Toddlers and Pre Schoolers

Transcription

1 Welcome to Allied Health Telehealth Neonatal brachial plexus palsy To receive an attendance certificate please complete your online evaluation at: Neonatal brachial plexus palsy Toddlers and Pre Schoolers Allied Health Telehealth Session Presented by: Fiona Sampson OT & Alison Chivers PT 1

2 Indicators of Brachial Plexus Palsy Birth history often involving trauma Lack of movement in affected upper limb Lack of response to stimulation of affected arm Atypical posturing- ie waiter s tip posture (internal rotation, pronation and wrist flexion) Waiters tip 2

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4 Neonatal Brachial Plexus Palsy Protocol of Surgical Intervention 4-5 months : Severe injuries require nerve graft surgery. 9 months : Botox and casting considered for tightness into shoulder external rotation. 12 months : If shoulder external rotation movement is absent consider further botox and/or transfer of 1 nerve for external rotation months consider shoulder rebalancing (tendon transfer) if external rotation still limited. When to refer to a specialist centre? Mild lesion cannot be distinguished reliably from severe lesions in the perinatal period. Only time reveals whether or not spontaneous recovery will occur. Absence of active flexion at one month of age is a good indicator for referral to a specialist centre. 4

5 TODDLERS Toddlers Frequency of intervention Management of body function and structure Management of activity and participation Surgical considerations 5

6 Body Function and Structure Maintenance of passive ROM External rotation: most important Adequate external rotation required for movement above 90 o Elbow extension Pronation / supination Why do specific ROM losses occur? Growth Issues with denervated muscle Muscle imbalance 6

7 Passive ROM: External Rotation Difference between shoulder abducted and adducted 7

8 Shoulder External Rotation Stretch Pect Major, Ant Deltoid, Subscapularis, Teres Major, Latissimus Dorsi Facilitating active movements Shoulder external rotation 8

9 Facilitating active movements Reaching into: shoulder abduction shoulder flexion Elbow extension Facilitating active movements Supination and Pronation 9

10 Specific strengthening Limits if muscle not adequately innervated Limits of cognitive understanding and cooperation E.g. Scapula winging/control Strengthening Developmentally appropriate Positioning to eliminate gravity initially Progression to against gravity Functional goals 10

11 Focus on affected upper limb development and function Prehension with affected hand Bimanual play development PREHENSION: affected hand Initiation of reach Grasp and release Hands to midline Hand to mouth Prehension 11

12 Prehension with affected hand Digital grasp Pincer grasp Bimanual upper limb development Issues: Focus on awareness of affected arm Static stabilisation against body Static holding in affected hand Use of affected hand as assist (helper hand) Motor planning 12

13 Developmental disregard and learned non use Affected non dominant hand vs affected dominant hand Reduced awareness of affected upper limb Interventions Modified Constraint Induced Movement Therapy (Mod CIMT) 13

14 Bimanual Therapy 14

15 DOMINANCE Affected dominant hand Underlying weakness but easier to facilitate use Affected non dominant hand? Changing dominance 15

16 Activities and Participation Child care Dressing Eating Pre-writing Play Climbing Early Ball skills Pre Schoolers 16

17 Management of body function and structure Maintenance of Passive ROM Shoulder external rotation Elbow extension Pronation / supination Facilitating active movements Maintaining Passive ROM Maintaining and facilitating Shoulder external rotation Elbow extension Forearm pronation Child actively involved 17

18 Shoulder movements Abduction/ flexion External and internal rotation Active movements Supination and pronation: Gravity eliminated 18

19 Supination Against gravity Pronation: active 19

20 Pre-Schoolers Activity and participation Table top fine motor function Prewriting development Stabilising paper Pencil grip Cutting Issues with hand dominance Typical posture Shoulder internally rotated Forearm across body Elbow off the table Forearm in mid position 20

21 Ideal posture Shoulder in mid position Hand at side of paper Forearm using full active pronation 21

22 Bimanual skills Bimanual skill development Motor planning for bimanual tasks Affected hand: dominant vs non dominant 22

23 Cutting skills Typical issues: Wrist posture Pronation or mid position of affected hand Motor planning Pre-Schoolers Activity and participation ADL issues and self help skills (Developing independence) 23

24 Getting ready for school Ball skills Playground issues Falls Climbing Protection of arm Interventions: Modified Constraint Induced Movement Therapy 24

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