MOVEMENT AND CEREBRAL PALSY WEBINAR 16 MARCH 2021 - MARIE STANLEY, MCSP BOBATH TUTOR
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MOVEMENT AND
CEREBRAL PALSY
WEBINAR
16 MARCH 2021
MARIE STANLEY, MCSP
BOBATH TUTOR
Copyright The Bobath Centre
• WHAT DO WE UNDERSTAND BY CEREBRAL PALSY? • WHAT DO WE UNDERSTAND BY MOVEMENT? • GETTING GOING AGAIN
MOVEMENT HAS ALWAYS BEEN PART OF THE
DEFINTION OF CEREBRAL PALSY
EARLY DEFINITIONS OF CEREBRAL PALSY
“A DISORDER OF MOVEMENT AND POSTURE DUE
TO A DEFECT IN THE OR LESION OF THE
IMMATURE BRAIN” BAX (1964)
“AN UMBRELLA TERM COVERING A GROUP OF
NON PROGRESSIVE, BUT OFTEN CHANGING,
MOTOR IMPAIRMENT SYNDROMES SECONDARY
TO LESIONS OR ANOMALIES OF THE BRAIN
ARISING IN THE EARLY STAGES OF ITS
DEVELOPMENT”
MUTCH ET AL (1992)
DEFINITION OF CEREBRAL PALSY “CP DESCRIBES A GROUP OF PERMANENT DISORDERS OF THE DEVELOPMENT OF MOVEMENT AND POSTURE, CAUSING ACTIVITY LIMITATION, THAT ARE ATTRIBUTED TO NON- PROGRESSIVE DISTURBANCES THAT OCCURRED IN THE DEVELOPING FOETAL OR INFANT BRAIN. THE MOTOR DISTURBANCES OF CEREBRAL PALSY ARE OFTEN ACCOMPANIED BY DISTURBANCES OF SENSATION, PERCEPTION, COGNITION, COMMUNICATION, AND BEHAVIOUR; BY EPILEPSY AND BY SECONDARY MUSCULOSKELETAL PROBLEMS.” BAX, ET AL (2005)
Movement difficulties Sensory difficulties Perceptual difficulties
IT’S AN EVOLVING OR CHANGING CONDITION –
CHILDREN WITH CEREBRAL PALSY
BECOME ADULTS WITH CEREBRAL PALSY
WHAT IS MOVEMENT?
CONSIDER THE DIFFERENT WAYS IN WHICH WE CAN ANSWER
gross muscles contracting
vs automatic
- body parts and
fine vs
joints moving
motor skills voluntary
Oro-
motor movement of our body
vs
movement of the
environment
WHAT IS MOVEMENT?
movement posture
IMPLICITLY LINKEDWHAT IS MOVEMENT?
• MOVEMENT CAN BE SEEN AS A
SEQUENCE OF POSTURES – IT HAS A
START AND AN END
• MOVEMENT OF SOME PARTS MAY
REQUIRE STABILITY (NO MOVEMENT)
OF OTHER PARTS
• IT IS ACTIVE BUT CAN BE PASSIVE IF
SOMEONE ELSE DOES THE MOVEMENT
FOR YOUWHAT IS POSTURE? • POSTURE CAN BE SEEN AS ARRESTED MOVEMENT • JUST AS IMPORTANT AS MOVEMENT, SERVING TO KEEP THE TRUNK UPRIGHT AND THE HEAD AND EYES IN MIDLINE FOR FUNCTION AND TO MAKE MOVEMENT IN OTHER PARTS POSSIBLE • DEPENDING ON THE LEVEL OF SUPPORT AND THE TASK, POSTURE CAN STILL BE QUITE ACTIVE (IN TERMS OF MUSCLE ACTIVITY)
MOVEMENT = MOBILITY & POSTURE = STABILITY
WE NEED A BALANCE BETWEEN THE TWO AND TO BE ABLE TO COMBINE THEM
IN DIFFERENT PARTS OF THE BODY AT THE SAME TIMEWHY IS MOVEMENT IMPORTANT? PHYSIOLOGICAL / HEALTH BENEFITS: • INVOLVES CHANGES IN LENGTHS OF MUSCLES, NERVES AND SOFT TISSUES - SO MAINTAINS LENGTHS AND ELASTICITY • INVOLVES MOVEMENT OF JOINT SURFACES SO MAINTAINS JOINT MOBILITY • GENERATED BY MUSCLE ACTIVITY SO HELPS TO DEVELOP & MAINTAIN MUSCLE STRENGTH • MAKES IT EASIER TO EXPLORE DIFFERENT ENVIRONMENTS, SOCIAL, WORK SITUATIONS – MENTAL AND FINANCIAL WELL-BEING • LINK BETWEEN PHYSICAL ACTIVITY AND SLEEP
WHY IS MOVEMENT IMPORTANT? UNDERSTANDING YOURSELF AND YOUR ENVIRONMENT • MOVEMENT INVOLVES COORDINATION OF MANY SYSTEMS – SENSORY, VESTIBULAR, MOTOR • WE DO NOT LEARN MOVEMENTS, BUT THE SENSATION OF MOVEMENT (K BOBATH 1984) • IMPORTANT FOR INTEGRATION OF SENSORY AND MOTOR • MOTOR LEADING TO SENSORY FEEDBACK • SENSORY STIMULATION LEADING TO MOTOR ACTION
WHY IS MOVEMENT IMPORTANT? ROLE IN COGNITION • NEW MOVEMENT AND PLAY EXPERIENCES ARE IMPORTANT FOR BRAIN DEVELOPMENT & MAINTENANCE OF NEURAL CONNECTIONS • MOVEMENT MAY CHANGE CONTEXT IN WHICH YOU FUNCTION – UP AGAINST GRAVITY, SMALLER BASE OF SUPPORT, ENTER A CROWED ENVIRONMENT ETC, SO LEADS TO PROBLEM SOLVING • PART OF FEEDBACK-FEEDFORWARD SYSTEM THAT ALLOWS US TO ANTICIPATE AND ADJUST OUR MOVEMENT FOR PLANNING MOVEMENT & LEARNING NEW SKILLS • PERFORMANCE IS EVALUATED, REFINED, REPEATED AND EVENTUALLY OPTIMIZED
WHEN IS MOVEMENT IMPORTANT?
• EVERYDAY!!
• BRAIN CAN BE DESCRIBED AS ‘PLASTIC’ – CHANGES & ADAPTS AS A RESULT
OF EXPERIENCE
• SPECIAL PERIODS OF RAPID BRAIN GROWTH & / OR ADAPTATION
• FIRST 3 YEARS
• LEARNING NEW SKILLS
• FOLLOWING DAMAGE TO THE BRAIN
• PUBERTYMOVEMENT & POSTURE & POSTURAL TONE • BACKGROUND STATE OF MUSCLE ACTIVITY • READINESS FOR ACTION • ADAPTABLE
MOVEMENT & POSTURE & POSTURAL TONE
severe hypertonus Related to quality of
movement & posture
moderate
Too much stability
Too much co-contraction
mild Inefficient mobility
Typical
mild Related to quality of postural
control against gravity
moderate
Lack stability
severe hypotonus Insufficient co-contraction
Too much mobilityMOVEMENT & POSTURE & POSTURAL TONE
• OBSERVING THE MOVEMENT DIFFICULTIES HELPS US TO ASSESS THE POSTURAL
TONE FOR A CHILD WITH CEREBRAL PALSY
• A BODY PART THAT RESISTS MOVEMENT MAY HAVE INCREASED TONE
• A BODY PART THAT DOES NOT TAKE UP THE BASE OF SUPPORT SO
MAINTAINS A POSTURE OFF THE SURFACE MAY HAVE INCREASED TONE
• A BODY PART THAT IS TOO EASY TO MOVE MAY HAVE DECREASED TONE
• ASSESSING POSTURAL TONE CAN HELP US PREDICT MOVEMENT DIFFICULTIES
NOW AND IN THE FUTUREHOW WE MOVE - PATTERNS OF MOVEMENT • AT BOBATH WE TALK ABOUT MOVEMENT OCCURRING IN BASIC PATTERNS: • FLEXION – BENDING COMING INTO TOWARDS CENTRE OF BODY • EXTENSION – STRAIGHTENING A JOINT OR COMING AWAY FROM THE CENTRE OF THE BODY • ROTATION - WHEN FLEXION AND EXTENSION OCCUR AT THE SAME TIME
Flexion – important for grasping and coming into midline Extension – important for support and weight bearing
Rotation – important for weight shift and dissociation and crossing midline
MOVEMENT & POSTURE & PATTERNS OF MOVEMENT • MOVEMENT IN ONE PATTERN IS CONTROLLED BY RELAXATION OF ACTIVITY IN THE OPPOSING PATTERN • FOR MOVEMENT WE NEED TO BE ABLE TO RECRUIT THE MOST APPROPRIATE PATTERN AT THE RIGHT TIME WITH THE RIGHT AMOUNT OF FORCE • FOR POSTURE WE NEED TO BE ABLE TO BALANCE THE ACTIVITY IN THE TWO PATTERNS
FEATURES OF TYPICAL AND ATYPICAL MOVEMENT
FEATURES OF TYPICAL MOVEMENT
Full
range
Voluntary
or
automatic
Motor
STIMULATING smooth &
co-
Sensory
ordinated
Copyright The Bobath CentreFEATURES OF TYPICAL MOVEMENT • COMBINATIONS OF MOBILITY & STABILITY, FLEXION AND EXTENSION AT SAME TIME • SEPARATE MOVEMENT OF ARMS AND LEGS FROM EACH OTHER AND FROM TRUNK – SEPARATION OF LEFT AND RIGHT SIDES OF THE BODY • TRUNK ROTATION – SEPARATION OF UPPER AND LOWER PARTS OF THE BODY • SHOULDER AND PELVIC STABILITY AND MOBILITY • WEIGHT SHIFT • BALANCE
FEATURES OF ATYPICAL MOVEMENT IN CP
Less
Limited or
voluntary,
excessive
more
range
involuntary
Motor
LIMITING jerky &
poorly
Sensory co-
Copyright The Bobath Centre
ordinatedFEATURES OF ATYPICAL MOVEMENT FOR A CHILD
WITH INCREASED POSTURAL TONE
• STEREOTYPED PATTERNS WITH FEWER COMBINATIONS OF FLEXION AND
EXTENSION
• TOO MUCH STABILITY, LACK OF MOBILITY
• LIMITED SEPARATE MOVEMENT OF ARMS AND LEGS FROM EACH OTHER AND
FROM TRUNK – USE MASS PATTERNS
• LACK OF TRUNK ROTATION – SHOULDERS AND PELVIS IN LINE – SYMMETRY+
• POOR LATERAL WEIGHT SHIFT
• POOR BALANCE RESPONSESFEATURES OF ATYPICAL MOVEMENT FOR A CHILD
WITH FLUCTUATING TONE
• STEREOTYPED PATTERNS, OFTEN ALTERNATING BETWEEN FLEXION AND EXTENSION
• TOO MUCH MOBILITY, LACK OF STABILITY
• LIMITED SEPARATE MOVEMENT OF ARMS AND LEGS FROM EACH OTHER AND FROM
TRUNK – USE MASS PATTERNS
• OFTEN TOO MUCH TRUNK ROTATION – ASYMMETRY+
• POOR CONTROL OF WEIGHT SHIFT
• POORLY CONTROLLED BALANCE RESPONSESCOMMON MOVEMENT PROBLEMS
FOR CHILDREN WITH CP
• USE OF ATYPICAL PATTERNS OF MOVEMENT
• EXCESS OR REDUCED RANGES OF MOVEMENT
• LACK OF VARIETY
• MOVEMENT IS MORE EFFORTFUL
• MOVEMENT MAY NOT BE SUCCESSFUL – USE MORE OF WHAT THEY HAVE
• MUSCLES WEAKNESS
• REDUCED AWARENESS / UNDERSTANDING OF OWN BODY / FEARFUL?
• GENERAL FATIGABILITY / LACK OF CARDIOVASCULAR FITNESSCOMMON MOVEMENT PROBLEMS
FOR ADULTS WITH CP
• HAD YEARS OF PRACTISING UNHELPFUL MOVEMENTS
• COMPENSATIONS
• WEAR & TEAR
• PAIN AND DEFORMITIESGETTING GOING AGAIN – GENERAL POINTERS • IDENTIFY A REALISTIC GOAL AND STEPS TOWARDS ACHIEVING THIS • MAKE IT FUN – MOVEMENT THROUGH PLAY AND DAY TO DAY ACTIVITIES • REMEMBER YOUR CHILD NEEDS TO BE ACTIVE • TRY TO IDENTIFY WHAT THEY MIGHT BE DOING TOO MUCH OF AND TOO LITTLE OF • LOTS OF PRACTICE - REPETITION BUT WITH LOTS OF VARIETY
GETTING GOING AGAIN – SOME IDEAS ACTIVE STRETCHES – FOR: • IMPROVING THE RANGE OF MOVEMENT IN MUSCLES AND JOINTS • WAKING UP THE BODY (IMPROVING SENSORY AWARENESS) • LYING ON YOUR BACK OR FRONT WITH HANDS OVERHEAD (PARTICULARLY IF TOO MUCH FLEXION IN SPINE AND LIMBS) • LYING ON YOUR BACK WITH KNEES HUGGED TO CHEST (PARTICULARLY IF TOO MUCH EXTENSION IN SPINE) • LYING ON YOUR BACK DOING ‘SNOW ANGELS’ PALMS UPWARDS • STANDING AND REACHING FORWARDS TOWARDS KNEES OR FEET KEEPING KNEES STRAIGHT
GETTING GOING AGAIN – SOME IDEAS ROLLING – GREAT FOR: • EXPLORING • SEPARATE MOVEMENT OF LIMBS AND TRUNK • WEIGHT SHIFT • IMPROVING ACTIVE FLEXION AND EXTENSION AND ROTATION • CROSSING MIDLINE
GETTING GOING AGAIN – SOME IDEAS IMPROVING ABDOMINAL ACTIVITY HANDS TO KNEES & FEET LONG SITTING REACHING TO FLOOR
GETTING GOING AGAIN – SOME IDEAS FOR PLANNING AND SEQUENCING – TO HELP WITH THE ABILITY TO FOLLOW SEVERAL INSTRUCTIONS TO ACHIEVE A DEFINED OUTCOME OR END POINT • HOKEY KOKEY SONG • TWISTER – ADAPT AS NEEDED • SIMON SAYS SONGS • HELPING WITH UN/DRESSING
GETTING GOING AGAIN – SOME IDEAS
DYNAMIC WEIGHT BEARING - FOR:
MOVING THROUGH LARGER RANGES, IMPROVING WEIGHT SHIFT, CHANGING BOS,
STRETCHING FLEXOR MUSCLES & ARCHES IN HANDS, ARCHES OF FEET, CALVES–ACHILLES
TENDONS IN LEGS
• SEQUENCES - LONG SITTING TO LEFT SIDE SITTING TO FOUR POINT TO RIGHT
SIDE SITTING TO LONG SITTING
• CLIMBING – STAIRS ON HANDS AND KNEES, ON FEET
• SITTING TO STANDING
• REACHING OUT TO EITHER SIDE IN STANDING
• EXTENDED ARM SUPPORT IN PRONE (LYING ON TUMMY OVER SUPPORT)QUESTIONS
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