Effec%ve Evidence- Based Therapy for Children with Cerebral Palsy Novak, Morgan & Wallen

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1 Effec%ve Evidence- Based Therapy for Children with Cerebral Palsy vak, Morgan & Wallen Effec%ve Evidence- Based Therapy for Children with Cerebral Palsy Prof Iona NOVAK Cathy MORGAN Dr Margaret WALLEN Cerebral Palsy Alliance CanChild McMaster University Motor & skeletal treatments Many treatments Early treatments Func%onal treatments a group of disorders of the development of movement & posture, causing ac%vity limita%ons that are alributed to non- progressive disturbances that occurred in the developing fetal or infant brain Maternal treatments Brain treatments Rosenbaum et al, 2005 n=71! Number Cerebral Palsy! Systematic Reviews! n=3! n=14! n=35! Proven Effective Preferentially use this approach Insufficient evidence Uncertain Effect evidence Measure effects. Were goals met? Conflicting evidence Proven Ineffective Do NOT use this approach. Choose alternative vak 2012 GRADE of EVIDENCE QUALITY RECOMMENDATION TRAFFIC ALERT ACTION 2 in 3 children with cerebral palsy walk FAVOURABLE UNFAVOURABLE HIGH MODERATE LOW VERY LOW VERY LOW LOW MODERATE HIGH STRONG + WEAK + WEAK - STRONG - GREEN: GO YELLOW: MEASURE RED: STOP Ambulant n- Ambulant 32% 27% 15% 12% 14% GMFCS I GMFCS II GMFCS III GMFCS IV GMFCS V Cerebral Palsy Alliance 2014 vak & Msall 2013

2 Ataxic/Other Dyskinetic Spastic Movement potential 90% GMFCS I-IIII 24% 25% 23% 76% 75% 77% 23% Quadriplegia GMFCS IV-V I GMFCS I-IIII 39% CP 99% II 1% III GMFCS IV-V IV Hemiplegia V 38% Diplegia % GMFCS I-IIII 2% GMFCS IV-V AGE vak 2014 Effect of no treatment Hand Use Curves I II P AS GR NO III SP GRA IV V Holmefur CHILD- ACTIVE Promote skill acquisi%on 2 COMPENSATION Modify task or environment 3 PREVENT IMPAIRMENT 3 PREVENT IMPAIRMENT AGE Hanna 2009 CHILD-ACTIVE Manage alignment & health vak COMPENSATION WHO 2001

3 Treatment paradigm %ming I Stop natural history II III IV Goals realistic? Goals possible for us? YES UNSURE Identify goal limiting factors from more assessment Choose evidence based interventions Measure outcomes COPM & GAS +/Goals met? AGE 15 YES PARTIALLY Set review & check-up 1 CHILD- ACTIVE NO Deliver prognosis &/or messages needed for decision-making Provide interventions V 0 assessment Compensate re- evalua%on interven%on CHILD ACTIVE Set family goals COPM NO Review goals and interventions offered Use it or lose it Neural circuits not ac%vely engaged in task performance degrade Kleim Use it and improve it Training a specific func%on can enhance that func%on ths on 6m 3m on ths Ba se line % grey ma\er change Dragnaski 2004 n- Musician Musician Bangert et al 2006

4 DO IT CIMT Context Focused Therapy GoalDirected Training OT post Botulinum Toxin Bimanual Training Home Programs BioFeedback Hydrotherapy Hippotherapy EI SEMLS & therapy DON T DO IT INEFFECTIVE 3 Specificity Treadmill Training Botulinum Toxin Assistive Technology SDR How you prac%ce malers Orthotic? UNKNOWN IN CP WORTH IT LINE S - GoalTask Specific, Goal- Directed Training Based Training Home & Programs Learning- Based Interven%ons Seating W+ PROBABLY DO IT W- PROBABLY DON T DO IT IMPROVED FUNCTION & SELF CARE hand ITB Sensory Proc. Therasuits NDT Massage Vojta Conductive Education Hyperbaric O2 NDT SI Before A^er Control vak et al, 2013 Task oriented S+ IMPROVED MOTOR ACTIVITIES 4 Repe%%on ma\ers Induc%on of plas%city requires sufficient repe%%on n- specific EFFECTIVE Nelles Intensity ma\ers Induc%on of plas%city requires sufficient training intensity

5 ReWalk exoskeleton Virtual Reality 6 Time ma\ers Plas%city is a process not a one- off event event Different forms of plas%city occur at different %mes during training Boyd 2014 Esquenazi et al Goal- Directed Training / Func%onal Training Salience ma\ers Weighted importance must be assigned in order for encoding to happen Mo%va%on + alen%on + rewards increase learning Effect of Delayed Diagnosis 8 CHILD ACTIVE Age ma\ers I II III IV Training- induced plas%city occurs more readily in younger brains V 0 Hanna et al, AGE

6 Transference 9 Interna%onal Clinical Guideline Early Diagnosis and Early Interven%on of Infants with Cerebral Palsy = promo%on of subsequent plas%city Exercise creates a good climate for learning CO- OP Cogni%ve Orienta%on to Occupa%onal Performance 1O Interference = maladap%ve plas%city = development of bad habits Goal Plan Do Check Cri%cal Period CIMT Grade 4 IVH R Effec%ve home programs = Grade 2 IVH L CHILD- A CTIVE PARE EDUCA NT TION ENVIR MODIFONMENT ICATIO N vak 2009

7 TMS Constraint Induced Movement Therapy (CIMT) Bimanual Training Constraint- induced movement therapy is child- ac%ve repe%%ve, structure training in the use of the hemiplegic upper limb by constraining the dominant hand. The approach is equally effec%ve as Bimanual Training. Bimanual training is child- ac%ve repe%%ve, structured training in using 2 hands together, for children with hemiplegia. The approach is equally effec%ve as constraint- induced movement therapy. vak 2014 parent defini%on vak 2014 Child Active All CP sub-types Ages HOME PROGRAM: form of guidance and advice, which become a way of life for parents & children. Through regular prac%ce of ac%vi%es at home, parents maximise their child s poten4al. Parents use the guidance & support that they gain from home programs to build confidence about how to help their child vak x week for 15mins (1hr pw) Home

8 Effec%ve Evidence- Based Therapy for Children with Cerebral Palsy vak, Morgan & Wallen WHO WHAT HOW TRADITIONAL For the child between treatment sessions List of ac%vi%es Therapist determines priori%es PARTNERSHIP For the parent to gain guidance about paren%ng Library of ideas to meet goals. Ideas for environment, tasks and parent Parent and child determine priori%es and goals Therapist determines Parent determines WHEN 10-40mins/day WHY Therapist is the expert Parent is the expert WHERE Program devised from ins%tu%onal sehng Program devised based on a home visit vak 2011 Parent perceived benefits support that sustains realistic expectations flexibility goals are motivating translates to real life reminder to practice progress updates role identity parent not therapist vak 2011 GOAL: Fast neat writing NEAT: YES Choose evidence based interventions Home program: Goal Directed Training + Assistive Technology Measure outcomes COPM & GAS +/- Goals met? YES Set review & check-up Realistic & possible? FAST: NO Deliver prognosis messages One- handed touch typing COMPENSATION PARENT EDUCATION TEACHING IMPROVEMENTS Cerebral Palsy Alliance 2014

9 Effec%ve Evidence- Based Therapy for Children with Cerebral Palsy vak, Morgan & Wallen ENVIRONMENT MODIFICATIONS CHILD- ACTIVE PARENT EDUCATION Botulinum Toxin + Occupa%onal Therapy Upper Motor Neurone Syndrome Child Active OR Prevent Impairment Pharmacological for +ve symptoms Spas%city Dystonia Botulinum toxin A Therapy for ve symptoms Weakness Fa%gue ê Control Strength Training Func%onal Training Motor Control Training Cas%ng etc. Spastic & Dystonic Ages mon injection + intense therapy Home Clinic Treat which children? IMPROVING FUNCTION <5 yrs Mild- moderate spas%city Minimal fixed contracture Ac%ve movement of limb Adequate grip strength Tolerates intense therapy Mo%vated family Cerebral Palsy Alliance 2014 SYMPTOM MANAGEMENT Moderate- severe spas%city Fixed contracture (requiring cas%ng) May not have ac%ve movement of limb Adequate grip strength Tolerates splints Case 1 Child presents for BoNT- A assessment Assessment 1. Increased tone present? Discon%nue assessment for BoNT- A 2. Establish if spas%city or dystonia & severity (ASAS, HAT & MTS) 3. Spas%city/dystonia focal? Consider generalised spas%city/ dystonia medica%on

10 4. Full passive ROM (goniometry)? 1. Cast to gain ROM 2. Splint to maintain ROM 3. +/- BoNT- A 4. Consider surgery 5. Set family goals (COPM & GAS) 6. Hypertonia limi%ng goal achievement? 8. Determine upper limb func%on and quality of movement (QUEST & AHA) Determine Injec%on Plan 9. Select muscles for injec%on 10. Select dose and dilu%on Discon%nue assessment for BoNT- A 11. Localise muscles for injec%on A^er BoNT- A injec%on 7. Determine purpose of BoNT- A Improve func%on Improve func%on 13. Structured prac%ce of tasks 14. Decreased strength? Strength Training Characteris%cs: * High tone * LiLle ability to ac%vate hand 12. Spas%city / dystonia reduced? Manage symptoms eg pain 19. Contracture present? 17. Reduced pain? Consider immobilisa%on splint &/or further pain assessment 15. Limb Disregard? CIMT/ Bimanual Training Case 2 Immobilisa%on splint Assessment 1. Increased tone present? Discon%nue assessment for BoNT- A 2. Establish if spas%city or dystonia & severity (ASAS, HAT & MTS) 3. Spas%city/dystonia focal? Consider generalised spas%city/ dystonia medica%on Splint to maintain ROM? Re- Assessment 20. Goals achieved? Assess why 21. Favourable response? Consider re- injec%on Consider: dosage used, muscles selected, post- treatment provided, BoNT- A brand used Child presents for BoNT- A assessment Cast to gain ROM 18. Improved skin integrity? 16. Posi%ons hand for func%on? Func%onal Splints Occupa%onal Therapy Manage symptoms eg pain Characteris%cs: * Adequate grip strength * Can ac%vate antagonists Discon%nue Consider: surgical consulta%on 4. Full passive ROM (goniometry)? 1. Cast to gain ROM 2. Splint to maintain ROM 3. +/- BoNT- A 4. Consider surgery 5. Set family goals (COPM & GAS) 6. Hypertonia limi%ng goal achievement? Discon%nue assessment for BoNT- A 7. Determine purpose of BoNT- A Improve func%on Characteris%cs: * Adequate grip strength * Can ac%vate antagonists Manage symptoms eg pain Characteris%cs: * High tone * LiLle ability to ac%vate hand

11 Effec%ve Evidence- Based Therapy for Children with Cerebral Palsy vak, Morgan & Wallen 8. Determine upper limb func%on and quality of movement (QUEST & AHA) Determine Injec%on Plan 9. Select muscles for injec%on 10. Select dose and dilu%on 11. Localise muscles for injec%on A^er BoNT- A injec%on Occupa%onal Therapy 12. Spas%city / dystonia reduced? Improve func%on 13. Structured prac%ce of tasks 14. Decreased strength? Strength Training 15. Limb Disregard? CIMT/ Bimanual Training 16. Posi%ons hand for func%on? Func%onal Splints Manage symptoms eg pain 17. Reduced pain? Consider immobilisa%on splint &/or further pain assessment 18. Improved skin integrity? Immobilisa%on splint 19. Contracture present? Cast to gain ROM Splint to maintain ROM Goal Directed Training Re- Assessment 20. Goals achieved? 21. Favourable response? Consider re- injec%on Consider: dosage used, muscles selected, post- treatment provided, BoNT- A brand used Assess why Discon%nue Consider: surgical consulta%on AIM: establish/ restore func%onal skills of daily living DESCRIPTION: task specific prac%ce of child set goal based ac%vi%es using a motor learning approach AKA: Func%onal therapy/training Goal focussed task training Motor Func%onal Training Motor Learning Child Active All with functional goals Massed practice of part and whole task Key Features of GDT ACTIVITY RELATED GOAL IDENTIFY GOAL LIMITING FACTORS INTERVENTION Use of appropriate tools eg COPM Child/family goals Realis%c and possible? Child Environment Task Focus on outcome not normal What changes need to be made in task or environment? Natural environment Cerebral Palsy Alliance 2014 PRACTICE REGIME EVALUATION When/where/how much Use of valid and sensi%ve outcome measure

12 Equipment Prescription WALKING AIDS, FRAMES, AND STICKS to promote independent mobility. This type of assis%ve technology is a compensatory and environmental approach for children unable to independently ambulate. WHEELCHAIRS (MANUAL AND POWER) to promote independent mobility. This type of assis%ve technology is a compensatory and environmental approach for children unable to independently ambulate CPUP Project: Results Hip Surveillance Almost complete eradica%on of hip disloca%on Decrease in severe contractures by 70% Reduced orthopaedic surgery AIM: reduce hip disloca%on and the need for orthopaedic surgery DESCRIPTION: ac%ve surveillance and treatment for hip joint integrity to prevent hip disloca%on Includes planned regular hip x- rays and %mely interven%ons eg ITB; preventa%ve so^ %ssue surgery Gordon, 2006 Hagglund et al 2005

13 Effec%ve Evidence- Based Therapy for Children with Cerebral Palsy vak, Morgan & Wallen % CPUP Project: Benefits Hip Disloca%on Severe Contracture Severe Scoliosis Prevent hip dislocation GMFCS I-V Surveillance and treatment as per published protocols Clinic/ hospital Hagglund et al, professionals Ankle Foot Orthoses AIM: Prevent contracture Improve ankle joint ROM Improve lower limb func%on DESCRIPTION: Removable external devices designed to support the ankle due to weak or ineffec%ve muscles Figueiredo, 2008 Prevent calf contracture +/- improve gait quality All CP subtypes Fabrication of customised orthotic Clinic/ hospital Cerebral Palsy Alliance 2014