Bottom Up Approaches in children with Cerebral Palsy

1Tehran CP Workshop, May 2017
‫تخصصی‬ ‫کارگاه‬
‫رویکردهای‬ ‫ای‬ ‫مقایسه‬ ‫بررسی‬‫باتم‬‫و‬ ‫آپ‬‫تاپ‬‫در‬ ‫دان‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬ ‫کاردرمانی‬ ‫مداخالت‬
‫تهیه‬‫تنظیم‬ ‫و‬:‫خیاط‬ ‫محمد‬ ‫دکتر‬‫زاده‬
‫بهار‬1396

Approaches To Evaluation and Therapy
Bottom Up approach
Top Down approach
Tehran CP Workshop, May 2017 2

Bottom Up Therapeutic approaches
 A bottom up approach to assessment and treatment
focuses on the deficits of components of function,
such as strength, range of motion, balance, and so on,
which are believed to be prerequisites to successful
occupational performance or functioning.
 An assumption inherent in the bottom-up approach is
that acquisition or reacquisition of motor, cognitive,
and psychological skills will ultimately result in
successful performance of ADLs.

Traditional B-U approaches in CP
 Patterning ( Delacato)
 Feldenkrais (Feldenkrais)
 Reflex Locomotion(Vojta)
 Conductive Education (Peto)
 PNF (Kabat, Knott, Voss)
 Sensory Integration(Ayres)
 Rood(Rood)
 NDT ( Bobath and Bobath)
 Orthotic Management
 Botulinumtoxin -A (BTX-A)
 Electrical Stimulation (
NMES, FES)
 Strength Training
 Selective Dorsal Rhizotomy
(SDR)
 Intrathecal Baclofen Pump
 Surgery/ Single Event Multi
Level Surgery(SEMLS)

Patterning

Patterning
 Temple Fay, C. H. Delacato, and Glenn Doman noted
that normal development progresses in an established
sequence, e.g., crawling, then cruising, and then
walking.
 They argued that failure to properly complete any
stage of neurological development adversely affected
all subsequent stages.
 They hypothesized that the development of a child
who had a neurological injury could be improved by
making him or her undergo normal sequences in a
frequent, repetitious fashion.

Patterning effectiveness
 MacKay and Bridgman et al
found either no or only short
lived improvements in
children treated with
patterning.
 Parents who used patterning
with their child often spent
many hours a day, utilizing
tremendous energy doing the
patterning.
 Controlled trails show no
benefits

Feldenkrais Method
(Moshe Feldenkrais)
8Tehran CP Workshop, May 2017

Feldenkrais concept
 The Feldenkrais Method is a form of somatic education
that uses gentle movement and directed attention to
improve movement and enhance mental and physical
functioning
 With functional integration, a coach uses hands-on and
light touch stimulations to guide a patient through various
motion patterns.
 In the awareness through motion approach, the teacher
verbally directs participants through various movements,
breaking down complex motions into smaller sequences
and varying the order and types of motion.


Feldenkrais Effectiveness
 The goals are to improve
flexibility, posture, mental
status, and comfort.
 Proponents report that
individuals may develop
greater endurance, improved
ease in walking, and a
smoother gait.
 However, there are very few
studies of the Feldenkrais
method and there is no
evidence that it is effective
for individuals with CP.

Reflex Locomotion
(Václav Vojta)

Vojta therapy
 According to Vojta, reflex
locomotion is activated from
the three main positions:
prone, supine and side lying.
 To stimulate the patterns of
movement, there are available
zones on the body and on the
arms and legs.
 Through a combination of
different zones and changes in
pressure and extension both
patterns of movement, reflex
rolling and reflex creeping, can
be activated.

Reflex creeping
 The main position is
prone lying with the
head creeping resting
on the bed rotated to
one side.
 Reflex creeping can be
fully activated from one
zone; in older children
and in adults, a
combination of several
pressure points is
necessary

Reflex rolling
 Reflex rolling
transitions from
supine to side lying
and leads to
crawling.
 Therapeutically,
reflex rolling is used
in different phases of
supine and side lying

Vojta therapy
 For Vojta Therapy to be successful,
it must as a rule be performed
several times a day (up to four
times where necessary).
 A therapy session lasts between
five and twenty minutes.
 Since parents or caregivers
perform the therapy daily, they
play a significant role in the
application of Vojta Therapy.

Vojta effectiveness
 No controlled studies are available
supporting Vojta
approach in the treatment of
children with CP.
 The new-born babies will cry as
pressure applied . This leads to
parents feeling concerned, and
makes them assume that it is
“hurting” their child.
 But their practitioner claim that this
method is effective specially in
newborn babies( below 1 year) as a
early intervention.

Conductive Education
(András Pető)

Conductive Education(CE)
 CE is taught in a group classroom
setting by a trained Conductor
like a school.
 Conductors use repeated verbal
reinforcement to promote and
facilitate intended motor activity
by the child.

 A Conductor has a four year degree
from the Peto Institute, which
basically encompasses learning
about the motor, sensory, speech,
and processing of individuals with
neurologically based motor
impairments.

CE concepts
 It is based on the concept that children with motor disabilities learn
the same way as those with no disability.
 Participation in CE requires reasonable cognitive abilities to
comprehend the verbal instructions.
 The child is encouraged to participate and practice all daily activities
to the best of his or her abilities.
 CE is typically carried out in separate group sessions for school age
children.

CE effectiveness
 The effectiveness of CE in children with CP has not been established
by any controlled clinical trials.
 The importance of group as a motivating factor is stressed.
 The emphasis on verbal reinforcement before and during the task.
 The emphasis on independence rather than on quality of movement.
 Comparison between CE and traditional therapies showed little
difference in functional outcomes but more contractures in CE group

PNF
(Maggie Knott)

PNF philosophy
 PNF is an integrated approach: Each treatment is directed at the total
human being, not just at a specific problem or body segment.
 Mobilizing reserves: Based on the untapped existing potential of all
patients, the therapist will always focus on mobilizing the patient’s reserves.
 Positive approach: The treatment approach is always positive, reinforcing
and using what the patient can do, on a physical and psychological level.
 Highest level of function: The primary goal of all treatments is to help
patients achieve their highest level of function.
 Motor learning and motor control: To reach this highest level of
function, the therapist integrates principles of motor control and motor
learning

Multisensory approach
 Auditory ( Verbal instruction)
 Visual (demonstration)
 Somatosensory
1. Manual guidance/contact
2. stretch
3. Resistance
4. Approximation
5. Traction

Sequence of Treatment
 Guided resistance, manual
contact, verbal instruction,
rhythmic initiation,
combination of isotonic and
replication can be used as
possibilities to learn new skill.
 Exercises will be done in
functional diagonal patterns
 Ultimately, the trainings
situation is adapted to the
daily life situation

PNF effectiveness
 PNF techniques mostly have been used for adult
people, but they can be used for adolescents and
young adults with CP respectively.
 It is an evolving and ever-changing approach
 Although no clinical controlled trials are available
supporting PNF approach in the treatment of children
with CP, some techniques could be used as a
preparatory methods to facilitate motor function.


Rood approach
(Margaret Rood)

Rood approach
 Rood's philosophy of treatment is concerned with the
interaction of somatic, autonomic and psychological
factors and their role in the regulation of motor
behavior.
 The basic points of Rood's Approach are:
1. Duality
2. Ontogenetic sequence
 Effects upon the anterior horn cell(AHC)
 Effects upon the autonomic nervous system (ANS)

Duality

Duality
 Using more contemporary terminology, Rood's light work
and heavy work muscles could correspond to muscles with
a predominance of phasic (fast glycolytic) and tonic (slow
oxidative) motor units, respectively.

Muscle fibers
 Type I: These fibers are also known as slow twitch fibers. They are red in
color due to the presence of large volumes of myoglobin and high numbers
of Mitochondria. Due to this fact they are very resistant to fatigue and are
capable of producing repeated low-level contractions by producing large
amounts of ATP through an aerobic metabolic cycle.
 Type IIa: These fibers are also sometimes known as fast oxidative fibers
and are a hybrid of type I and II fibers. These fibers contain a large number
of mitochondria and Myoglobin, hence their red color. They manufacture
and split ATP at a fast rate by utilizing both aerobic and anaerobic
metabolism and so produce fast, strong muscle contractions, although they
are more prone to fatigue than type I fibers.
 Type IIb: Often known as fast glycolytic fibers. they are white in color due
to a low level of myoglobin and also contain few mitochondria. They
produce ATP at a slow rate by anaerobic metabolism and break it down very
quickly. This results in short, fast bursts of power and rapid fatigue.

Ontogenetic sequence
 Mobility(reciprocal innervation)
 Stability(co-innervation)
 Mobility superimposed on stability(heavy work)
 Distal mobility with proximal stability(Skill)
 The ontogenetic sequence are generally accepted as outdated.
 Relearning of movement neither occurs from proximal to distal, nor does it
return in adults in a style corresponding to development in children.
 More contemporary models of treatment, especially those of motor control
and motor learning focus treatment on the analysis of component parts of
a movement, finally combined into a task.

Effects upon the anterior horn cell(AHC)
Facilitation V Inhibition

Facilitation V Inhibition
 Although, Rood's Approach was based on a Reflex/Hierarchical
view of the nervous system, as a modular model, it has
components which can be justified in light of current scientific
evidence.
 Critics of the Rood approach argue that if patients' movements
are not self-initiated then they are not learned.
 More attention on techniques focused on some proprioceptive
and extroceptive ones such as: Quick stretch, prolonged
stretch, resistance, slow stroking
 Clinical use often involves the combination of several
techniques, exteroceptive and proprioceptive, in order to
maximize the effects through summation.
 Some techniques such as Fact brushing or icing are not
supported scientifically.

Effects upon the ANS
Sympathetic V Parasympathetic

ANS
 The ANS and emotional system are more complex
than rood oversimplified.
 A more credible model is that central circuits involved
in emotion and in motivation are strongly connected
to autonomic and neuroendocrine systems, so that
emotional states are accompanied by, and reflected in,
autonomic and endocrine changes which, in turn, feed
back to modulate the emotional state.
 These central circuits, principally residing in the
orbitofrontal cortex, limbic cortex, amygdala,
hypothalamus and brainstem, influence somatic
sensory and motor function as well.

Sensory Integration
( Jean Ayres)

SI concept
 In this concept difficulties in planning and executing
organized behavior are attributed to problems of
processing sensory inputs within the CNS, including
vestibular, proprioceptive, tactile, visual and auditory.
 Treatment focuses on integrating neurological processing
by facilitating the individual to register and process the
type, quality and intensity of sensation provided by the
environment to enable effective behavior

Sensory Modulation Disorders
 Children may show a poor ability to register sensory
information and therefore seek sensory input, and those who
are hypersensitive to sensory stimuli and therefore require
desensitizing.
 A significant number of children with CP have sensory
impairments. SI may help processing and integration of this
sensory information.
 SI can be successfully combined with NDT in specific groups of
children with CP.

SI Effectiveness
 Some studies find SI as a
useful treatment
approach in children with
CP, while others do not
find any functional
benefit.
 Sensory processing
approach seems more
evidenced based than SI

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