mcelroy, haynes, & franjoine 2009. m r franjoine & m p haynes dimensionfunctional...

McElroy, Haynes, & Franjoine 2009

McElroy, Haynes, & Franjoine 2009 M R Franjoine & M P Haynes

Dimension Functional Domain Disability Domain

A. Body structure & functions

Structural & functional integrity

Impairments

A.Primary

B.Secondary

B. Motor functions Effective posture & movement

Ineffective posture & movement

C. Individual functions

Functional activities Functional activity limitations

D. Social functions Participation Participation restriction

+ Domains -

From: NDT Approach Theoretical Foundations & Principles of Clinical Practice, Table 2.1 pg. 82


Be transient and disappearPreterm infantsMedically fragile children

Continue as Hypotonic CP

Later be diagnosed as Athetoid, Ataxic, or Spastic CP

May:


Be part of an obvious or later diagnosed genetic syndrome

Down SyndromePrader-WilliJoubert Syndrome

Other syndromesFetal alcohol syndrome (FAS)Fragile X syndromeMaternal drug abuse

May:


A muscle fiber type disorder

Sensory integration disorder

MR

Autism

May be:


CognitionNeuromuscular SystemSensory SystemMusculoskeletal SystemRegulatoryGastrointestinalCardiopulmonaryIntegumentary


Variable:Child to childEtiology

Cognition often underestimatedFlat affectAppears “slow” or “lazy”Latency of response time


Abnormally low muscle resting tone

Abnormally low resistance to being lengthened

Feels “soft” when handledDescribed as “floppy”


Impaired Muscle Synergies

Impaired Muscle Activation

Inability to Initiate, Sustain, Terminate

Insufficient Co-activation


Holding joint positions in midrange is difficultMove quickly through transitions

Tend to work at end rangesDecrease degrees of freedom distallyHyperextention of elbows and knees


Difficulty initiating muscle contractionThreshold for fiber firingInsufficient number of fibers recruitedSlow to respondResponse is then short-lived“Good baby”…later “lazy”May have a flat affectIn supine “look flat”


Difficulty in sustained holding against gravity…especially postural muscles

Look like gravity is pulling them downHave a “belly” when upright

Often turns muscles off to quicklyi.e. Collapse when standing


• Impaired Motor Execution

Impaired Modulation and Scaling of Forces

Impaired Timing and Sequencing

Excessive overflow of Intra-Interlimb contractions


Phasic bursts of movement

Little grading – moves quickly to end ranges

Overshoots target or strikes target inappropriately


Primary—Difficulty grading agonists and antagonists

Timing and sequencing difficulties may be secondary to initiate, sustain, and strength issues


Impaired Force Generation

Strength: the ability to contract a muscle to a sufficient degree to impact the task

Primaryinability to reach threshold for muscle firinginability to recruit enough muscle fibers

SecondaryLittle muscle holding: decreased strength/atrophyChanges in muscle fiber type 2°to phasic use


Anticipatory Postural Control—Probably not a primary impairment

Difficult with latency of initiation

Often they may anticipate a movement and “lock out their joints” in anticipation

Anticipation may be present…just not appropriate


Poverty of Movement

“Poverty”--they don’t move muchHappy to stay in one place

Movement repertoires are somewhat limited

Secondary to strength, alignment, and stability available to them during developmentMovements in the frontal and, especially, the transverse planes are less frequently seen


Fractionated or Dissociated Movements

Often use pure reciprocal innervation rather than co-contraction

Movements may be “too dissociated”Need to control degrees of freedom to support purposeful isolated controlOften fix distally

Splaying of fingersPlantar-flexion of ankles


Vision

Vestibular

Somatosensory


Primary ImpairmentsRefractory errorsVisual field lossStrabismusCortical visual impairment not as common as in SQ

Secondary ImpairmentUses eyes for postural stabilization


Difficulty using: proprioceptive informationtactile information

Primary impairmentIf inappropriate firing of receptors

Secondary impairmentIf caused by lack of experience due to little movement, ability to read the input didn’t develop well


“ the ability of the nervous system to perceive, interpret, modulate, and organize sensory input for use in generating or adapting motor responses… (Miller & Lane 2000)

Degree of difficulty varies widely by etiology of the hypotonia


Bones:Changes are usually secondary to static positons

PlagiocephalyFlattend ribcageKyphosisShoulder instabilityHip instability


Muscles:AtrophyWeaknessFiber type changesMuscle shorteningMuscle overlengthening

Connective tissue:


Muscles:AtrophyWeaknessFiber type changesMuscle shorteningMuscle overlengthening

Primary or Secondary Impairments?


Connective Tissue:Hyperextensible jointsLigamentous laxity

Primary or Secondary Impairments?





Impairments

A.Primary

B.Secondary






+ Domains -



Antigravity postures are difficult so use phasic bursts of movement

Move quickly to ends of range

Rest on ligaments, joint capsules, and bones


Use wide BOS in both UEs and LEs

Move quickly to ends of range

Rest on ligaments, joint capsules, and bones


Postures:Hyperextends neck and “rests” head backMouth is often openShoulder complex is often elevated to support headLower extremities are widely abducted and externally rotated

Movement:Even neck extension is phasic…head may fall forward without controlNo lateral weight shifts!!!!


Postures:Prefers arms abducted and legs abductedBody “melted” onto the floor

Movement:Antigravity of extremities difficultSometimes “walks” extremities with hand movementsCan’t lift head against gravity“Flings” extremities


Postures:Retains flexed spinal position with hyperextended head resting positionSometimes looks like their chest “folds” in frontUses UEs for support (hyperextended elbows)

May use feet as handsPosteriorly tilted pelvisBOS is very wide, knees flexed or extended


Movement:Keeps the COM in the middle of the BOS

Will pivot rather than rotate spine

Often transitions out of sitting in the sagittal plane with legs abducted


Postures:Hyperextension at the neck and elbowsUEs abductedHips and knees flexed greater than 90°Hips abducted

Movement:Moves extremities rapidly with longer periods of 4s support with extremities “locked” when possibleMuch rather scoot on bottom!!!


Postures:Support with UEsHips are abductedHips rest on feet or floor

Movement:Difficult position to maintainWill not transition to ½ kneel, pushes with legs at the same time to get to standing


Postures:Still like hyperextended neck and kyphotic upper spineUEs used to increase stiffness of trunkPelvis may be anteriorly or posteriorly tiltedWide BOS in LEs Knees hyperextended, out-toeing


Movement:Legs may “fold” unexpectedlyDifficulty shifting weight laterally to unweight one leg for gaitWide BOS and short steps make gait awkward and inefficient





Impairments

A.Primary

B.Secondary






+ Domains -



LOCOMOTOR SKILLS

• Independent, efficient upright mobility difficult• Coordination and safety is a concern

COMMUNICATION • Though may be difficult to understand, communication is usually verbal

BASIC ADL’S • Usually can master ADLs• May be more limited by cognition than motor ability





Impairments

A.Primary

B.Secondary






+ Domains -



Accepted by family…”good child” or “lazy child”

Often not accepted by peers due to latency of responses and communicationsSometimes problems safely accessing playgrounds and community centers


Work upright whenever possible

Attend closely to alignment

Narrow the base of supportEmphasize weight shifts

May need to increase attention and/or arousal


Increase proprioception by activating co-contraction around joints…holding and graded movements

Build strength working in midranges… concentric and eccentric


“Good” babies and children are often ignored

The static situation of these children interferes with exploration and learning

Don’t under-estimate the power of the biomechanical limits these children face.

mcelroy, haynes, & franjoine 2009. m r franjoine & m p haynes dimensionfunctional...

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