164, 164f, 164t seating, 170–177, 170f physician-patient discussion of, 21 foot positioners on, 365t footrests on, 169–170, 169f for anterior trunk support, 175–177, Wrist contractures, 64 frames of, 169, 169f 176f Wrist deformities, surgical treatment of, guidelines for, 361–363t for hamstring contracture patients, 184 for back support, 160f, 175 373t headrests on, 177, 177f back-to-seat angle of, 178 Wrist flexion, range-of-motion in, 378 health insurance coverage for, 163, 179 barrel-shaped, 185 Wrist flexion contractures, 371, 373t for hemiplegia type 4 patients, 308 base for, 172, 172f for hip disorder patients, 183–184 as bath chairs, 187, 189f orthotic treatment of, 138, 139–140 hip guide restraints on, 172 with closed-cell t-foams, 172 Wrist orthoses, 139–140, 140f hip guides on, 362t customized modular, 170–171, 172 Wrist splints, 372, 373t inappropriate, 158 durability of, 178–179 knee adductors on, 362t feeding seats, 186, 186f postoperative, 380, 384 knee blocks on, 362t for foot deformity management, 184 formfitting, custom-molded, Y Young adults 170–172 with gel pads, 172 back-kneeing in, 326 inappropriate, 170, 170f crouched gait in, 318–327 for lateral trunk support, 175, 176f as play chairs, 186, 187f treatment of, 319–326 pressure mapping of, 172, 173f occupational therapy for, 121–122 seating clinics, 157–158 physical therapy with, 119 toilet seating, 186–187, 188f Z Zellweger syndrome, 37t
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